In an effort to promote care that is necessary and supported by evidence, nine physician societies on Wednesday identified a total of 45 tests and treatments they say should be questioned by physicians and patients because of the potential for needless cost, waste, and harm.
The "Choosing Wisely" campaign, launched by the American Board of Internal Medicine, has been seeking consensus on types of care that are overused or unnecessary, but which remain the standard of care in many physician practices.
The nine participating groups are:
- American Academy of Allergy, Asthma & Immunology
- American Academy of Family Physicians
- American College of Physicians
- American College of Cardiology
- American College of Radiology
- American Gastroenterological Association
- American Society of Clinical Oncology
- American Society of Nephrology
- American Society of Nuclear Cardiology
"These societies have shown tremendous leadership in starting a long overdue and important conversation between physicians and patient about what care is really needed," said Christine K. Cassel, MD, ABIM Foundation president and CEO in a prepared statement. "Physicians, working together with patients, can help ensure the right care is delivered at the right time for the right patient."
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.
American College of Cardiology
11. 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. Low-risk patients account for 45% of unnecessary "screening." Testing should occur only in the presence of diabetes in patients older than 40, peripheral artery disease or greater than 2% yearly risk for coronary artery disease patients.
12. Don't perform annual stress cardiac imaging or advanced non-invasive imaging as follow-up in asymptomatic patients. This rarely results in any meaningful course of care but may lead to unnecessary invasive procedures and excess radiation exposure. Patients' five years post bypass surgery are an exception.
13. 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 with low-risk, non-cardiac surgery such as cataract removal.
14. Don't perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adults with no change in symptoms.
15. Don't perform stenting of non-culprit lesions during percutaneous coronary intervention for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction. This could increase mortality and complications, although may be beneficial in patients who are hemodynamically unstable.
American College of Physicians
16. Don't obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. It does not improve outcomes.
17. Don't obtain imaging studies with non-specific low back pain. Plain radiography, CT or magnetic resonance imaging does not improve outcomes.
18. In the evaluation of simple syncope and a normal neurological exam, don't obtain brain imaging studies with CT or MRI. The likelihood of central nervous system cause is extremely low and these tests do not improve patient outcomes.
19. In patients with low pretest probability of venous thromboembolism, obtain a high sensitive D-dimer measurement as the initial diagnostic test; don't obtain imaging studies as the initial diagnostic test.
20. Don't obtain preoperative chest radiography in the absence of suspicion for intrathoracic pathology or cardiopulmonary symptoms.
American College of Radiology
21. Don't do imaging for uncomplicated headache. It's not likely to change management or improved outcome unless there are specific risk factors for structural disease.
22. Don't image for suspected pulmonary embolism without moderate or high pre-test probability. Deep-vein thrombosis and PE are rare in the absence of elevated d-Dimer levels and certain risk factors. CT pulmonary angiography has limited value.
23. Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam. Only 2% of these tests lead to change in management.
24. Don't use CT to evaluate suspected appendicitis in children until an ultrasound has been considered. Ultrasound is nearly as good and provides less radiation exposure, preferred for children.
25. Don't recommend follow-up imaging for inconsequential adnexal cysts because in women of reproductive age, they are almost always physiologic. Ovarian cancer does not arise from these benign-appearing cysts. In post menopausal women, use 1 cm as a threshold for simple cysts.
American Gastroenterological Association
26. For pharmacological treatment of patients with gastroesophageal reflux disease, long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest dose to achieve therapeutic goals.
27. Do not repeat colorectal cancer screening by any method for 10 years after a high-quality colonoscopy is negative in average-risk individuals. Screening should begin at 10 year intervals at age 50.
28. 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.
29. For patients with Barrett's esophagus who underwent a second endoscopy confirming absence of dysplasia on biopsy, follow-up exam should not be performed in less than three years.
30. For a patient with functional abdominal pain syndrome, CT scans should not be repeated unless there is a major change in clinical findings or symptoms.
American Society of Clinical Oncology
31. Don't use cancer-directed therapy for solid tumor patients who have low performance status (3 or 4), no benefit from prior evidence-based interventions, are not eligible for a clinical trial, and for whom there is no strong evidence supporting the value of further anti-cancer treatment. The care plan should include appropriate palliative and supportive care.
32. Don't perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer patients at low risk for metastasis. Evidence is lacking that they improve survival or detection of metastatic disease.
33. Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis. These tests are often used in staging low-risk cancers despite a lack of evidence they improve survival or detection of metastatic disease.
34. 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. Serum tumor markers may have clinical value for some cancers such as colorectal, but not breast, and false positives can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation and misdiagnosis.
35. Don't use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication.
American Society of Nephrology
36. Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms unless they are transplant candidates. This includes mammography, colonoscopy, PSA testing, and pap smears. It is neither cost-effective nor does it improve survival.
37. Don't administer erythropoiesis-stimulating agents to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dl without symptoms of anemia. ESAs have no survival or cardiovascular disease benefit and may be harmful. They should be used to maintain hemoglobin at lowest levels that minimize need for transfusion.
38. Avoid nonsteroidal anti-inflammatory drugs in people with hypertension or heart failure or chronic kidney disease of all causes, including diabetes. This can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function. Acetaminophen, tramadol, or short-term narcotic analgesics may be safer.
39. Don't place peripherally inserted central catheters in stage III-V chronic kidney disease patients without consulting nephrology. Excessive venous puncture damages veins. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis.
40. Don't initiate chronic dialysis without ensuring a shared decision-making process between patients, families, and physicians. Limited observational data suggest survival may not differ for older adults with multiple co-morbidities who initiate chronic dialysis versus those who manage their disease conservatively.
American Society of Nuclear Cardiology
41. Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present. Asymptomatic, low-risk patients account for up to 45% of inappropriate stress testing, which should be performed only with patients with the following findings: diabetes in patients older than 40, peripheral arterial disease, and greater than 2% yearly coronary heart disease event rate.
42. Don't perform cardiac imaging for low-risk patients. Chest pain patients at low risk of cardiac death and myocardial infarction based on history, physical exam, electrocardiogram, and cardiac biomarkers do not merit stress radionuclide myocardial perfusion imaging or stress echocardiography initially if they have a normal Electrocardiogram and are able to exercise.
43. Don't perform radionuclide imaging as part of routine follow-up in asymptomatic patients. This practice may lead to unnecessary invasive procedures and excess radiation exposure without improving outcomes.
44. Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low or intermediate risk non-cardiac surgery.
45. Use methods to reduce radiation exposure in cardiac imaging, including not performing such tests when limited benefits are likely.
The Congressional Budget Office estimates that up to 30 percent of care delivered in the United States goes toward unnecessary tests, procedures, doctor visits, hospital stays, and other services that may not improve health.