Choosing Wisely Initiative

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Courtesy of Dr. Michael Jones @treatNstreetEM

Check out this article in the NY Times and the referenced guidelines from the Choosing Wisely initiative:

http://well.blogs.nytimes.com/2013/02/21/doctor-groups-issue-list-of-overused-medical-tests/?ref=health

Some recommendations that I found particularly interesting and useful to us as Emergency Physicians (or for our interns rotating on the medical service):

  1. Don’t order sinus computed tomography (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.
  1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.
  1. 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.
  1. 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.
  2. 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.
  3. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Occlusive carotid artery disease does not cause fainting but rather causes focal neurologic deficits such as unilateral weakness. Thus, carotid imaging will not identify the cause of the fainting and increases cost. Fainting is a frequent complaint, affecting 40% of people during their lifetime.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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, computed tomography (CT) and magnetic resonance imaging (MRI) is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis. Acute rhinosinusitis is defined as up to four weeks of purulent nasal drainage (anterior, posterior or both) accompanied by nasal obstruction, facial pain-pressure-fullness or both. Imaging is costly and exposes patients to radiation. Imaging may be appropriate in patients with a complication of acute rhinosinusitis, patients with comorbidities that predispose them to complications and patients in whom an alternative diagnosis is suspected.
  9. 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.
  10. 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.
  11. Computed tomography (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.
  12. 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.
  13. Computed tomography (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.
  14. 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.
  15. 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.
  16. 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.
  17. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.
  18. 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.
  19. 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 computed tomography (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.
  20. 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.
  21. Don’t do computed tomography (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.
  22. Avoid routine preoperative testing for low risk surgeries without a clinical indication.  Most preoperative tests (typically a complete blood count, 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. In 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.
  23. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or 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.
  24. Don’t use coronary computed tomography angiography in high risk* emergency department patients presenting with acute chest pain. To date, randomized controlled trials evaluating use of coronary computed tomography angiography for individuals presenting with acute chest pain in the emergency department have been limited to low or low-intermediate risk individuals.
    *Risk defined by the Thrombolysis In Myocardial Infarction (TIMI) risk score for unstable angina/acute coronary syndromes.
  25. 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 <2 days for 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.
  26. 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 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.
  27. 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.
  28. Don’t perform repetitive 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.
  29. 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.
  30. 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.
  31. 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.
  32. Avoid using a computed tomography 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.

And one more interesting article from the Times that might make you think twice about ordering a test just to feel better or because some consult service requests it to be certain (i.e. pan-scan):

http://well.blogs.nytimes.com/2013/01/17/the-fallout-of-a-chance-medical-finding/

One Comment

  • sannman

    Good read. Long read. I can think of several occasions where I did the opposite of these recommendations. Certain habits are hard to break (especially stuff like preoperative and admission imaging requests).

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