This has been a busy month for the “Choosing Wisely” campaign, an initiative launched almost two years ago by the American Board of Internal Medicine Foundation and Consumer Reports magazine “to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources in the United States.”
For the campaign, some 35 different medical specialities have been making specific recommendations for reducing or eliminating the use of common health-care services that provide little or no benefit to patients.
On Tuesday, the American Academy of Family Physicians (AAFP) released its latest list of “Choosing Wisely” recommendations, joining several other medical specialties who did the same earlier in the month. By the end of this year, about 250 recommendations will have been made.
That’s an impressive number. But will these lists make a difference? Will they reduce unnecessary medical tests and treatments?
A need to educate ourselves
If there’s been any published data about the effectiveness of the “Choosing Wisely” lists in getting physicians to change their practices, I haven’t seen it yet. I’m sure, though, such studies are in the works. But it’s not just physicians who need to pay attention to these recommendations. All the rest of us should do so as well. Too many of us demand unnecessary treatments and tests from our doctors, whether it be antibiotics for sinusitis or an MRI for knee pain.
We need to educate ourselves to have more informed conversations with our health-care practitioners.
Here, then, are Tuesday’s AAFP’s recommendations (along with their explanations), followed by a sampling of some of the recommendations made by other medical specialties earlier this month:
- Don’t prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable. The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child’s age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child.
- Don’t perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2-24 months. [A VCUG is a special kind of x-ray examination of the bladder.] The risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI.
- Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. There is convincing evidence that PSA-based screening leads to substantial overdiagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.
- Don’t screen adolescents for scoliosis. There is no good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The potential harms of screening and treating adolescents include unnecessary follow-up visits and evaluations resulting from false-positive test results and psychological adverse effects.
- Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications. Hormonal contraceptives are safe, effective, and well tolerated for most women. Data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptives. Hormonal contraception can be safely provided on the basis of medical history and blood-pressure measurement.
From the American Society for Radiation Oncology:
- Don’t initiate management of low-risk prostate cancer without discussing active surveillance. Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients.
From the Society of General Internal Medicine:
- Don’t recommend daily home finger glucose testing in patients with type 2 diabetes who are not using insulin. Although the self-monitoring of blood glucose is important for maintaining glucose control in patients with type 1 diabetes, there is no benefit in patients with type 2 diabetes who are not on insulin or hypoglycemia medications.
- Don’t perform routine general health checks for asymptomatic adults. As opposed to office visits for acute illness or chronic care management, regularly scheduled general health checks without a specific cause have not been shown to be effective in reducing morbidity, mortality or hospitalization.
From the American Academy of Orthopaedic Surgeons:
- Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee. Neither glucosamine nor chondroitin sulfate provide relief for patients with symptomatic osteoarthritis of the knee.
From the American College of Surgeons:
- 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 st able cardiopulmonary diseases in patients older than age 70 who have not had chest radiography within six months.
From the American Psychiatric Association: (The explanations for these two recommendations point out some disturbing statistics on how frequently they are currently not followed.)
- Don’t routinely prescribe two or more antipsychotic medications concurrently. Research shows that use of two or more antipsychotic medications occurs in 4 to 35 percent of outpatients and 30 to 50 percent of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased.
- Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders. Recent research indicates that use of antipsychotic medication in children has nearly tripled in the past 10 to 15 years, and this increase appears to be disproportionate among children with low family income, minority children and children with externalizing behavior disorders (i.e., rather than schizophrenia, other psychotic disorders and severe tic disorders). Evidence for the efficacy and tolerability of antipsychotic medications in children and adolescents is inadequate and there are notable concerns about weight gain, metabolic side effects and a potentially greater tendency for cardiovascular changes in children.
You can download and read all the “Choosing Wisely” lists to date through the initiative’s website.