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Groups Urge Caution on 45 Standards of Care

Cheryl Clark, for HealthLeaders Media, April 5, 2012

American Academy of Allergy, Asthma & Immunology
1. Don't perform unproven diagnostic tests such as immunoglobulin G testing or perform indiscriminate battery of immunoglobulin E tests in the evaluation of allergy diagnosis. These tests are unproven and can lead to inappropriate diagnosis and treatment. Any testing should be based on a patient's clinical history.

2. Don't order sinus CT scans or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis, which is a viral infection. Only .5% to 2% of rhinosinusitis cases progress to bacterial infections, and most resolve without treatment within two weeks. However, if there is a decision to treat with an antibiotic, amoxicillin should be the first line antibiotic used.

3. Don't routinely perform diagnostic testing in patients with chronic urticaria. In overwhelming majority of patients, a definite etiology is elusive. "Routine extensive testing is neither cost-effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor.

4. Don't recommend replacement of immunoglobulin therapy for recurrent infections unless impaired antibody response to vaccines is demonstrated. Gammaglobulin replacement is expensive and does not improve outcomes unless antigen-specific IgG antibody responses to vaccine immunizations or natural infections are impaired. Low levels of immunoglobulins without impaired antigen-specific IgG antibody responses do not indicate a need for immunoglobulin replacement therapy.

5. Don't diagnose or manage asthma without spirometry, which is essential to confirm the diagnosis. Spirometry can stratify disease severity and monitor control. Misdiagnosis can increase costs of care, and delay a correct diagnosis and treatment. 

American Academy of Family Physicians
6. Don't do imaging for low back pain within the first six weeks, unless red flags, such as severe or progressive neurological deficits with such underlying conditions as osteomyelitis, are present or suspected. Imaging in these settings improve outcomes and does increase costs, and low back pain is the fifth most common reason for all physician visits.

7. 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. Most sinusitis in ambulatory settings is due to viral infections that resolve on their own. "Despite constant recommendations to the contrary, antibiotics are prescribed in more than 90% of outpatient visits for acute sinusitis" which accounts for 16 million office visits and $5.8 billion in health care costs per year.

8. 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 because it is not cost-effective in this population.

9. Don't order annual EKGs or any other cardiac screening for low risk patients without symptoms because there is little evidence it improves health outcomes. False positives are likely to result in unnecessary invasive procedures that potentially cause harm through overtreatment and misdiagnosis.

10. Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Pap smears are not helpful in younger women, or in women after non-cancer hysterectomy and there is little evidence for improved outcomes.

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