The American Board of Internal Medicine (ABIM) is encouraging the healthcare industry to change the way testing and procedures are handled in order to reduce waste and minimize the potential risk to patients. A recent JAMA study, “The ‘Top 5’ Lists in Primary Care: Meeting the Responsibility of Professionalism”, estimated that just 12 unnecessary treatments and screenings accounted for $6.8 billion of 2009’s medical cost. Choosing Wisely, an initiative by the ABIM, aims to help physicians use healthcare resources more wisely. Originally a pilot by the National Physicians Alliance, nine medical specialty organizations as well as Consumer Reports have identified five tests or procedures commonly used in their fields whose necessity should be questioned.
Five Things Physicians and Patients Should Question:
American Academy of Allergy, Asthma & Immunology
- Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
- Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
- Don’t routinely do diagnostic testing in patients with chronic urticaria.
- Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
- Don’t diagnose or manage asthma without spirometry.
American Academy of Family Physicians
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
- Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
- Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
- Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
- Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
American College of Cardiology
- Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
- Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
- Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
- Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
- Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).
American College of Physicians
- Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
- Don’t obtain imaging studies in patients with non-specific low back pain.
- In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
- In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
- Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
American College of Radiology
- Don’t do imaging for uncomplicated headache.
- Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
- Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
- Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
- Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.
American Gastroenterological Association
- For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
- Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
- Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without highgrade dysplasia, completely removed via a high-quality colonoscopy.
- For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.
- For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
American Society of Clinical Oncology
- Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.
- Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
- Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
- Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
- Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.
American Society of Nephrology
- Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
- Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
- Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.
- Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.
- Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.
American Society of Nuclear Cardiology
- Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
- Don’t perform cardiac imaging for patients who are at low risk.
- Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
- Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
- Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.
For more information on Choosing Wisely, or details about each list, please visit Choosing Wisely Lists.