McGill University, Montreal , Canada aZowall Consulting Inc. Health Economics and Outcomes Research, Montreal, Canada
Zowall Consulting Inc. Health Economics and Outcomes Research, Montreal, Canada
McGill University, Montreal , Canada Zowall Consulting Inc. Health Economics and Outcomes Research, Montreal, Canada
Given current and future budgetary constraints, issues of what constitute appropriate level of care are becoming paramount. As more evidence-based data are accumulated, identifying the appropriate use of medical tests and procedures becomes imperative. In the United States, the “Choosing Wisely” campaign is an initiative of the American Board of Internal Medicine Foundation to allow physicians to be leaders in better management of finite health care resources. As part of a campaign, each participating medical specialty society has created lists of “Things Physicians and Patients Should Question” that provide specific, evidence-based recommendations, so physicians and patients can reach informed decisions about the appropriate level of care. Here we provide the summary of the most important recommendations. The aim of this paper is to disseminate the information in order to stimulate discussions about the appropriateness of frequently ordered tests or treatments and about variations in patterns of care, and cost-effective ways of managing finite health care resources. Central to the best practice of medicine becomes comparative-effectiveness research, including long term studies on clinical benefits and costs. Physicians must change practice patterns, through standard-of-practice guidelines, to practice in the most knowledge-based, least invasive, and less costly way. Physicians need to take a leadership role in teaching patients that more medicine is not better medicine, that costly efforts do not equal better health care. We need to explain to patients that new medical technology must be used with care and wisdom.
As many countries focus on ways to provide safer, higher-quality care to patients at affordable prices, the rational use of health care resources is an issue of considerable concern [1-5]. Given the fast pace of technological change, the use of many routine medical tests becomes questionable, as newer and perhaps “better”, but usually more expensive tests become available. As more evidence-based data are accumulated, identifying the appropriate use of medical tests becomes imperative. In many jurisdictions, where the majority of health care services are publicly provided, there is no room for delivering duplicative or unnecessary care. Given current and future budgetary constraints, moves away from fee-for-service towards pay-for-performance arrangements, issues of what constitute appropriate level of care are becoming paramount. It is important to provide health care, supported by evidence-based data that is not duplicative, and is truly necessary, where clinical benefits outweigh harm. Many experts agree that in the United States, health care delivery contains waste, with some stating that as much as 30 percent of care delivered is duplicative or unnecessary, and may not improve patients’ health [3-4]. The aim of this paper is disseminate the information in order to stimulate discussions about the appropriateness of frequently ordered tests or treatments and to encourage discussions about variations in patterns of care, and cost-effective ways of managing finite health care resources.
U.S. Choosing Wisely campaign sponsored by American Board of Internal Medicine Foundation
In the United States, the “Choosing Wisely” campaign is an initiative of the American Board of Internal Medicine (ABIM) Foundation . It is part of a continuous effort to allow physicians to be leaders in better management of finite health care resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on cost-effective management of limited clinical resources. Since 1999, the ABIM Foundation has worked toward its mission of advancing medical professionalism into clinical policy and practice. “Choosing Wisely” is intended to help physicians and patients engage in conversations about the appropriate use of tests and procedures and support physician efforts to help patients make smart and effective care choices. As part of “Choosing Wisely”, each participating medical specialty society has created lists of “Things Physicians and Patients Should Question” that provide specific, evidence-based practice, so physicians and patients can reach informed decisions about the appropriate care based on the patients’ individual situation.
The resulting list is intended to stimulate discussion about the appropriateness of frequently ordered tests or treatments. This concept was originally piloted by the US National Physicians Alliance, who through the ABIM Foundation created a list for physicians to use in their practices to promote more effective use of health care resources. The “Top 5” lists in primary care study was published in Archives of Internal Medicine, 2011 . The list included tests and procedure of questionable value in three medical specialties: Family Medicine, Internal Medicine and Pediatrics. Briefly, panels of experts evaluated the current pattern of care and reviewed them according to evidence-based data. The new, updated and enlarged list prepared by 25 leading physician specialty societies in the United States, representing over 725,000 physicians, were released in February 2013 . Each medical specialty society identified major tests or procedures that are commonly performed, but whose use should be questioned. For each recommendation the data sources were compiled. Here, selected recommendations are cited. The full list is provided at www.choosingwisely.org.
Selected list of tests and procedures for physicians and patients to question (quoted from www.choosingwisely.org)
American Academy of Family Physicians
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.
Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.
Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.
Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.
Delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.
Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care clinicians should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.
Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.
There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction.
Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
There is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit.
Don’t screen women younger than 30 years of age for cervical cancer with human papilloma virus (HPV) testing, alone or in combination with cytology.
There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate. The harms include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety and distress.
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.
DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.
Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.
American College of Physicians
Don’t obtain imaging studies in patients with non-specific low back pain.
In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.
Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes.
In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies.
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.
In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.
The American College of Obstetricians and Gynecologists
Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.
Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the
HPV, which does not require treatment in average risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.
Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.
American Academy of Pediatrics
Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
Although overall antibiotic prescription rates for children have fallen, they still remain alarmingly high. Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contributes to higher health care costs and the risks of adverse events.
Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
Research has shown these products offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.
CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
Minor head injuries occur commonly in children and adolescents. Approximately 50% of children who visit hospital emergency departments with a head injury are given a CT scan, many of which may be unnecessary. Unnecessary exposure to x-rays poses considerable danger to children including increasing the lifetime risk of cancer because a child’s brain tissue is more sensitive to ionizing radiation. Unnecessary CT scans impose undue costs to the health care system. Clinical observation prior to CT decision-making for children with minor head injuries is an effective approach.
Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.
CT scanning is associated with radiation exposure that may escalate future cancer risk. MRI also is associated with risks from required sedation and high cost. The literature does not support the use of skull films in the evaluation of a child with a febrile seizure. Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child’s fever.
CT scans are not necessary in the routine evaluation of abdominal pain.
Utilization of CT imaging in the emergency department evaluation of children with abdominal pain is increasing. The increased lifetime risk for cancer due to excess radiation exposure is of special concern given the acute sensitivity of children’s organs. There also is the potential for radiation overdose with inappropriate CT protocols.
American College of Cardiology (ACC)
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.
Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events.
Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation.
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.
Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery (e.g., cataract removal). These types of tests do not change the patient’s clinical management or outcomes and will result in increased costs.
Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
Patients with native valve disease usually have years without symptoms before the onset of deterioration. An echocardiogram is not recommended yearly unless there is a change in clinical status.
Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).
Stent placement in a noninfarct artery during primary PCI for STEMI in a hemodynamically stable patient may lead to increased mortality and complications. While potentially beneficial in patients with hemodynamic compromise, intervention beyond the culprit lesion during primary PCI has not demonstrated benefit in clinical trials to date.
American Society of Nuclear Cardiology
Don’t perform cardiac imaging for patients who are at low risk.
Chest pain patients at low risk of cardiac death and myocardial infarction (based on history, physical exam, electrocardiograms and cardiac biomarkers) do not merit stress radionuclide myocardial perfusion imaging or stress echocardiography as an initial testing strategy if they have a normal electrocardiogram (without baseline ST-abnormalities, left ventricular hypertrophy, pre-excitation, bundle branch block, intra-ventricular conduction delay, paced rhythm or on digoxin therapy) and are able to exercise.
Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.
The key step to reduce or eliminate radiation exposure is appropriate selection of any test or procedure for a specific person, in keeping with medical society recommendations, such as appropriate use criteria. Health care providers should incorporate new methodologies in cardiac imaging to reduce patient exposure to radiation while maintaining high-quality test results.
Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
Performing stress radionuclide imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation.
American College of Radiology
Don’t do imaging for uncomplicated headache.
Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.
Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability of PE.
While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly CT pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.
Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.
Don’t do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.
Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.
Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst
Society of Hospital Medicine
Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for ‹2days urologic procedures:use weights instead to monitor diuresis)
Catheter Associated Urinary Tract Infections (CAUTIs) are the most frequently occurring health care acquired infection (HAI). Use of urinary catheters for incontinence or convenience without proper indication or specified optimal duration of use increases the likelihood of infection and is commonly associated with greater morbidity, mortality and health care costs. Published guidelines suggest that hospitals and long-term care facilities should develop, maintain and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies and replacement indications.
Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
According to published guidelines, medications for stress ulcer prophylaxis are not recommended for adult patients in non-intensive care unit (ICU) settings. Histamine-2 receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs), commonly used to treat stress ulcers, are associated with adverse drug events and increased medication costs, and commonly enhance susceptibility to community-acquired nosocomial pneumonia and Clostridium difficile. Adherence to therapeutic guidelines will aid health care providers in reducing treatment of patients without clinically important risk factors for gastrointestinal bleeding.
Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
The American Association of Blood banks (AABB) recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients. The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration. According to a National Institutes of Health Consensus Conference, no single criterion should be used as an indication for red cell component therapy. Instead, multiple factors related to the patient’s clinical status and oxygen delivery should be considered.
Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
Telemetric monitoring is of limited utility or measurable benefit in low risk cardiac chest pain patients with normal electrocardiogram. Published guidelines provide clear indications for the use of telemetric monitoring in patients which are contingent upon frequency, severity, duration and conditions under which the symptoms occur. Inappropriate use of telemetric monitoring is likely to increase cost of care and produce false positives potentially resulting in errors in patient management.
Don’t perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability.
Hospitalized patients frequently have considerable volumes of blood drawn (phlebotomy) for diagnostic testing during short periods of time. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals.
Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.
National guidelines articulate a reliance on physical examination and patient history for diagnosis of asthma and bronchiolitis in the pediatric population. Multiple studies have established limited clinical utility of chest radiographs for patients with asthma or bronchiolitis. Omission of the use of chest radiography will reduce costs, but not compromise diagnostic accuracy and care.
Don’t routinely use bronchodilators in children with bronchiolitis.
Published guidelines do not advocate the routine use of bronchodilators in patients with bronchiolitis. Comprehensive reviews of the literature have demonstrated that the use of bronchodilators in children admitted to the hospital with bronchiolitis has no effect on any important outcomes. There is limited demonstration of clear impact of bronchodilator therapy upon the course of disease. Additionally, providers should consider the potential impact of adverse events upon the patient.
Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.
Published guidelines recommend that corticosteroid medications not be used routinely in the management of bronchiolitis. Furthermore, additional studies in patients with other viral lower respiratory tract infections have failed to demonstrate any benefits.
Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy.
Antireflux therapy has been demonstrated to have no effect in reducing the symptoms of gastroesophageal reflux disease (GERD) in children. Concerns regarding the use of proton-pump inhibitor therapy in infants include an inability to definitively diagnose pediatric patients according to the established criteria of GERD, lack of documented efficacy of acid suppression therapy in infants and the potential adverse effects associated with acid suppression therapy.
Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
The utility of continuous pulse oximetry in pediatric patients with acute respiratory illness is not well established. Use of continuous pulse oximetry has been previously associated with increased admission rates and increased length of stay. The clinical benefit of pulse oximetry is not validated or well documented.
American Geriatrics Society
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke e and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.
Avoid using medications to achieve hemoglobin A1c < 7.5% in most adults age 65 and older; moderate control is generally better.
There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.
Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.
Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.
American Academy of Hospice and Palliative Medicine
Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
In advanced dementia, studies have found feeding tubes do not result in improved survival, prevention of aspiration pneumonia, or improved healing of pressure ulcers. Feeding tube use in such patients has actually been associated with pressure ulcer development, use of physical and pharmacological restraints, and patient distress about the tube itself. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems; in the final phase of this disease, assisted feeding may focus on comfort and human interaction more than nutritional goals.
Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations.
Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
In about a quarter of patients with ICDs, the defibrillator fires within weeks preceding death. For patients with advanced irreversible diseases, defibrillator shocks rarely prevent death, may be painful to patients and are distressing to caregivers/family members. Currently there are no formal practice protocols to address deactivation; fewer than 10% of hospices have official policies. Advance care planning discussions should include the option of deactivating the ICD when it no longer supports the patient’s goals.
Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
As stated in the American Society for Radiation Oncology (ASTRO) 2011 guideline, single-fraction radiation to a previously un-irradiated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared to multiple-fraction regimens while optimizing patient and caregiver convenience. Although it results in a higher incidence of later need for retreatment (20% vs. 8% for multi-fraction regimens), the decreased patient burden usually outweighs any considerations of long-term effectiveness for those with a limited life expectancy.
Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea.
Topical drugs can be safe and effective, such as topical non-steroidal anti-inflammatory drugs for local arthritis symptoms. However, while topical gels are commonly prescribed in hospice practice, anti-nausea gels have not been proven effective in any large, well-designed or placebo-controlled trials. The active ingredients in ABH are not absorbed to systemic levels that could be effective. Only diphenhydramine (Benadryl) is absorbed via the skin, and then only after several hours and erratically at subtherapeutic levels. It is therefore not appropriate for “as needed” use. The use of agents given via inappropriate routes may delay or prevent the use of more effective interventions.
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 anti- cancer treatment.
Studies show that cancer directed treatments are likely to be ineffective for solid tumor patients who meet the above stated criteria. Exceptions include patients with functional limitations due to other conditions resulting in a low performance status or those with disease characteristics (e.g., mutations) that suggest a high likelihood of response to therapy. Implementation of this approach should be accompanied with appropriate palliative and supportive care.
Don’t perform positron emission tomography (PET), CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival. Evidence does not support the use of these scans for staging of newly diagnosed low grade carcinoma of the prostate (Stage T1c/T2a, prostate-specific antigen (PSA).
Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival. In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT, or radionuclide bone scans in asymptomatic individuals with newly identified ductal carcinoma in situ (DCIS), or clinical stage I or II disease. Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.
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.
Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g., colorectal). However for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients. False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.
American College of Rheumatology
Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
Data evaluating MRI for the diagnosis and prognosis of rheumatoid arthritis are currently inadequate to justify widespread use of this technology for these purposes in clinical practice. Although bone edema assessed by MRI on a single occasion may be predictive of progression in certain RA populations, using MRI routinely is not cost-effective compared with the current standard of care, which includes clinical disease activity assessments and plain film radiography.
Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs).
High quality evidence suggests that methotrexate and other conventional non-biologic disease modifying antirheumatic drugs (DMARD) are effective in many patients with rheumatoid arthritis (RA). Initial therapy for RA should be a conventional non-biologic DMARDs unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial 3-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features (functional limitations, disease outside the joints, seropositivity or bony damage), where biologic therapy may be appropriate first-line treatment.
Don’t routinely repeat DXA scans more often than once every two years.
Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation recommendations. The optimal interval for repeating Dual-energy X-ray Absorptiometry (DXA) scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, frequent testing (e.g.,
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.
The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient’s quality of life rather than as a disease control measure.
Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
A screening colonoscopy every 10 years is the recommended interval for adults without increased risk for colorectal cancer, beginning at age 50 years. Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population. Therefore, following a high-quality colonoscopy with normal results the next interval for any colorectal screening should be 10 years following that normal colonoscopy.
Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high- grade dysplasia, completely removed via a high-quality colonoscopy.
The timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Evidence- based (published) guidelines provide recommendations that patients with one or two small tubular adenomas with low grade dysplasia have surveillance colonoscopy five to 10 years after initial polypectomy. “The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician).”
For a patient with functional abdominal pain syndrome (as per ROME III criteria) CT scans should not be repeated unless there is a major change in clinical findings or symptoms.
There is a small, but measurable increase in one’s cancer risk from x-ray exposure. An abdominal CT scan is one of the higher radiation exposure x-rays — equivalent to three years of natural background radiation. Due to this risk and the high costs of this procedure, CT scans should be performed only when they are likely to provide useful information that changes patient management.
American Urological Association
A routine bone scan is unnecessary in men with low-risk prostate cancer.
Low-risk patients (defined by using commonly accepted categories such as American Urological Association and National Comprehensive Cancer Network guidelines) are unlikely to have disease identified by bone scan. Accordingly, bone scans are generally unnecessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 ng/mL and a Gleason score 6 or less unless the patient’s history or clinical examination suggests bony involvement. Progression to the bone is much more common in advanced local disease or in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes.
Don’t prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.
While testosterone treatment is shown to increase sexual interest, there appears to be no significant influence on erectile function, at least not in men with normal testosterone levels. The information available in studies to date is insufficient to fully evaluate testosterone’s efficacy in the treatment of men with erectile dysfunction who have normal testosterone levels.
Don’t treat an elevated PSA with antibiotics for patients not experiencing other symptoms.
It had previously been suggested that a course of antibiotics might lead to a decrease in an initially raised PSA and reduce the need for prostate biopsy; however, there is a lack of clinical studies to show that antibiotics actually decrease PSA levels. It should also be noted that a decrease in PSA does not indicate an absence of prostate cancer. There is no information available on the implications of deferring a biopsy following a decrease in PSA.
American Society of Nephrology
Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
Due to high mortality among end-stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, PSA and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis and increased stress. An individualized approach to cancer screening incorporating patients’ cancer risk factors, expected survival and transplant status is required.
Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or chronic kidney disease (CKD) of all causes, including diabetes.
The use of NSAIDS, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function in these individuals. Other agents such as acetaminophen, tramadol or short-term use of narcotic analgesics may be safer than and as effective as NSAIDs.
Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.
Venous preservation is critical for stage III–V CKD patients. Arteriovenous fistulas (AVF) are the best hemodialysis access, with fewer complications and lower patient mortality, versus grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture.
Don’t initiate chronic dialysis without ensuring a shared decision- making process between patients, their families, and their physicians.
The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process between patients, their families, and their physicians. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefits and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not differ substantially for older adults with a high burden of co morbidity who initiate chronic dialysis versus those managed conservatively.
American Academy of Otolaryngology — Head and Neck Surgery Foundation
Don’t order CT scans of the head/brain for sudden hearing loss.
CT scanning is expensive, exposes the patient to radiation and offers no useful information that would improve initial management. CT scanning may be appropriate in patients with focal neurologic findings, a history of trauma or chronic ear disease.
Don’t prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea.
Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.
Don’t prescribe oral antibiotics for uncomplicated acute external otitis.
Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.
Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
Imaging of the paranasal sinuses, including plain film radiography, CT and magnetic resonance imaging (MRI) is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis.
Don’t obtain CT or magnetic resonance imaging (MRI) in patients with a primary complaint of hoarseness prior to examining the larynx.
Examination of the larynx with mirror or fiberoptic scope is the primary method for evaluating patients with hoarseness. Imaging is unnecessary in most patients and is both costly and has potential for radiation exposure. After laryngoscopy, evidence supports the use of imaging to further evaluate 1) vocal fold paralysis, or 2) a mass or lesion of the larynx.
American Society of Echocardiography
Don’t order follow up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram.
Trace mitral, tricuspid and pulmonic regurgitation can be detected in 70% to 90% of normal individuals and has no adverse clinical implications. The clinical significance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown.
Don’t repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no significant pathology.
Repeat imaging to address the same question, when no pathology has been previously found and there has been no clinical change in the patient’s condition, is not indicated.
Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
Perioperative echocardiography is used to clarify signs or symptoms of cardiovascular disease, or to investigate abnormal heart tests. Resting left ventricular (LV) function is not a consistent predictor of perioperative ischemic events; even reduced LV systolic function has poor predictive value for perioperative cardiac events.
Avoid using stress echocardiograms on asymptomatic patients who meet “low risk” scoring criteria for coronary disease.
Stress echocardiography is mostly used in symptomatic patients to assist in the diagnosis of obstructive coronary artery disease. There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors.
Avoid transesophageal echocardiography (TEE) to detect cardiac sources of embolization if a source has been identified and patient management will not change.
Tests whose results will not alter management should not be ordered. Protocol-driven testing can be useful if it serves as a reminder not to omit a test or procedure, but should always be individualized to the particular patient. While TEE is safe, even the small degree of risk associated with a procedure is not justified if there is no expected clinical benefit.
Society of Cardiovascular CT
Don’t use coronary CT angiography (CTA) in high risk* emergency department patients presenting with acute chest pain.
To date, randomized controlled trials evaluating use of coronary CTA angiography for individuals presenting with acute chest pain in the emergency department have been limited to low or low-intermediate risk individuals.
Society of Nuclear Medicine and Molecular Imaging
Don’t use PET/CT for cancer screening in healthy individuals.
The likelihood of finding cancer in healthy adults is extremely low (around 1%), based on studies using PET/CT for screening. Imaging without clear clinical indication is likely to identify harmless findings that lead to more tests, biopsy or unnecessary surgery.
Don’t perform routine annual stress testing after coronary artery revascularization.
Routine annual stress testing in patients without symptoms does not usually change management. This practice may lead to unnecessary testing without any proven impact on patient management.
Don’t use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.
Nuclear medicine thyroid scanning does not conclusively determine whether thyroid nodules are benign or malignant. Cold nodules on thyroid scans will still require biopsy. Nuclear medicine thyroid scans are useful to evaluate the functional status of thyroid nodules in patients who are hyperthyroid.
Avoid using a CT angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.
When the clinical question is whether or not pulmonary emboli are present, a V/Q study can provide the answer with lower overall radiation dose to the breast than can CTA, even when performed with a breast shield.
Don’t use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in this field.
Without objective evidence of dementia, the potential benefit of PET is unlikely to justify the cost or radiation risk. Dementia subtypes have overlapping patterns in PET imaging. Clinical evaluation and imaging often provide additive information and should be assessed together to make a reliable diagnosis and to plan care. For β-amyloid PET imaging, it is not currently known what a positive PET result in a cognitively normal person means; this method is not established for an individual prediction.
The Society of Thoracic Surgeons
Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
Carotid stenosis with symptoms (stroke or transient ischemic attacks [TIA]) is a known risk for cardiovascular accident and appropriate for preoperative testing. The presence of a carotid bruit does not equate to an increased risk of stroke after cardiac surgery. Patients with carotid stenosis have a higher rate of cerebrovascular complications after cardiac surgery, but there is no evidence that prophylactic or concomitant carotid surgery decreases this rate of complications in asymptomatic patients. ACC/American Heart Association (P) 2011 guidelines for coronary artery bypass graft surgery indicate carotid artery duplex scanning is reasonable in selected patients who are considered to have high-risk features. However, this was based on a consensus and a low level of evidence. In addition, a recent consensus report from the United Kingdom questioned whether neurologic sequellae developing in cardiac surgery patients with asymptomatic carotid disease are due to the carotid artery disease or rather act as a surrogate for an increased stroke risk from atherosclerotic issues with the aorta. The Northern Manhattan Stroke Study concluded that carotid auscultation had poor sensitivity and positive predictive value for carotid stenosis and so decisions on obtaining carotid duplex studies should be considered based on symptoms or risk factors rather than findings on auscultation.
Don’t perform a routine pre-discharge echocardiogram after cardiac valve replacement surgery.
Pre-discharge cardiac echocardiography is useful after cardiac valve repair. It provides information regarding the integrity of the repair and allows the opportunity for early identification of problems that may need to be addressed surgically during the index hospitalization. Unlike valve repair, there is a lack of evidence that supports the routine use of cardiac echocardiography pre-discharge after cardiac valve replacement. Scenarios that would justify the use of pre-discharge cardiac echocardiography include: inability to perform intraoperative transesophageal echocardiography, clinical signs and symptoms worrisome for valvular malfunction or infection, or a large pericardial effusion.
Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.
PFTs can be helpful in determining risk in cardiac surgery, but patients with no pulmonary disease are unlikely to benefit and do not justify testing. Symptoms attributed to cardiac disease that are respiratory in nature should be better characterized with PFTs. Risk models for cardiac surgery developed from review of The Society of Thoracic Surgeons Adult Cardiac Surgery Database incorporate a variable for chronic lung disease. Only recently have actual forced expiratory volume (FEV1) and carbon monoxide diffusing capacity (DLCO) data been collected in the database. In the absence of respiratory symptoms or suggestive medical history, pulmonary function testing is quite unlikely to change patient management or assist in risk assessment. Although some data are beginning to emerge about preoperative pulmonary rehabilitation prior to cardiac surgery for patients with even mild to moderate obstructive disease, this does not directly extrapolate to asymptomatic patients.
Society for Vascular Medicine
Refrain from percutaneous or surgical revascularization of peripheral artery stenosis in patients without claudication or critical limb ischemia.
Patients without symptoms will not benefit from attempts to improve circulation. No evidence exists to support improving circulation to prevent progression of disease. There is no proven preventive benefit, only symptomatic benefit.
Don’t screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.
Performing surgery or angioplasty to improve circulation to the kidneys has no proven preventive benefit, and shouldn’t be considered unless there is evidence of symptoms, such as elevated blood pressure or decreased renal function.
American Academy of Neurology
Don’t perform electroencephalography (EEG) for headaches.
EEG has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes and increases cost. Recurrent headache is the most common pain problem, affecting 15% to 20% of people.
Don’t use opioid or butalbital treatment for migraine except as a last resort.
Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments.
American Society for Clinical Pathology
Don’t perform population based screening for 25-OH-Vitamin D deficiency.
Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, CKD, malabsorption, some infections, obese individuals).
Avoid routine preoperative testing for low risk surgeries without a clinical indication.
Most preoperative tests (typically a CBC, Prothrombin Time and Partial Prothomboplastin Time, basic metabolic panel and urinalysis) performed on elective surgical patients are normal. Findings influence management in under 3% of patients tested. I n almost all cases, no adverse outcomes are observed when clinically stable patients undergo elective surgery, irrespective of whether an abnormal test is identified. Preoperative testing is appropriate in symptomatic patients and those with risks factors for which diagnostic testing can provide clarification of patient surgical risk.
American Academy of Allergy, Asthma & Immunology
Don’t order sinus CT or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinsutis.
Don’t diagnose or manage asthma without spirometry.
Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.
American Academy of Ophthalmology
Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.
For many, preoperative tests are not necessary because eye surgeries are not lengthy and don’t pose serious risks. An EKG should be ordered if patients have heart disease. A blood glucose test should be ordered if patients have diabetes. A potassium test should be ordered if patients are on diuretics. In general, patients scheduled for surgery do not need medical tests unless the history or physical examination indicates the need for a test, e.g., the existence of conditions noted above. Institutional policies should consider these issues.
Don’t routinely order imaging tests for patients without symptoms or signs of significant eye disease.
If patients do not have symptoms or signs of significant disease pathology, then clinical imaging tests are not generally needed because a comprehensive history and physical examination will usually reveal if eye disease is present or is getting worse. Examples of routine imaging include: visual-field testing; optical coherence tomography (OCT) testing; retinal imaging of patients with diabetes; and neuro imaging or fundus photography. If symptoms or signs of disease are present, then imaging tests may be needed to evaluate further and to help in treatment planning.
Don’t order antibiotics for adenoviral conjunctivitis (pink eye).
Adenoviral conjunctivitis and bacterial conjunctivitis are different forms of infection that can be diagnosed by the ophthalmologist by clinical signs and symptoms, and if needed, by cultures. Antibiotics are useful for patients with bacterial conjunctivitis, particularly those with moderate to severe bacterial conjunctivitis. However, they are not useful for adenoviral conjunctivitis, and the overuse of antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments. In cases of diagnostic uncertainty, patients may be followed closely to see if their condition resolves on its own, or if further treatment is required.
Reengineering health care: towards appropriate level of care
Impact of clinical guidelines and financial incentives
Clinical practice guidelines usually advise physicians to screen earlier to detect occult disease. Many physicians believe that early diagnosis and subsequent intervention might improve health . However, in order to prove that early diagnosis and intervention do improve health, physicians use surrogate end points, such as an improvement in the same test that diagnosed the disease in the first place. Detecting subclinical disease in some cases might do harm by leading to false labeling, causing inappropriate treatment, and making people who are otherwise well, feel sick . Perhaps more importantly, the clinical practice guidelines rarely take into account the long-term potential harms of decisions to broaden screening guidelines, and long-term cost considerations. Not only screenings are performed with widespread testing at younger ages, but the definition of disease is also shifting. In a recent US study, expanding the diagnosis of high cholesterol from 6.2 mmol/L to 5.2 mmol/L results in an 82% increase in individuals with a diagnosis of dyslipidemia, which represents more than 4.3 million people in the United States .
Furthermore, through primary care reform initiatives, physicians in many jurisdictions are now paid pay-for-performance for many chronic diseases, which entails ordering more tests. These arrangements encourage more testing and more diagnosing, and treating more people. Financial incentives can foster or inhibit the appropriate use of health resources. Skeptics of pay-for-performance arrangements warn that particular care must be taken to ensure that any incentive-based system places a premium on making the most appropriate clinical decisions, instead of the least expensive ones . Physicians’ resistance or cooperation that is cognitively, rather than economically-based, raises a completely different set of incentives.
Many physicians often comply with patient requests for tests whether these are appropriate or not. Patients who come in requesting tests commonly want to be reassured. However, anyone rarely considers the cost consequences of such reassurance. Moreover, there is some evidence that higher levels of patient satisfaction are associated with ordering more tests and procedures or prescribing more medications .
Some researchers suggest that misunderstanding and miscommunication between physicians and patients explain a significant part of why unnecessary and even harmful tests and treatments are ordered [8-14]. For example, many primary care physicians state that pressure from patients leads them to prescribe antibiotics when these are not indicated. Yet studies have shown that patients do not expect antibiotics nearly as often as doctors believe they do [15-17]. Patient satisfaction and understanding are closely related, and physicians can improve patient satisfaction by focusing on understanding. This can be achieved by acknowledging and validating patient concerns while providing factual information in an easy-to-understand manner . Learning the communication skills necessary to enlist patient partnership in collaborative work is important. Clarifying that the risks may outweigh the benefits, and explaining the link between overutilization and cost increases, might prove essential in reengineering patient-physician relationship. Patient-centered approaches that discuss expectations and share information with patients have been shown to reduce antibiotic prescriptions in primary care [19-20].
Earlier diagnoses and more aggressive treatments appeal to most physicians to help patients dealing with uncertainty and to avoid any future lawsuits. In patients with chronic pain, or with enigmatic symptoms, tests and procedures buy time while waiting for the patient’s body to heal on its own or to declare a serious illness. Because tests and procedures are available, physicians and patients use them. These tests might not contribute to diagnosis or treatment, but they make a patient believe that a physician is “doing something”. One of the greatest challenges for physicians is to know when not to test. Perhaps physicians should “go back to the basics” of making a clinical diagnosis based on history and physical examination . This would require reengineering of health care on part of both doctors and patients. Discussions about variation in patterns of care, appropriateness of care, and cost-effective ways of managing finite health care resources, should be carried out more often.
Central to the best practice of medicine becomes comparative-effectiveness research, including long term studies of clinical benefits and costs. Physicians must change practice patterns, through standard-of-practice guidelines, to practice in the most knowledge-based, least invasive, and less costly way. Physicians need to take a leadership role in teaching patients that more medicine is not better medicine, that costly efforts do not equal better health care. We need to explain to patients that new medical technology must be used with care and wisdom.
- Emanuel E., Tanden N., Altman S., Armstrong S., Berwick D., de Brantes F., Calsyn M., Chernew M., Colmers J., Cutler D., Daschle T., Egerman P., Kocher B., Milstein A., Oshima Lee E., Podesta JD., Reinhardt U., Rosenthal M., Sharfstein J., Shortell S., Stern A., Orszag PR., Spiro T. A systemic approach to containing health care spending. N Engl J Med. 2012 Sep 6; 367(10): 949-54
- Lipitz-Snyderman A., Bach PB. Overuse of Health Care Services: When Less Is More . . . More or Less. JAMA Intern Med. 2013 May 27: 1-2
- Chien Alyna T., Rosenthal Meredith B. Waste Not, Want Not: Promoting Efficient Use of Health Care Resources. Annals of Internal Medicine. 2013 Jan; 158(1): 67-68
- Berwick DM., Hackbarth AD. Eliminating waste in US health care. JAMA. 2012 Apr 11; 307(14): 1513-6. doi: 10.1001/jama.2012.362. Epub 2012 Mar 14
- Qaseem A., Alguire P., Dallas P., Feinberg L.E., Fitzgerald FT., Horwitch C., Humphrey L., LeBlond R., Moyer D., Wiese JG., Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17; 156(2): 147-9
- ABIM Foundation: Choosing Wisely. 2012
- Avorn J., Fischer M.: “Bench to behavior”: translating comparative effectiveness research into improved clinical practice. Health Aff (Millwood). 2010; 29(10): 1891-1900
- Korenstein D., Falk R., Howell EA., Bishop T., Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med 2012; 172(2): 171-178
- Welch HG., Schwartz I., Woloshin S. Overdiagnosed-making people sick in the pursuit of health. Beacon Press; Boston, MA; 2011
- Constant A., Peterson S., Mallory CD., Major J. Research synthesis on cost drivers in the health sectors and proposed policy options. Canadian Health Service Research Foundation; Ottawa, ON; 2011
- Kale MS., Bishop TF., Federman AD., Keyhani S.: “Top 5” lists top $5 billion in potential savings. Arch Intern Med 2011; 171(20): 1856-1858
- Fenton JJ., Jerant AF., Bertakis KD., Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012; 172(5): 405-411
- Palfrey S. Daring to practice low-cost medicine in a high-tech era. N Engl J Med 2011; 364(11): e21
- Brook RH. Do physicians need a shopping cart for health care services? JAMA 2012; 307(8): 791-792
- Britten N., Ukoumunne O.: The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire survey. BMJ. 1997; 315(7121): 1506-1510
- Cockburn J., Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ. 1997; 315(7107): 520-523
- Stivers T., Mangione-Smith R., Elliott MN., McDonald L., Heritage J. Why do physicians think parents expect antibiotics? What parents report vs. what physicians believe. J Fam Pract. 2003; 52(2): 140-148
- Mangione-Smith R., McGlynn EA., Elliott MN., McDonald L., Franz CE., Kravitz RL.: Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001; 155(7): 800-806
- Altiner A., Brockmann S., Sielk M., Wilm S., Wegscheider K., Abholz HH. Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother. 2007; 60(3): 638-644
- Gwyn R., Elwyn G. When is a shared decision not (quite) a shared decision? Negotiating preferences in a general practice encounter. Soc Sci Med. 1999; 49 (4): 437-447