Listas De "five Things Physicians And Patients Should Question" Publicadas Pelas Sociedades De Especialidades Médicas Americanas

As Sociedades de especialidades médicas dos Estados Unidos publicaram listas de recomendações baseadas em evidências para ajudar médicos e pacientes a tomar decisões mais adequadas com base na sua situação clínica individual, evitando testes e procedimentos desnecessários.
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American Academy of Allergy, Asthma & Immunology Five Things Physicians and Patients Should Question 1 Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy. Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment. Appropriate diagnosis and treatment is both cost e ective and essential for optimal patient care. 2 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. Don’t routinely do diagnostic testing in patients with chronic urticaria. 3 In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost e ective 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 for urticaria. 4 Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated. Immunoglobulin (gammaglobulin) replacement is expensive and does not improve outcomes unless there is impairment of antigen-specific IgG antibody responses to vaccine immunizations or natural infections. Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/ dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin. Don’t diagnose or manage asthma without spirometry. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Academy of Allergy, Asthma & Immunology (AAAAI) Executive Committee created a task force to lead work on Choosing Wisely consisting of board members, the AAAAI President and Secretary/Treasurer and AAAAI participants in the Joint Task Force on Practice Parameters. Through multiple society publications and notifications, AAAAI members were invited to o er feedback and recommend elements to be included in the list. A targeted email was also sent to an extended group of AAAAI leadership inviting them to participate. The work group reviewed the submissions to ensure the best science in the specialty was included. Based on this additional members were recruited for their expertise. Suggested elements were considered for appropriateness, relevance to the core of the specialty, potential overuse of resources and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. Finally, the work group chose its top five recommendations which were then approved by the Executive Committee. AAAAI’s disclosure and conflict of interest policy can be found at www.aaaai.org. Sources 1 Cox L, Williams PB, Sicherer S, et al. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and Immunology/ American Academy of Allergy, Asthma & Immunology Specific IgE Test Task Force. Ann All Asthma Immunol. 2008;101:580-92 Bernstein I, Li J, Bernstein D et al. Allergy diagnostic testing: an updated practice parameter. Ann All Asthma Immunol 2008;100:s1-148. Terr AI. Unconventional theories and unproven methods in allergy. In: Allergy Principles and Practice, 7th Ed, 97:1691-1709. Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis. Cochrane database of systematic reviews 2008:CD000243. American College of Radiology ACR Appropriateness Criteria® for Sinonasal Disease, 2009 http://www.acr.org/SecondaryMainMenuCategories/ quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/SinonasalDisease.aspx; 2009. Wanderer, AA, Bernstein, IL, Goodman, DL, et al. The Diagnosis and Management of Urticaria: a Practice Parameter. Ann Allergy Asthma Immunol 2000;85:521-44. Tarbox JA, Gutta RC, Ching EL, Radojicic C, Lang DM. Utility of routine laboratory testing in management of chronic urticaria/angioedema. Ann Allergy Asthma Immunol 2011, 107: 239-43. 2 & colors 3 Bernstein IL, Li, JT, Bernstein DI et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008 Mar;100(3 Suppl 3):S1-148. and the ABIM Foundation MM, Bossuyt PM, Mekkes JR, Bos JD. Laboratory tests and identified diagnoses in patients with physical and chronic urticaria and angioedema: Kozel logos and A systematic review. J Am Acad Dermatol. 2003 Mar;48(3):409-16. he basic building blocks of each ® n’s graphic identity and areJS et al. Use of intravenous immunoglobulin in human disease: a review of evidence by members of the Primary Immunodeficiency Orange, the Ballow, a “Immunoglobulin Therapy: Replacement and Immunomodulation” in Clinical Immunology, Third Edition Rich RR (Editor), Chapter 85, pp. properly and consistently,M. unique 1265-1280, 2008. 4 ve visual style can be established and Stiehm ER, Orange JS, Ballow M, Lehman H. Therapeutic use of immunoglobulins. Adv Pediatr 2010;57:185-218. sion on the public will be clear and Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. Annals of Allergy, Asthma & Immunology. 2005;94(Suppl 1):S1-S63. . PaNTONe hexadecimal Committee of the American Academy of Allergy, Asthma and Immunology. JACI 117:S525-S553, 2006. ual symbols presented to the public. Approved 2006 005B99 National Asthma Education and Prevention Expert Panel Report 3: Guidelines for the diagnosis and Management of Asthma. NIH Publication Number 301 c traditional color for ABIM logos. To 2007. 08-5846 October Li J, Oppenheimer asthma control. A or consistency, ABIM has chosen theJ, Bernstein IL et al. AttainingR: 0, G: 82 , B: 145practice parameter. J Allergy Clin Immunol. 2005;115:S3-11. C: 100, M: 69, Y: 24, K: 7 Global strategy for olor palettes (pictured on the right) asthma management and prevention: GINA executive summary Eur Respir J 2008 31:143-178. Fuhlbrigge A, M and ABIM Foundation logos, Kitch B, Paltielet D et. al. FEV1 is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107:61-6. 5 Magadle R The Risk of Hospitalization and Near-Fatal and Fatal Asthma in Relation to the Perception of Dyspnea Chest. 2002;121:329-333. based on the Pantone Matching About the American Academy of Allergy, Asthma & Immunology ApprovedThe American Academy of Allergy, Asthma & Immunology (AAAAI) represents allergists, 2006 MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance medical professionalism to improve the health ch as RGB and Hexadecimal, this by collaborating with care system. We achieve physicians and physician leaders, medical trainees, e preferred color format forsystems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® asthma specialists, clinical immunologists, allied health professionals, and others with a special interest in the research and treatment of allergic and immunologic diseases. Established in 1943, the AAAAI has more than 6,500 members in the United States, Canada, and 60 other countries. ation of these specific colors will For more information or questions, please visit www.aaaai.org. ong and consistent information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. For more identity for both PaNTONe 3155 c hexadecimal 006d75 nd the ABIM Foundation. ABIM ations should approve all materials American Academy of Family Physicians Five Things Physicians and Patients Should Question 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 2 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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. American Academy of Family Physicians Five More Things Physicians and Patients Should Question 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. 6 7 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. 8 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. 9 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. 10 Don’t screen women younger than 30 years of age for cervical cancer with 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created (1–5) The American Academy of Family Physicians (AAFP) list is an endorsement of the five recommendations for Family Medicine previously proposed by the National Physicians Alliance (NPA) and published in the Archives of Internal Medicine, as part of its Less is More™ series. The goal was to identify items common in primary care practice, strongly supported by the evidence and literature, that would lead to significant health benefits, reduce risks and harm, and reduce costs. A working group was assembled for each of the three primary care specialties; family medicine, pediatrics and internal medicine. The original list was developed using a modification of the nominal group process, with online voting. The literature was then searched to provide supporting evidence or refute the activities. The list was modified and a second round of field testing was conducted. The field testing with family physicians showed support for the final recommendations, the potential positive impact on quality and cost, and the ease with which the recommendations could be implemented. More detail on the study and methodology can be found in the Archives of Internal Medicine article: The “Top 5” Lists in Primary Care. How This List Was Created (6–10) The American Academy of Family Physicians (AAFP) has identified this list of clinical recommendations for the second phase of the Choosing Wisely campaign. The goal was to identify items common in the practice of family medicine supported by a review of the evidence that would lead to significant health benefits, reduce risks, harms and costs. For each item, evidence was reviewed from appropriate sources such as evidence reviews from the Cochrane Collaboration, and the Agency for Healthcare Research and Quality. The AAFP’s Commission on Health of the Public and Science and Chair of the Board of Directors reviewed and approved the recommendations. In the case of the first two items on our list – “Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age” and “Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable” – we collaborated with the American College of Obstetricians and Gynecologists in developing the final language. AAFP’s disclosure and conflict of interest policy can be found at www.aafp.org. Sources 1 2 3 4 5 6 7 Agency for Health Care Research and Policy (AIICPR), Cochrane Reviews. Center for Disease Control and Prevention (CDC), Cochrane, and Annals of Internal Medicine. U.S. Preventive Services Task Force (USPSTF), American Association of Clinical Endocrinology (AACE), American College of Preventive Medicine (ACPM), National Osteoporosis Foundation (NOF). U.S. Preventive Services Task Force (USPSTF). U.S. Preventive Services Task Force (USPSTF) (for hysterectomy), American College of Obstetrics and Gynecology (ACOG) (for age). Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L (California Maternal Quality Care Collaborative). Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. California: March of Dimes; First edition July 2010. California Department of Public Health; Maternal, Child and Adolescent Health Division; Contract No: 08-85012. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. 450 p. Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:386–97. Gulmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term (review). The Cochrane Collaboration. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub3. Available from: onlinelibrary.wiley.com/doi/10.1002/14651858.CD004945.pub3/abstract;jsessionid=242792D050CDB79D0D80C0F6FDE85031.d02t03 American Academy of Family Physicians. Carotid Artery Stenosis [Internet]. 2007[cited 2012 Oct 10]. Available from: www.aafp.org/online/en/home/clinical/exam/carotidartery.html 8 U.S. Preventive Services Task Force. Screening for Carotid Artery Stenosis [Internet]. 2007 Dec. [Cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspsacas.htm Wolff T, Guirguis-Blake J, Miller T, et al. Screening For Asymptomatic Carotid Artery Stenosis [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Dec. (Evidence Syntheses, No. 50). Available from: www.ncbi.nlm.nih.gov/books/NBK33504/ American Academy of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html 9 U.S. Preventive Services Task Force. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm Vesco KK, Whitlock EP, Eder M, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 May. (Evidence Syntheses, No. 86.) Available from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?book=es86 American Academy of Family Physicians. Cervical Cancer [Internet]. 2012 [cited 2012 Oct 10]. www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html 10 U.S. Preventive Services Task Force. Screening for Cervical Cancer. 2012 Mar. [cited 2012 Oct 10]. Available from: www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm Vesco KK, Whitlock EP, Eder M, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 May. (Evidence Syntheses, No. 86.) Available from: preview.ncbi.nlm.nih.gov/bookshelf/booktest/br.fcgi?book=es86 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy of Family Physicians Founded in 1947, the American Academy of Family Physicians (AAFP) represents 105,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care. Approximately one in four of all doctor’s of ce visits are made to family physicians. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care. For information about health care, health conditions and wellness, please visit the AAFPs award-winning consumer website, www.familydoctor.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Academy of Hospice and Palliative Medicine Five Things Physicians and Patients Should Question Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. 1 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. 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 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Academy of Hospice and Palliative Medicine’s (AAHPM) president appointed a special task force to coordinate the development of the Academy’s recommendations. Chaired by a member of the Board of Directors who had previously overseen AAHPM’s education and training committees, the task force included representatives of the Academy’s Quality and Practice Standards Task Force, Research Committee, Ethics Committee, Public Policy Committee and External Awareness Task Force, as well as at-large appointees that represent distinguished leaders in the field. The task force solicited input from AAHPM’s 17 Special Interest Groups, and task force members also offered their own suggestions for the list. Considering the potential impact and evidence to support the proposed recommendations, the task force identified seven finalists for which a rationale and evidence base was further developed. All AAHPM members were invited to comment on and rank these seven recommendations. Member feedback informed the task force’s final deliberation, which included narrowing the list to the “Five Things” and refining the verbiage of the recommendations. The list was then reviewed and approved by the AAHPM Executive Committee. AAHPM’s disclosure and conflict of interest policy can be found at www.aahpm.org. Sources Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA. 1999;282(14):1365-1370. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000;342(3):206-210. Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: A systematic review. J Am Geriatr Soc. 2011;59(3):463-472. Kuo S, Rhodes RL, Mitchell SL, Mor V, Teno JM. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc. 2009;10(4):264-270. Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: A proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010;58(3):580-584. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209. Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, Elia M. Enteral nutritional support in prevention and treatment of pressure ulcers: A systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422-450. Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012;172(9):697-701. Teno JM, Mitchell SL, Gozalo PL, Dosa D, Hsu A, Intrator O, Mor V. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA. 2010;303(6):544-550. Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, Mor V. Decision-making and outcomes of feeding tube insertion: A five-state study. J Am Geriatr Soc. 2011;59(5):881-886. Delgado-Guay MO, Parson HA, Li Z, Palmer LJ, Bruera E. Symptom distress, intervention and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer. 2009;115:437-445. Elsayem A, Smith ML, Palmer JL, Jenkins R, Reddy S, Bruera E. Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center. J Pall Med. 2006;9:894-902. Elsayem A, Swint K, Fisch MJ, Palmer JL, Reddy S, Walker P, Zhukovsky D, Knight P, Bruera E. Palliative care inpatient services in a comprehensive cancer center: Clinical and financial outcomes. J Clin Oncol. 2004 May 14;22(10):2008-2014. 1 2 Gelfman LP, Meier D, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008 Jul;36f:22-28. Higginson IJ, Finlay IG, Goodwin DM, Hood K, Edwards AG, Cook A, Douglas HR, Normand CE. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manage. 2003;25:150-168. Jordhoy MS, Fayers P, Saltnes T, Ahlner-Elmqvist M, Jannert M, Kaasa S. A palliative care intervention and death at home: A cluster randomized trial. Lancet. 2000 Sep 9;356(9233):888-893. London MR, McSkimming S, Drew N, Quinn C, Carney B. Evaluation of a comprehensive, adaptable, life-affirming, longitudinal (CALL) palliative care project. J Pall Med. 2005;8:1214-1225. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med. 2010;363:733-742. Berger JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634. 3 Goldstein N, Carlson M, Livote E, Kutner J. Brief communication: Management of implantable cardioverter-defibrillators in hospice: A nationwide survey. Ann Intern Med. 2010;152(5):296-299. Goldstein NE, Lampert R, Bradley EH, Lynn J, Krumholz HM. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141(11):835–838. Russo, J. Deactivation of ICDs at the end of life: A systematic review of clinical practices and provider and patient attitudes. Am J Nurs. 2011;111(10):26-35. 4 5 Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, Howell D, Konski A, Kachnic L, Lo S, Sahgal A, Silverman L, von Gunten C, Mendel E, Vassil A, Bruner DW, Hartsell W. Palliative radiotherapy for bone metastases: An ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;79(4),965-976. Smith TJ, Ritter JK, Poklis JL, Fletcher D, Coyne PJ, Dodson P, Parker G. ABH gel is not absorbed from the skin of normal volunteers. J Pain Symptom Manage. 2012;43(5):961-966. Weschules DJ. Tolerability of the compound ABHR in hospice patients. J Palliat Med. 2005;8(6):1135-1143. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy of Hospice and Palliative Medicine The American Academy of Hospice and Palliative Medicine (AAHPM) is the professional organization for physicians specializing in Hospice and Palliative Medicine. AAHPM’s 4,900 members also include nurses and other healthcare providers committed to improving quality of life for patients and families facing life-threatening or serious conditions. AAHPM is dedicated to advancing the discipline of Hospice and Palliative Medicine through professional education and training, development of a specialist workforce, support for clinical practice standards, research and public policy. For more information, visit www.aahpm.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Academy of Neurology Five Things Physicians and Patients Should Question 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. 1 2 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. 3 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. 4 Don’t prescribe interferon-beta or glatiramer acetate to patients with disability from progressive, non-relapsing forms of multiple sclerosis. Interferon-beta and glatiramer acetate do not prevent the development of permanent disability in progressive forms of multiple sclerosis. These medications increase costs and have frequent side effects that may adversely affect quality of life. Don’t recommend CEA for asymptomatic carotid stenosis unless the complication rate is low (<3%). 5 Based on studies reporting an upfront surgical complication rate ranging from 2.3% (ACAS) to 3.1% (ACST) among patients undergoing carotid endarterectomy (CEA) for asymptomatic stenosis of >60%, and an absolute risk reduction for stroke or death of roughly 5–6% in the surgical group at 5 years, several specialty societies (Goldstein et al, 2011; Brott et al, 2011; Chaturvedi et al; Ricotta et al) have recommended that surgery for asymptomatic patients should be reserved for those with a perioperative complication risk of <3% and a life expectancy of greater than 3–5 years. The cited 3% threshold for complication rates may be high because more recent studies have reported lower stroke rates with improvements in both surgical (Brott, 2010) and medical (Marquardt) management. However, there are no recent randomized trials comparing these treatments. Given this, the more recent AHA guidelines (Brott 2011) state that it is “reasonable” to perform CEA for asymptomatic patients with >70% stenosis if the surgical complication rate is “low.” Reported complication rates vary widely by location (Kresowik), and are dependent on how complications are tracked (self-report vs. neurologist’s evaluation vs. administrative data (Wolff T). Despite calls for rigorous monitoring 15 years ago (Goldstein), most patients will likely need to rely on the surgeon’s self-reported rates. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Academy of Neurology (AAN) established a Choosing Wisely Working Group to develop its list of recommendations. Members of this group were selected to broadly represent varying practice settings and neurological subspecialties. Neurologists with methodological expertise in evidence-based medicine and practice guideline development were also included. The working group solicited recommendations from AAN members, which were then rated based upon their judgments of harm and benefit that would result based upon compliance with the recommendation. Based on committee voting and a literature review, candidate recommendations were sent to relevant AAN sections, committees, specialty societies and patient advocacy groups for review and comment. The working group reviewed this feedback and voted on the final Top Five recommendations, which were approved by the AAN Practice Committee and Board of Directors. AAN’s disclosure and conflict of interest policy can be found at www.aan.com. Sources 1 Gronseth GS, Greenberg MK. The utility of the electroencephalogram in the evaluation of patients presenting with headache: a review of the literature. Neurology [Internet]. 1995;45(7):1263-1267. Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, Epstein AE, Friedman P, Goldberger J, Heidenreich PA, Klein GJ, Knight BP, Morillo CA, Myerburg RJ, Sila CA. AHA/ ACCF scientific statement on the evaluation of Syncope: From the American Heart Association councils on clinical cardiology, cardiovascular nursing, cardiovascular disease in the young, and stroke, and the quality of care and outcomes research interdisciplinary working group; and the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society. J Am Coll Cardiol [Internet]. 2006 January 17;47(2):473-84. The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. [Internet]. 2009 Aug 27 Nov;30(21):2631-2671. National Institute for Health and Clinical Excellence. Transient loss of consciousness (‘Blackouts’) Management in adults and young people. [Internet]. London: Royal College of Physicians (UK); 2010 [cited 2012 Oct 25]. Available from: publications.nice.org.uk/transient-loss-of-consciousness-blackouts-management-in-adults-and-young-people-cg109/notes-on-the-scope-of-the-guidance. Silberstein SD; US Headache Consortium. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology [Internet]. 2000;55(6):754-762. 2 3 Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS, European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. Eur J Neurol [Internet]. 2009 Sep;16(9):968-81. Institute for Clinical Systems Improvement. Headache, Diagnosis and Treatment of (Guideline) [Internet]. Bloomington, MN: Institute for Clinical Systems Improvement; 2011 [cited 2012 Oct 25]. Available from: www.icsi.org/headache/headache__diagnosis_and_treatment_of_2609.html. Rice GPA, Incorvaia B, Munari LM, Ebers G, Polman C, D’Amico R, Parmelli E, Filippini G. Interferon in relapsing-remitting multiple sclerosis. Cochrane Database Syst Rev. 2001, Issue 4. Art. No.: CD002002. DOI: 10.1002/14651858.CD002002. 4 La Mantia L, Munari LM, Lovati R. Glatiramer acetate for multiple sclerosis. Cochrane Database Syst Rev. 2010, Issue 5. Art. No.: CD004678. DOI: 10.1002/14651858.CD004678.pub2. La Mantia L, Vacchi L, Di Pietrantonj C, Ebers G, Rovaris M, Fredrikson S, Filippini G. Interferon beta for secondary progressive multiple sclerosis. Cochrane Database Syst Rev. 2012, Issue 1. Art. No.: CD005181. DOI: 10.1002/14651858.CD005181.pub3. Rojas JI, Romano M, Ciapponi A, Patrucco L, Cristiano E. Interferon Beta for Primary Progressive Multiple Sclerosis. Cochrane Database Syst Rev. 2010, Issue 1. Art. No.: CD006643. DOI: 10.1002/14651858.CD006643.pub3. Walker MD, Marler JR, Goldstein M, Grady PA, Toole JF, Baker WH, Castaldo JE, Chambless LE, Moore WS, Robertson JT, Young B, Howard VJ, Marler JR, Purvis S, Vernon DD, Needham K, Beck P, Celani VJ, Sauerbeck L, von Rajcs JA, Atkins D. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (ACAS). JAMA. 1995 May 10;273(18):1421-8. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet [Internet]. 2004 [cited 2013 Jan 3];363(9420):1491-1502. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JV, Pearson TA. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke [Internet]. 2011 Feb [cited 2013 Jan 3];42(2):517-84. Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy: an evidence-based report of the Technology and Therapeutics Committee of the American Academy of Neurology. Neurology [Internet]. 2005 [cited 2013 Jan 3];65:794-801. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg [Internet]. 2011 Sep[cited 2013 Jan 3];54(3)e1-31. 5 Kresowik TF, Bratzler DW, Kresowik RA, Hendel ME, Grund SL, Brown KR, Niladena DS. Multistate improvement in process and outcomes of carotid endarterectomy. J Vasc Surg [Internet]. 2004 [cited 2013 Jan 3];39:372-380. Brott TG, Hobson RW II, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med [Internet]. 2010 Jul 1[cited 2013 Jan 3];363(1):11-23. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke [Internet]. 2010 [cited 2013 Jan 1];41:e11-e7. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor RJ. 2011 ASA/ACCF/AHA/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation [Internet]. 2011[cited 2013 Jan 3];124:e54-e130. Wolff T,Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening For Asymptomatic Carotid Artery Stenosis. Rockville: Agency for Health Care Quality (US). 2007 Dec. Appendix 4-Evidence Table on Complication Rates for Carotid Endarterectomy. Goldstein LB, Moore WS, Robertson JT, Chaturvedi S. Complication rates for carotid endarterectomy—a call to action. Stroke [Internet]. 1997[cited 2013 Jan 3];28(5):889-890. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy of Neurology With more than 25,000 members, the American Academy of Neurology is the world’s largest association of neurologists dedicated to promoting the highest quality patient-centered neurologic care. A neurologist is a doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system such as Alzheimer’s disease, stroke, Parkinson’s disease and epilepsy. The Academy provides valuable resources for neurologists and neuroscience professionals worldwide who look to the Academy for the most comprehensive professional development, career enhancement, and practice improvement opportunities available. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Academy of Ophthalmology Five Things Physicians and Patients Should Question 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 indicate the need for a test, e.g., the existence of conditions noted above. Institutional policies should consider these issues. 1 2 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; ocular coherence tomography (OCT) testing; retinal imaging of patients with diabetes; and neuroimaging 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). 3 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. Don’t routinely provide antibiotics before or after intravitreal injections. 4 The routine use of antibiotics before or after intravitreal injections is unnecessary because research has shown that topical antibiotics don’t prevent the occurrence of eye infection. The risks of antibiotic eye drops include allergic reactions. The overuse and repeated exposure to antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments. Routine antisepsis is appropriate and important for prevention of eye infection. 5 Don’t place punctal plugs for mild dry eye before trying other medical treatments. Medical treatments to address dry eye are available, such as artificial tears, lubrication and hot, moist compresses. These medical methods, as well as ways to modify the environment, should be tried first to improve dry eye and normalize the tear film before using punctal plugs. If the patient’s tear film and eyelids have been treated and dry eye symptoms persist, then punctal plugs can be added. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their ophthalmologist. How This List Was Created The American Academy of Ophthalmology’s Medical Director of Health Policy and Health Policy Committee led the Academy’s list development process. Members of the Health Policy Committee initially identified potential recommendations based on relevance, appropriateness and potential for improvement and efficiency. Through society notifications and newsletter notices, other ophthalmic organizations and subspecialty societies and members were invited to offer feedback and recommend ideas to be included in the final recommendations. Health Policy Committee members and the Medical Director of Health Policy reviewed the ideas and supporting evidence, and ranked them in order of potential impact. The top five recommendations were presented to the Academy’s Board of Trustees for approval. The American Academy of Ophthalmology’s disclosure and conflict of interest policy can be found at www.aao.org. Sources Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. N Engl J Med [Internet]. 2000;342:168-75. Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012, Issue 3. Art. No.: CD007293. DOI: 10.1002/14651858.CD007293.pub3. Bartley GB, Narr BJ. Preoperative medical examinations for patients undergoing ophthalmic surgery. Am J Ophthalmol 1991; 112(6):725-7. 1 Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database of Syst Rev. 2009, Issue 2. Art. No.: CD007293. DOI: 10.1002/14651858.CD007293.pub2. Imasogie N, Wong DT, Luk K, Chung F. Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report. Can J Anesth [Internet]. 2003; 50(3):246-8. Bass EB, Steinberg EP, Luthra R, Tielsch JM, Jowitt JC, Shoukey PD, Petty BG, Feldman MA, Steinwachs DM. Do ophthalmologists, anesthesiologists and internists agree about preoperative testing in healthy patients undergoing cataract surgery? Arch Ophthalmol [Internet]. 1995;113(10):1248-56. American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern® Guidelines. Comprehensive Adult Medical Eye Evaluation [Internet]. San Francisco, CA: American Academy of Ophthalmology;2010 [cited 2012 28 Sep]. Available from: one.aao.org/CE/PracticeGuidelines/ PPP_Content.aspx?cid=64e9df91-dd10-4317-8142-6a87eee7f517. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Idiopathic Macular Hole [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2008 [cited 2012 28 Sep]. Available from: one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=6f2be59d-6481-4c64-9a3e-8d1dabec9ffa. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Age-Related Macular Degeneration [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2008 [cited 2012 28 Sep]. Available from: one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=f413917a-8623-4746-b441-f817265eafb4. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Diabetic Retinopathy [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2008 [cited 2012 28 Sep]. Available from: one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=d0c853d3-219f-487b-a524-326ab3cecd9a. Javitt JC, Canner JK, Frank RG, Steinwachs DM, Sommer A. Detecting and treating retinopathy in patients with Type 1 diabetes mellitus – A health policy model. Ophthalmology. 1990;97(4):483-95. Khalaf SS, Al-bdour MD, Al-Til MI. Clinical biomicroscopy versus fluorescein angiography: effectiveness and sensitivity in detecting diabetic retinopathy. E J Ophthalmol. 2007;17(1):84–88. 2 McDonald HR, Williams GA, Scott IU, Haller JA, Maguire MA, Marcus DM. Laser scanning imaging for macular disease: a report by the American Academy of Ophthalmology. Ophthalmology [Internet]. 2007;114:1221-8. Wilkinson CP. The clinical examination. Limitations and overutilization of angiographic services. Ophthalmology. 1986;93(3):401-4. Wykes WN, Livesay S. Review of fluorescein angiographs performed in one year. Brit J Ophthalmol [Internet].1991;75(7):398–400. Macular Photocoagulation Study Group. Argon laser photocoagulation for neovascular maculopathy. Five-year results from randomized clinical trials. Arch Ophthalmol [Internet]. 1991;109(8):1109-14. Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials. Arch Ophthalmol [Internet]. 1993;111(9):1200-9. Macular Photocoagulation Study Group. Laser photocoagulation for juxtafoveal choroidal neovascularization. Five-year results from randomized clinical trials. Arch Ophthalmol [Internet]. 1994;112(4):500-9. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmol [Internet]. 1985;103(12):1796-806. Early Treatment Diabetic Retinopathy Study Research Group. Focal photocoagulation treatment of diabetic macular edema. Relationship of treatment effect to fluorescein angiographic and other retinal characteristics at baseline: ETDRS report number 19. Arch Ophthalmol [Internet]. 1995;113(9):1144-55. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Conjunctivitis - Limited revision [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2011 [cited 2012 Sep 28]. Available from: www.aao.org/ppp. Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2006 Issue 2. Art No: CD001211. DOI: 10.1002/14651858. CD001211.pub2. 3 American Academy of Ophthalmology, Practicing Ophthalmologists Learning System. Intravitreal injections [Internet]. San Francisco: American Academy of Ophthalmology, 2008 Nov. [cited 2012 Sep 28]; Available from: one.aao.org/CE/PracticeGuidelines/ClinicalStatements_Content.aspx?cid=404813e9-b3dc-4d6d-a2c5-d1f1e78a926b#section4. Bhavsar AR, Googe JM, Stockdale CR Bressler NM, Brucker AJ, Elman MJ, Glassman AR. Diabetic Retinopathy Clinical Research Network. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required. The Diabetic Retinopathy Clinical Research Network Laser-Ranibizumab-Triamcinolone Clinical trials. Arch Ophthalmol [Internet]. 2009 Dec;127(12):1581-3. Scott IU, Flynn HW. The role of topical antibiotic prophylaxis for intravitreal injections. Arch Ophthalmol [Internet]. 2007 Jul;125(7):974-6. Bhatt SS, Stepien KE, Joshi K. Prophylactic antibiotic use after intravitreal injection: Effect on endophthalmitis rate [Internet]. Retina. 2011 Nov;31(10):2032-6. 4 Kim SJ, Toma HS, Midha, Cherney EF, Recchia FM, Doherty TJ. Antibiotic resistance of conjunctiva and nasopharynx evaluation study: A prospective study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2010 Dec(12):117-2372-8. Kim SJ, Toma KS. Ophthalmic antibiotics and antimicrobial resistance. A randomized, controlled study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2011 Jul(7);118:1358–1363. Cheung CSY; Wong AWT, Kertes PJ, Devenyi RG, Lam WC. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmol [Internet]. 2012 Aug:119(8):1609-14. Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injections. Ophthalmol [Internet]. 2012 Jul:119(7):1420-4. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Conjunctivitis - Limited revision [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2011 [cited 2012 Sep 28]. Available from: www.aao.org/ppp. Ervin AM, Wojciechowski R, Schein O. Punctal occlusion for dry eye syndrome. Cochrane Database Syst Rev. 2010, Issue 9. Art. No.: CD006775. DOI: 10.1002/14651858.CD006775.pub2. Altan-Yaycioglu R, Gencoglu EA, Akova YA, Dursun D, Cengiz F, Akman A. Silicone versus collagen plugs for treating dry eye: Results of a prospective randomized trial including lacrimal scintigraphy. Am J Ophthalmol [Internet]. 2005 Jul;140(1):88–93. 5 Nava-Castaneda A, Tovilla-Canales JL, Rodriguez L, Tovilla Y Pomar JL, Jones CE. Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eye. Cornea [Internet]. 2003 Jan;22(1):10-4. Tai MC, Cosar CB, Cohen EJ, Rapuano CJ, Laibson PR. The clinical efficacy of silicone punctal plug therapy. Cornea [Internet]. 2002 Mar;21(3):135-9. Horwath-Winter J, Thaci A, Gruber A, Boldin I. Long-term retention rates and complications of silicone punctal plugs in dry eye. Am J Ophthalmol [Internet]. 2007 Sep;144(3):441-4. Mazow ML, McCall T, Prager TC. Lodged intracanalicular plugs as a cause of lacrimal obstruction. Ophthal Plast Reconstr Surg [Internet]. 2007 Mar-Apr;23(2):138-42. SmartPlug Study Group. Management of complications after insertion of the SmartPlug punctal plug: a study of 28 patients. Ophthalmology [Internet]. 2006 Oct;113(10):1859. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy of Ophthalmology The American Academy of Ophthalmology is the largest national membership association of Eye M.D.s. Eye M.D.s are ophthalmologists, medical and osteopathic doctors who provide comprehensive eye care, including medical, surgical and optical care. Eye M.D.s are dedicated to enhancing the quality of life for every individual they treat by helping each to see his or her best and by protecting their patients’ vision and eye health throughout life. More than 90 percent of practicing U.S. Eye M.D.s are Academy members, and the Academy has more than 7,000 international members. Academy members include experts among all sub-specialties of ophthalmology. For more information, visit www.aao.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Academy of Otolaryngology — Head and Neck Surgery Foundation Five Things Physicians and Patients Should Question Don’t order computed tomography (CT) scan of the head/brain for sudden hearing loss. Computed tomography 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. 1 2 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. 3 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. 4 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. 5 Don’t obtain computed tomography (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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Academy of Otolaryngology—Head and Neck Surgery’s (AAO-HNS) Patient Safety and Quality Improvement (PSQI) Committee was charged with developing the Foundation’s recommendations for the Choosing Wisely campaign. The PSQI Committee initially sought the input of the Specialty Society Advisory Council (SSAC) and requested each member society submit potential topics along with supporting evidence. From those submissions, an initial list of 20 items was distributed to Academy and Foundation committees and the Guidelines Development Task Force (GDTF) for review. PSQI Committee leadership reviewed feedback from the committees and identified six potential recommendations for inclusion in the campaign. The six topics were selected based on their supporting evidence (for example, clinical practice guidelines), committee support, and the current use (frequency) of the test or procedure. The members of SSAC ranked the six topics, and the top five topics were submitted to the Foundation board for approval. AAO-HNS’ disclosure and conflict of interest policy can be found at www.entnet.org. Sources 1 Stachler RJ, Chandrasekhar SS, Archer SM, Rosenfeld RM, Schwartz SR, Barrs DM, Brown SR, Fife TD, Ford P, Ganiats TG, Hollingsworth DB, Lewandowski CA, Montano JJ, Saunders JE, Tucci DL, Valente M, Warren BE, Yaremchuk KL, Robertson PJ. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head Neck Surg [Internet]. 2012 Mar [cited 2012 Oct 18];146(3 Suppl):S1-35. Goldblatt EL, Dohar J, Nozza RJ, Nielsen RW, Goldberg T, Sidman JD, Seidlin M. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol. 1998 Nov 15;46(1-2):91-101. 2 Rosenfeld RM, Schwartz SR, Pynnonen MA, Tunkel DE, Hussey HM, Fichera JS, Grimes AM, Hackell JM, Harrison MF, Haskell H, Haynes DS, Kim TW, Lafreniere DC, LeBlanc K, Mackey WL, Netterville JL, Pipan ME, Raol NP, Schellhase KG. Clinical Practice Guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013; Submitted for publication. Rosenfeld RM, Brown L, Cannon CR, Dolor RJ, Ganiats TG, Hannley M, Kokemueller P, Marcy SM, Roland PS, Shiffman RN, Stinnett SS, Witsell DL. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg [Internet]. 2006 Apr [cited 2012 Oct 18];134(4 Suppl):S4-23. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL.Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg [Internet]. 2007 Sep [cited 2012 Oct 18]:137(3 Suppl):S1-31. Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, Granieri E, Hapner ER, Kimball CE, Krouse HJ, McMurray JS, Medina S, O’Brien K, Ouellette DR, Messinger-Rapport BJ, Stachler RJ, Strode S, Thompson DM, Stemple JC, Willging JP, Cowley T, McCoy S, Bernad PG, Patel MM. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg [Internet]. 2009 Sep [cited 2012 Oct 18];141(3 Suppl 2):S1-S31. 3 4 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy of Otolaryngology— Head and Neck Surgery and Its Foundation The American Academy of Otolaryngology— Head and Neck Surgery is the world’s largest organization representing nearly 12,000 otolaryngologist–head and neck surgeons who treat the ear, nose, throat, and related structures of the head and neck. Medical disorders in this specialty are among the most common affecting patients, young and old. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology–head and neck surgery through education, research, and lifelong learning. For more information, visit www.entnet.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Five Things Physicians and Patients Should Question 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. 1 2 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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Academy of Pediatrics (AAP) employed a three-stage process to develop its list. Using the Academy’s varied online, print and social media communication vehicles, the first stage invited leadership of the Academy’s 88 national clinical and health policy-driven committees, councils and sections to submit potential topics via an online survey. The second stage involved expert review and evaluation of the management groups that oversee the functions of the committees, councils and sections. Based on a set of criteria (evidence to document unproven clinical benefit, potential to cause harm, over-prescribed and utilized, and within the purview of pediatrics) a list of more than 100 topics was narrowed down to five. Finally, the list was reviewed and approved by the Academy’s Board of Directors and Executive Committee. AAP’s disclosure and conflict of interest policy can be found at www.aap.org. Sources American Academy of Pediatrics. Subcommittee on diagnosis and management of bronchiolitis. Pediatrics [Internet]. 2006 Oct;118(4):1774-93. Kelly LF. Pediatric cough and cold preparations. Pediatrics Rev. 2004 April;25(4):115-123. O’Brien KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis – principles of judicious use of antimicrobial agents. Pediatrics [Internet]. 1998;101(supplement):178-81. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Benden C. Clinical practice guideline for the diagnosis and management of Group A Streptococcal Pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis.[Internet]. 2012 Sep 9. Dopi:10.1093/cid/cis629. Williamson IG, Rumsby K, Benge S, Moore M, Smith PW, Cross M, Little P. Antibiotics and topical nasal steroids for treatment of acute maxillary sinusitis: A randomized controlled trial. JAMA [Internet]. 2007;298(21):2487-96. Carr BC. Efficacy, abuse, and toxicity of over-the-counter cough and cold medications in the pediatric population. Currt Opin Pediatrics. 2006 Apr;18(2):184-88. Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, Brown KK, Canning BJ, Chang AB, Dicpinigaitis PV, Eccles R, Glomb WB, Goldstein LB, Graham LM, Hargreave FE, Kvale PA, Lewis SZ, McCool FD, McCrory DC, Prakash UB, Pratter MR, Rosen MJ, Schulman E, Shannon JJ, Smith Hammond C, Tarlo SM; American College of Chest Physicians (ACCP). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1_suppl): 1S-23S. Isbister GK, Prior F, Kilham HA. Restricting cough and cold medications in children. J Paediatr Child Health [Internet] 2012 Feb;48(2):91-8. Schaeffer MK, Shehab N, Cohen AL, Budnitz DS. Adverse events from cough and cold medication in children. Pediatrics [Internet]. 2008 Apr;121(4):783-87. Sharfstein JM, North M, Serwint JR. Over the counter but no longer under the radar – pediatric cough and cold medications. N Eng J Med [Internet]. 2007 Dec 6;357(23):2321-4. Dunning J, Batchelor J, Stratford-Smith P, Teece S, Browne J, Sharpin C, Mackway-Jones K. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child [Internet]. 2004 Jul;89(7):653-9. Kuppermann N, Holmes, JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, WoottonGorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low-risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet [Internet]. 2009 Oct;374(9696):1160-70. Nigrovic LE, Schunk JE, Foerster A, Cooper A, Miskin M, Atabaki SM, Hoyle J, Dayan PS, Holmes JF, Kuppermann N, Traumatic Brain Injury Group for the Pediatric Emergency Care Applied Research Network. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics [Internet]. 2011 Jun;127(6):1067-1073. Oman JA, Cooper RJ, Holmes JF, Viccellio P, Nyce A, Ross SE, Hoffman JR, Mower WR. Performance of a decision-rule to predict need for computed tomography among children with blunt head trauma. Pediatrics [Internet]. 2006 Feb;117(2):e238-46. 1 2 3 4 American Academy of Pediatrics. Subcommittee on Febrile Seizures. Febrile Seizures: Guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics [Internet]. 2011 Feb;127(2):389-394. Brenner DJ, Hall EJ. Computed tomography – an increasing risk of radiation exposure. N Eng J Med [Internet]. 2007 Nov 29;357:2277-2284. Burr A, Renaud EJ, Manno M, Makris J, Cooley E, DeRoss A, Hirsh M. Glowing in the dark: Time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children. J Pediatr Surg [Internet]. 2011 Jan;46(1):188-191. 5 Kim K, Kim YH, Kim SY, Lee YJ, Kim KP, Lee HS, Ahn S, Kim T, Hwang SS, Song KJ, Kang SB, Kim DW, Park SH, Lee KH. Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med [Internet]. 2012 Apr 26;366:1596-1605. Stewart K, Olcott W. Jeffrey RB. Sonography for appendicitis: Nonvisualization of the appendix is an indication for active clinical observation rather than direct referral for computed tomography. J Clin Ultrasound [Internet]. 2012 Oct;40(8):455-61. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Craft AW, Parker L, Berrington de González A. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: A retrospective cohort study. Lancet [Internet] 2012 Aug 4;380(9840):499-505. Saito JM. Beyond appendicitis: Evaluation and surgical treatment of pediatric acute abdominal pain. Curr Opin Pediatr [Internet]. 2012 Jun;24(3):357-364. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Academy Pediatrics The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. ® For more information, visit www.aap.org. For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American College of Cardiology Five Things Physicians and Patients Should Question 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. 1 2 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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American College of Cardiology (ACC) asked its standing clinical councils to recommend between three and five procedures that should not be performed or should be performed more rarely and only in specific circumstances. ACC sta took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the tightest inappropriate score in the AUCs and were Class III recommendations in the guidelines. The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval. ACC’s disclosure and conflict of interest policy can be found at http://www.cardiosource.org/RWI. Sources Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. Hendel RC, Abbott BG, Bateman TM, et al. Role of radionuclide myocardial perfusion imaging for asymptomatic individuals. J Nucl Cardiol. 2011;18:3-15. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. 1 2 Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. & colors and the ABIM FoundationRC, Bermanand Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. 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ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007;50:e159-242. PaNTONe hexadecimal for Echocardiography. the American College of American Heart Association, American Society ve visual style can be established A Report ofSociety of America, HeartCardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography,Medicine, Society of Cardiovascular Computed of and Nuclear Cardiology, Heart Failure Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care sion on the public will be clear and . 005B99 301 c Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria traditional color for ABIM logos. ToReport of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of for Echocardiography. A 4 Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed R: 0, G: 82 B: 145 Tomography, and Society for or consistency, ABIM has chosen the Cardiovascular Magnetic Resonance Endorsed by the, American College of Chest Physicians. J Am Coll Cardiol. 2011 Mar 1;57(9):1126-66. olor palettes (pictured on the right) Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Tomography. J Am Coll Cardiol. 2009 Feb 10;53(6):530-53. C: 100, M: 69, Y: 24, K: 7 M and ABIM5Foundation logos,the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Association, and based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. can be converted into many About the American College of Cardiology: ApprovedThe American College of Cardiology (ACC) is a 40,000-member nonprofit medical society 2006 The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve ch as RGB and Hexadecimal, this by collaborating with physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and patients to foster a shared uter programs, such asof professionalism and how they can understanding Microsoft werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. ation of these specific colors will PaNTONe 3155 c hexadecimal 006d75 ong and consistent identity for both Learn more at www.cardiosource.org/ACC. nd the ABIM Foundation. ABIM ations should approve all materials For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. R: 0, G: 101, B: 120 C: 100, M: 44, Y: 43, K: 15 BIM or the ABIM Foundation logos. The American College of Obstetricians and Gynecologists Five Things Physicians and Patients Should Question 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 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. 1 2 Don’t schedule 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 practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications. 3 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. 4 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 human papillomavirus (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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created As a national medical specialty society, the American College of Obstetricians and Gynecologists relies on the input of any number of its committees in the development of various documents. In the case of the items submitted for the Choosing Wisely® campaign, input from the following committees was solicited: the Committees on Patient Safety and Quality Improvement; Obstetric Practice; and Gynecologic Practice. A literature search was conducted related to the initial list of approximately ten items. We then sent this list to the College’s Executive Board and asked them to select five of the items based on their potential to improve quality and reduce cost. We explained to them that the items were written to avoid complex or clinical terminology, but not at the risk of reducing the value and credibility of the recommendations made. In the case of the first two items on our list – “Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age” and “Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable” – we collaborated with the American Academy of Family Physicians in developing the final language. The College’s disclosure and conflict of interest policy can be found at www.acog.org. Sources 1 Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L (California Maternal Quality Care Collaborative). California: March of Dimes; First edition July 2010. California Department of Public Health; Maternal, Child and Adolescent Health Division; Contract No: 08-85012. Guidelines for perinatal care. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. 7th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2012. Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2009 Aug;114(2 Part 1):386–97. Systematic review: The value of the periodic health evaluation. Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D. Ann Intern Med [Internet]. 2007 Feb 20;146(4):289-300. 2 3 Screening Guidelines for the prevention and early detection of cervical cancer. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FA, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee, American Cancer Society, American Society for Colpoloscopy and Cervical Pathology, and American Society for Clinical Pathology. CA Cancer J Clin [Internet]. 2012 May-Jun;62(3):147–72. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2012 Aug;120:421–4. Screening for cervical cancer. Practice Bulletin No. 131. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012 Nov;120(5):1222-38. 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcionoma in situ. Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. Am J Obstet Gynecol. 2007;197:340-45. Management of abnormal cervical cytology and histology. Practice Bulletin No. 99. American College of Obstetricians and Gynecologists. Obstet Gynecol [Internet]. 2008 Dec;112(6):1419–44. Screening for ovarian cancer: Recommendation statement. U.S. Preventive Services Task Force. Ann Fam Med [Internet]. 2004 May 1;2(3):260–62. Screening for ovarian cancer: Evidence update for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Barton MB, Lin K. [Internet]. Rockville (MD); 2012 Apr. Agency for Healthcare Research and Quality; AHRQ Publication No. 12-05165-EF3. 4 5 Results from four rounds of ovarian cancer screening in a randomized trial. Partridge E, Kreimer AR, Greenlee RT, Williams C, Xu JL, Church TR, Kessel B, Johnson CC, Weissfeld JL, Isaacs C, Andriole GL, Ogden S, Ragard LR, Buys SS; PLCO Project Team. Obstet Gynecol [Internet]. 2009 Apr;113(4):775–82. The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer. Committee Opinion No. 477. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Obstet Gynecol 2011Mar;117(3):742–6. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonpro t membership organization of approximately 56,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. For more information, visit www.acog.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American College of Physicians Five Things Physicians and Patients Should Question 1 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. 2 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. 3 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. 4 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 e ectively excludes VTE and the need for further imaging studies. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American College of Physicians (ACP) formed a workgroup of eleven experienced internal medicine physicians with specific skills in the assessment of evidence. Members of this workgroup included physicians who were current members of the ACP Clinical Guidelines Committee, the Education and Publication Committee, the Board of Governors and the Board of Regents, as well as three ACP sta physicians. The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP sta physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1 percent of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care. Based upon this process, the final top five scenarios were identified. ACP’s disclosure and conflict of interest policy can be found at www.acponline.org. Sources 1 2011 USPSTF screening for coronary heart disease with electrocardiography (draft) guideline; 2011 AAFP recommendations for preventive services guideline; 2010 ACCF/AHA assessment of cardiovascular risk in asymptomatic adults guideline. 2009 NICE low back pain guideline; 2008 ACR Appropriateness Criteria® low back pain guideline; 2007 ACP/APS low back pain guideline; 2007 ACOM low back disorders guideline. 2010 ACR-ASNR CT of the brain guideline; 2010 NICE transient loss of consciousness guideline; 2000 ECS syncope guideline. 2011 ACEP pulmonary embolism guideline; 2008 ESC pulmonary embolism guideline; 2007 AAFP/ACP venous thromboembolism guideline; 2010 SIGN venous thromboembolism guideline. 2 3 4 & colors and the ABIM Foundation logos and 2008 ACR Appropriateness Criteria® for preoperative chest radiography guideline; ASPC patient safety advisory for pulmonary complications of surgery. 5 he basic building blocks of each ® n’s graphic identity and are the Approved 2006 properly and consistently, a unique ual symbols presented to the public. ve visual style can be established and sion on the public will be clear and . PaNTONe 301 c hexadecimal 005B99 traditional color for ABIM logos. To or consistency, ABIM has chosen the olor palettes (pictured on the right) R: 0, G: 82 , B: 145 C: 100, M: 69, Y: 24, K: 7 M and ABIM Foundation logos, based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American College of Physicians: ApprovedThe American College of Physicians (ACP) is the largest medical specialty organization and the second2006 largest physician group in the U.S. ACP’s 132,000 members include internal medicine physicians (internists), subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults. ACP’s mission is to enhance the quality of health care by fostering excellence and professionalism in medicine. ACP provides information and advocacy for its members in internal medicine and related subspecialties. medical professionalism to improve the health ch as RGB and Hexadecimal, this by collaborating with care system. We achieve physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® ation of these specific colors will ong and consistent identity for both PaNTONe 3155 c hexadecimal 006d75 nd the ABIM Foundation. ABIM For more information or questions, please visit www.acponline.org. ations should approve all materials For more information or BIM or the ABIM Foundation logos. to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. C: 100, M: 44, Y: 43, K: 15 R: 0, G: 101, B: 120 BIM Communications for reproduction– American College of Radiology Five Things Physicians and Patients Should Question Don’t do imaging for uncomplicated headache. 1 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. 2 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. 3 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. 4 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-e ective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent. 5 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 <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list. ACR’s disclosure and conflict of interest policy can be found at www.acr.org. Sources Jordan JE, Wippold FJ II, Cornelius RS, Amin-Hanjani S, Brunberg JA, Davis PC, De La Paz RL, Dormont D, Germano I, Gray L, Mukherji SJ, Seidenwurm DJ, Sloan MA, Turski PA, Zimmerman RD, Zipfel GJ, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® headache. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 8 p. http://www.acr.org/SecondaryMainMenuCategories/ quality_safety/app_criteria/pdf/ExpertPanelonNeurologicImaging/HeadacheDoc6.aspx. Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of headache. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2011 Jan. 84 p. 1 Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-Based Guidelines in the Primary Care Setting: Neuroimaging in Patients with Nonacute Headache. American Academy of Neurology. 2000. Available online: http://www.aan.com/professionals/practice/pdfs/gl0088.pdf (US Headache Consortium). Stephen D. Silberstein. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality. Standards Subcommittee of the American Academy of Neurology. 2000;55;754 Neurology. (US Headache Consortium). Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008; 29(18):2276-315. 2 Ne MJ. ACEP releases clinical policy on evaluation and management of pulmonary embolism. American Family Physician 2003; 68 (4): 759–60. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, Sos TA, Quinn DA, Leeper KV, Hull RD, Hales CA, Gottschalk A, Goodman LR, Fowler SE, Buckley JD. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. Radiology 2007; 242 (1): 15–21. American College of Radiology. ACR Appropriateness Criteria: routine admission and preoperative chest radiography. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ ExpertPanelonThoracicImaging/RoutineAdmissionandPreoperativeChestRadiographyDoc6.aspx. Gomez-Gil E, Trilla A, Corbella B, et al. Lack of clinical relevance of routine chest radiography in acute psychiatric admissions. Gen Hosp Psychiatry 2002; 24(2): 110-113. Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth 1993; 40(11): 1022-1027. Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997; 1(12):i-iv; 1-62. Grier DJ, Watson LF, Harnell GG, Wilde P. Are routine chest radiographs prior to angiography of any value? Clin Radiol 1993; 48(2):131-33. American College of Radiology. ACR Appropriateness Criteria: routine chest radiographs in ICU patients http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ ® & colors 3 Gupta SD, Gibbins and and the ABIM Foundation logos FJ, Sen I. Routine chest radiography in the elderly. Age Ageing. 1985; 14(1):11-14. he basic building blocks of each ExpertPanelonThoracicImaging/RoutineChestRadiographDoc7.aspx. n’s graphic identity and are the Wan MJ, et al. Acute appendicitis in young children: cost-e ectiveness of US versus CT in diagnosis-a Markov decision analytic model. Radiology 2009;250:378-86. Garcia K, et al. Suspected appendicitis in children: diagnostic importance of normal abdominopelvic CT findings with nonvisualized appendix. Radiology 2009;250:531-537. Krishnamoorthi R, et al. E ectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259:231-239. ExpertPanelonGastrointestinalImaging/RightLowerQuadrantPainDoc12.aspx. ual symbols presented to the US or CT for diagnosis of appenditicis in children? A meta-analysis. Radiology 2006;241:83-94. Doria AS, et al. public. Approved 2006 properly and consistently, a unique ve visual style can be establishedRadiology. ACR Appropriateness Criteria: right lower quadrant pain/suspected appendicitis. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ American College of and 4 sion on the public will be clearKS, Oldham KT. Imaging of acute appendicitis in children: EU versus U.S. or US versus CT? A North American perspective. Pediatr Radiolo. 2009; 39(5):500-5. and Frush DP. Frush Levine D, Brown DL, Andreotti RF, Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2010 256:943-54. hexadecimal PaNTONe American College of Radiology. ACR Appropriateness Criteria: clinically suspected adnexal masses. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ 301 c 005B99 . traditional color for ABIM logos. To ExpertPanelonWomensImaging/SuspectedAdnexalMassesDoc11.aspx. American College of Obstetricians and 5 R: 0, G: 82 , B: 145 or consistency, ABIM hasGynecol 2002;100(6):1413–1416.Gynecologists. ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. chosen the Obstet American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol 2007;110(1):201–214. olor palettes (pictured on the right) Timmerman D, Valentin L, Bourne TH, et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis C: 100, M: 69, Y: 24, K: 7 M and ABIM Foundation Group. Ultrasound Obstet Gynecol 2000;16(5):500–505. (IOTA) logos, based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American College of Radiology: ApprovedThe mission of the American College of Radiology (ACR) is to serve its 34,000 members in advancing the 2006 quality, safety, and science of radiology and radiation oncology. The ACR conducts cutting-edge clinical and socioeconomic research, establishes quality and safety standards and provides continuing education and advocacy for radiologists, radiation oncologists and medical physicists. Since 1923, the ACR has worked to keep medical imaging and radiation oncology safe, effective and accessible for all. medical professionalism to improve the health care system. We achieve ch as RGB and Hexadecimal, this by collaborating with physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and patients to foster a shared uter programs, such asof professionalism and how they can Microsoft understanding werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® ation of these specific colors will PaNTONe 3155 c hexadecimal 006d75 ong and consistent identity for both For more information or questions, please visit www.acr.org. nd the ABIM Foundation. ABIM ations should approve all materials For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. R: 0, G: 101, B: 120 C: 100, M: 44, Y: 43, K: 15 BIM or the ABIM Foundation logos. American College of Rheumatology Five Things Physicians and Patients Should Question Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease. Tests for anti-nuclear antibody (ANA) sub-serologies (including antibodies to double-stranded DNA, Smith, RNP, SSA, SSB, Scl-70, centromere) are usually negative if the ANA is negative. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA, in the setting of lupus or Sjögren’s syndrome. Broad testing of autoantibodies should be avoided; instead the choice of autoantibodies should be guided by the specific disease under consideration. 1 2 Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in one or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias or fibromyalgia alone are not criteria for musculoskeletal Lyme disease. 3 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). 4 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. 5 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., <2 years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DXA changes do not always correlate with probability of fracture. Therefore, DXAs should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women age 67 and older with normal bone mass may not need additional DXA testing for up to ten years provided osteoporosis risk factors do not significantly change. These items are provided solely for informational purposes and are not intended to replace a medical professional’s independent judgment or be used as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American College of Rheumatology (ACR) established a Top 5 Task Force to oversee the creation of its recommendations. As part of this group’s work, a multistage process combining consensus methodology and literature reviews was used to arrive at the final recommendations. Items were generated by a group of practicing rheumatologists in diverse clinical settings using the Delphi method. Recommendations with high content agreement and perceived prevalence advanced to a survey of ACR members, who comprise more than 90% of the U.S. rheumatology workforce. Based on member input related to content agreement, impact and item ranking, candidate items advanced to literature review. The Top 5 Task Force discussed the items in light of their relevance to rheumatology, level of evidence to support their inclusion, and the member survey results, and drafted the final rheumatology Top 5 list. The list was reviewed by a sample of patients with rheumatic disease and approved by the ACR Board of Directors. For further details regarding these methods, please see the manuscript published in Arthritis Care & Research at www.rheumatology.org/FiveThings. ACR’s disclosure and conflict of interest policy can be found at www.rheumatology.org. Sources Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000;124(1):71–81. 1 Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum 2002;47(4):434-44. Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24. Lyme Disease Diagnosis and Treatment. [Internet]. Atlanta (GA). Centers for Disease Control and Prevention. [Updated 2011 Nov 15; cited 2012 Sep 6]. Available from: www.cdc.gov/lyme/diagnosistreatment/index.html. American College of Physicians. Guidelines for laboratory evaluation in the diagnosis of Lyme disease. Ann Intern Med. 1997;127(12):1106-8 2 Hu LT. Lyme disease. Ann Intern Med 2012;157(3):ITC2-1. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43(9):1089-134. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LM, O’Dell J, Winthrop KL, Beukelman T, Bridges SL, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG . 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken);64(5):625-39. Combe B, Landewe R, Lukas C, Bolosiu HD, Breedveld F, Dougados M, Emery P, Ferraccioli G, Hazes JM, Klareskog L, Machold K, Martin-Mola E, Nielsen H, Silman A, Smolen J, Yazici H. EULAR recommendations for the management of early arthritis: Report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66(1):34–45. Singh JA, Furst DE, Bharat A, Curtis JR, Kavanaugh AF, Kremer JM, Moreland LM, O’Dell J, Winthrop KL, Beukelman T, Bridges SL, Chatham WW, Paulus HE, Suarez-Almazor M, Bombardier C, Dougados M, Khanna D, King CM, Leong AL, Matteson EL, Schousboe JT, Moynihan E, Kolba KS, Jain A, Volkmann ER, Agrawal H, Bae S, Mudano AS, Patkar NM, Saag KG. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken);64(5):625-39. Smolen JS, Landewe R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, Gorter S, Knevel R, Nam J, Schoels M, Aletaha D, Buch M, Gossec L, Huizinga T, Bijlsma JWJW, Burmester G, Combe B, Cutolo M, Gabay C, Gomez-Reino J, Kouloumas M, Kvien TK, Martin-Mola E, McInnes I, Pavelka K, van Riel P, Scholte M, Scott DL, Sokka T, Valesini G, van Vollenhove R, Winthrop KL, Wong J, Zink A, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis;69(6):964-75. Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, Curtis JR, Furst DE, McMahon M, Patkar NM, Volkmann E, Saag KG. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken);62(11):1515-26. National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. (2010). Washington (DC); National Osteoporosis Foundation. 36p. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med;154(5):356-64. 3 4 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American College of Rheumatology More than 50 million Americans, including 300,000 children, suffer from arthritis and rheumatic diseases, and rheumatologists are the specialists in the treatment of those diseases. The American College of Rheumatology represents over 8,500 rheumatologists and rheumatology health professionals around the world. The ACR offers its members the support needed to ensure they are able to continue their innovative research and quality patient care. To nd a rheumatologist in your area, or to learn about the ACR, visit www.rheumatology.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Gastroenterological Association Five Things Physicians and Patients Should Question 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 e ective 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. 1 2 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. 3 Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without highgrade 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. Evidencebased (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).” 4 For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines. In patients with Barrett’s esophagus without dysplasia (cellular changes) the risk of cancer is very low. In these patients, it is appropriate and safe to exam the esophagus and check for dysplasia no more often than every three years because if these cellular changes occur, they do so very slowly. 5 For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Gastroenterological Association (AGA) convened a work group that included members from the Clinical Practice and Quality Management Committee (CPQMC), chair of the Practice Management and Economics Committee (PMEC), the chief medical o cer for the AGA Digestive Health Outcomes Registry® and members of the AGA Institute Governing Board. Ideas for the “five things” were solicited from the workgroup for review by the CPQMC, which developed additional topics, resulting in six draft items. The workgroup continued to pare down and refine the list, before submitting a final draft to both the CPQMC and the PMEC for approval. After final refinements were made to simplify language and avoid complex clinical terminology, the final list was submitted to and approved by the AGA Institute Governing Board. AGA’s disclosure and conflict of interest policy can be found at www.gastro.org. Sources 1 American Gastroenterological Association Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology, 2008. Winawer S et. al. and US Multisociety Task Force on Colorectal Cancer. Colorectal Cancer Screening and Surveillance, Clinical Guidelines and Rationale—Update Based on New Evidence. Gastroenterology, 2003. Rex et. al. Quality indicators for colonoscopy. Gastrointestinal Endoscopy, 2006. Levin B et. al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline From the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology, 2008. Rex et. al. Quality indicators for colonoscopy. Gastrointestinal Endoscopy, 2006. American Gastroenterological Association Medical Position Statement on the Management of Barrett’s Esophagus Gastroenterology. 2 3 & colors 4 Wang KK, Sampliner RE and The Practice Parameters Committee of the American College of Gastroenterology. Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett’s Esophagus, Journal of Gastroenterology, 2008. and the ABIM Foundation logos and he basic building blocks of each Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, et al. , eds. Rome III. The Functional Gastrointestinal Disorders, ® n’s graphic identity and edn.,the 2nd are 2006. ual symbols presented to the public. Approved 2006 Clouse, RE et al. Functional Abdominal Pain Syndrome. Gastroenterology, 2006. properly and consistently, a unique U.S. Food and Drug Administration. Reducing Radiation from Medical X-rays This article appears on FDA’s Consumer Updates page, which features 5 ve visual style can be established FDA-regulated products. Date Posted: February 19, 2009. Accessed at http://www.fda.gov/ForConsumers/ConsumerUpdates/ the latest on all and ucm095505.htm. sion on the public will be clear and . Image Wisely and US Food and Drug Administration. My Medical Imaging History. Access at http://www.radiologyinfo.org/en/safety/ ImageWisely/7678_Medical%20Imaging%20History.pdf. hexadecimal PaNTONe 301 c 005B99 traditional color for ABIM logos. To or consistency, ABIM has chosen the olor palettes (pictured on the right) R: 0, G: 82 , B: 145 C: 100, M: 69, Y: 24, K: 7 M and ABIM Foundation logos, based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American Gastroenterological Association: ApprovedThe American Gastroenterological Association (AGA) is the trusted voice of the GI community. Founded in 2006 medical professionalism to improve the health ch as RGB and Hexadecimal, this by collaborating with care system. We achieve physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® 1897, AGA has grown to include 16,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. Become an AGA fan on Facebook. Join our LinkedIn group. Follow us on Twitter @AmerGastroAssn. ation of these specific colors will ong and consistent identity for both PaNTONe 3155 c hexadecimal 006d75 For more information or questions, please visit www.gastro.org. nd the ABIM Foundation. ABIM ations should approve all materials For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. R: 0, G: 101, B: 120 C: 100, M: 44, Y: 43, K: 15 BIM or the ABIM Foundation logos. American Geriatrics Society Five Things Physicians and Patients Should Question Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers. 1 2 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 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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Geriatrics Society (AGS) established a work group chaired by the Vice Chair of Clinical Practice and Models of Care Committee (CPMC). Work group members were drawn from that committee, as well as the Ethics, Ethnogeriatrics and Quality and Performance Measurement (QPMC) committees. AGS members were invited to submit feedback and recommendations as to what they thought should be included in the list via an electronic survey. The workgroup first narrowed the list down to the top 10 potential tests or procedures. The workgroup then reviewed the evidence and sought expert advice to further refine the list to five recommendations, which were then reviewed and approved by the AGS Executive Committee and the Chairs/Vice Chairs of CPMC, Ethics and QPMC. AGS’ disclosure and conflict of interest policy can be found at www.americangeriatrics.org. Sources Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA. 1999;282(14):1365-1370. Gabriel SE, Normand ST. Getting the methods right – The foundation of patient-centered outcomes research. N Engl J Med [Internet]. 2012 Aug 30;367(9):787-90. Teno JM, Feng Z, Mitchell SL, Kuo S, Intrator O, Mor V. Do financial incentives of introducing case mix reimbursement increase feeding tube use in nursing home residents? J Am Geriatr Soc. [Internet]. 2008 May;56(5):887–890. Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, Mor V. Decision-making and outcomes of feeding tube insertion: A five-state study. J Am Geriatr Soc.[Internet]. 2011 May;59(5):881–886. Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: A proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. [Internet]. 2010 Mar;58(3):580–584. Hanson LC, Carey TS, Caprio AJ, Lee TJ, Ersek M, Garrett J, Jackman A, Gilliam R, Wessell K, Mitchell SL. Improving decision-making for feeding options in advanced dementia: A randomized, controlled trial. J Am Geriatr Soc. [Internet]. 2011 Nov;59(11):2009–2016. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. 1 2 National Institute for Health and Clinical Excellence and Social Care Institute for Excellence NICE-SCIE. National Collaborating Centre for Mental Health. Clinical guidelines #42: Dementia: Supporting people with dementia and their careers in health and social care [Internet]London. 2006 Nov: Amended 2011 Mar [cited 2012 Oct 16]. Available from: www.nice.org.uk/CG042 Maher A, Maglione M, Bagley S, Suttorp M, Hu JH, Ewing B, Wang Z, Timmer M, Sultzer D, Shekelle PG. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: A systematic review and meta-analysis. JAMA [Internet]. 2011 Sep 28;306(12):1359-69. Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao JK, Ismail MS, Lebowitz BD, Lyketsos CG, Ryan JM, Stroup TS, Sultzer DL, Weintraub D, Lieberman JA; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med [Internet]. 2006 Oct 12;355(15):1525-38. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in Type 2 Diabetes. N Eng J Med [Internet]. 2008 Jun 12;258(24):2545–2559. The Action to Control Cardiovascular Risk in Diabetes Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Eng J Med [Internet]. 2011Mar 3;364(9):818–828. Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven P, Zeive FJ, Marks J, David SN, Hayward R, Warren SR, Goldman S, McCarren M, Vitek ME, Henderson WG, Huang GD. Glucose control and vascular complications in veterans with type 2 diabetes. N Eng J Med[Internet]. 2009. 360(2):129–139. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med[Internet]. 2008 Jun 12;358:2560-72. 3 UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet [Internet]. 1998;352:854-65. Montori VM, Fernández-Balsells M. Glycemic control in type 2 diabetes: Time for an evidence-based about-face? Ann Intern Med[Internet]. 2009 Jun 2;150(11):803-8. Erratum in: Ann Intern Med. 2009 Jul 21;151(2):144. PMID: 19380837 Finucane TE. “Tight Control” in geriatrics: The emperor wears a thong. J Am Geriatr Soc [Internet]. 2012 Aug 6;60:1571–1575. Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Nunshi MN, Odegard PS, Pratley RE, Swift CS. Diabetes in older adults: A consensus report. J Am Geriatr Soc. 2012 Oct;60(12):2342-2356. Finkle WD, Der JS, Greenland S, Adams JL, Ridgeway G, Blaschke T, Wang Z, Dell RM, VanRiper KB. Risk of fractures requiring hospitalization after an initial prescription of zolpidem, alprazolam, lorazepam or diazepam in older adults. J Am Geriatr Soc. [Internet]. 2011 Oct;59(10):1883–1890. 4 Allain H, Bentue-Ferrer D, Polard E, Akwa Y, Patat A. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging [Internet]. 2005;22(9):749–765. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. Nordenstam GR, Brandberg CA, Odén AS, Svanborg Edén CM, Svanborg A. Bacteriuria and mortality in an elderly population. N Engl J Med. 1986 May 1;314(18):1152–1156. 5 Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med. 1987Jul;83(1):27–33. Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med [Internet]. 2007 Aug;23(3):585–594. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM; Infectious Diseases Society of America; American Society of Nephrology; American Geriatric Society. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. [Internet]. 2005 Mar 1;40(5):643-65. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Geriatrics Society The American Geriatrics Society (AGS) works to improve the health, independence and quality of life of all older people. Our geriatrics health professional members work together to provide interdisciplinary, patient- and family-centered team care to older adults. The society also works to bring the knowledge and expertise of geriatrics health professionals to the public via www.healthinaging.org. To learn more about the AGS, please visit www.americangeriatrics.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Society of Clinical Oncology Five Things Physicians and Patients Should Question The American Society of Clinical Oncology (ASCO) is a medical professional oncology society committed to conquering cancer through research, education, prevention, and delivery of high-quality patient care. ASCO recognizes the importance of evidence-based cancer care and making wise choices in the diagnosis and management of patients with cancer. After careful consideration by experienced oncologists, ASCO highlights five categories of tests, procedures and/or treatments whose common use and clinical value are not supported by available evidence. These test and treatment options should not be administered unless the physician and patient have carefully considered if their use is appropriate in the individual case. As an example, when a patient is enrolled in a clinical trial, these tests, treatments, and procedures may be part of the trial protocol and therefore deemed necessary for the patient’s participation in the trial. 1 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 anticancer 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 PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis. 2 • 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) <10 ng/ml, Gleason score less than or equal to 6) with low risk of distant metastasis. • Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis. Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis. 3 • 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. 4 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. 5 Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication. • ASCO guidelines recommend using white cell stimulating factors when the risk of febrile neutropenia, secondary to a recommended chemotherapy regimen, is approximately 20 percent and equally effective treatment programs that do not require white cell stimulating factors are unavailable. • Exceptions should be made when using regimens that have a lower chance of causing febrile neutropenia if it is determined that the patient is at high risk for this complication (due to age, medical history, or disease characteristics). Disclaimer: These items are provided solely for informational purposes and are not intended to replace a medical professional’s independent judgement or as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider. New evidence may emerge following the development of these items. ASCO is not responsible for any injury or damage arising out of or related to any use of these items or to any errors or omissions. Abbreviations CT, computed tomography; DCIS, ductal carcinoma in situ; PET, positron emission tomography; PSA, prostate-specific antigen. How This List Was Created The American Society of Clinical Oncology (ASCO) has had a standing Cost of Cancer Care Task Force since 2007. The role of the Task Force is to assess the magnitude of rising costs of cancer care and develop strategies to address these challenges. In response to the 2010 New England Journal of Medicine article by Howard Brody, MD, “Medicine’s Ethical Responsibility for Health Care Reform – the Top Five List,” a subcommittee of the Cost of Cancer Care Task Force began work to identify common practices in oncology that were both common as well as lacking sufficient evidence for widespread use. Upon joining the Choosing Wisely campaign, the members of the subcommittee conducted a literature search to ensure the proposed list of items were supported by available evidence in oncology; ultimately the proposed Top Five list was approved by the full Task Force. The initial draft list was then presented to the ASCO Clinical Practice Committee, a group composed of community-based oncologists as well as the presidents of the 48 state/regional oncology societies in the United States. Advocacy groups were also asked to weigh in to ensure the recommendations would achieve the dual purpose of increasing physician-patient communication and changing practice patterns. A plurality of more than 200 clinical oncologists reviewed, provided input and supported the list. The final Top Five list in oncology was then presented to, discussed and approved by the Executive Committee of the ASCO Board of Directors and published in the Journal of Clinical Oncology. ASCO’s disclosure and conflict of interest policies can be found at www.asco.org. Sources Azzoli CG, Temin S, Aliff T, et al: 2011 focused update of 2009 American Society of Oncology clinical practice guideline update on chemotherapy for stage IV non–small cell lung cancer. J Clin Oncol 29:3825-3831, 2011 Ettinger DS, Akerley W, Bepler G, et al: Non-small cell lung cancer. J Natl Compr Canc Netw 8:740-801, 2010 Carlson RW, Allred DC, Anderson BO, et al: Breast cancer. J Natl Compr Canc Netw 7:122-192, 2009 Smith TJ, Hillner BE: Bending the cost curve in cancer care. N Engl J Med 364:2060-2065, 2011 Peppercorn JM, Smith TJ, Helft PR, et al: American Society of Clinical Oncology statement: Toward individualized care for patients with advanced cancer. J Clin Oncol 29:755-760, 2011 ® & colors 1 Engstrom PF, Benson AB and the ABIM Foundation logos and 3rd, Chen YJ, et al: Colon cancer clinical practice guidelines. J Natl Compr Canc Netw 3:468-491, 2005 he basic building blocks of each n’s graphic identity and are the ual symbols National Comprehensive properly and consistently, a unique Cancer Network: NCCN clinical practice guidelines in oncology (NCCN guidelines)-Prostate cancer. Version 4.2011 Thompson I, Thrasher JB, Aus G, et al: Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 177:2106-2130, 2007 2 Makarov DV, Desai RA, Yu JB, et al: The population level prevalence and correlates of appropriate and inappropriate imaging to stage incident prostate cancer in the Medicare population. J Urol presented to the public. 187:97-102, 2012 Approved 2006 ve visual style can be established and 3 Carlson RW, Allred DC, sion on the public will be clear and Anderson BO, et al: Invasive breast cancer. J Natl Compr Canc Netw 9:136-222, 2011 Locker GY, Hamilton S, Harris J, et al: ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol 24:5313-5327, 2006 Desch CE, Benson AB 3rd, Somerfield MR, et al: Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. J Clin Oncol 23:8512-8519, 2005 hexadecimal PaNTONe 005B99 301 c Carlson RW, Allred DC, Anderson BO, et al: Breast cancer. J Natl Compr Canc Netw 7:122-192, 2009 . 4 traditional color for ABIM logos. To Khatcheressian JL, Wolff AC, Smith TJ, et al: American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guideline in the adjuvant setting. J Clin Oncol 24: 5091-5097, 2006 or consistency, ABIM has chosen the R: 0, G: 82 , B: 145 olor palettes (pictured on the right) 24:3187-3205, 2006 Harris L, Fritsche H, Mennel R, et al: American Society of Clinical Oncology 2007 Y: 24, of recommendations for the use of tumor markers in breast cancer. J Clin Oncol 25:5287-5312, 2007 C: 100, M: 69, update K: 7 Smith logos, M and ABIM5Foundation TJ, Khatcheressian J, Lyman GH, et al: ASCO 2006 update of recommendations for the use of white blood cell growth factors: An evidence based clinical practice guideline. J Clin Oncol based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American Society of Clinical Oncology: ApprovedThe American Society of Clinical Oncology (ASCO) is the world’s leading professional 2006 medical professionalism to improve the health ch as RGB and Hexadecimal, this by collaborating with care system. We achieve physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ation of these specific colors will PaNTONe 3155 c ong and consistent identity for both nd the ABIM Foundation. ABIM organization representing physicians who care for people with cancer. With more than 30,000 members, ASCO is committed to improving cancer care through scientific meetings, educational programs ® and peer-reviewed journals. ASCO is supported by its affiliate organization, the Conquer Cancer Foundation, which funds ground-breaking research and programs that make a tangible difference in the lives of people with cancer. ASCO’s membership is comprised of clinical oncologists from all oncology disciplines and sub-specialties including medical oncology, therapeutic radiology, surgical oncology, pediatric oncology, gynecologic oncology, urologic oncology, and hematology; physicians and health care professionals participating in approved oncology training programs; oncology nurses; and hexadecimal other health care practitioners with a predominant interest in oncology. 006d75 For more information, please visit www.asco.org. ations should approve all materials BIM or the ABIM Foundation logos. R: 0, G: 101, B: 120 C: 100, M: 44, Y: 43, K: 15 BIM Communications for reproduction– © 2012 American Society of Clinical Oncology. All rights reserved. ies and digital images of the logos. For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Society for Clinical Pathology Five Things Physicians and Patients Should Question 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, chronic kidney disease, malabsorption, some infections, obese individuals). 1 Don’t perform low risk HPV testing. 2 National guidelines provide for HPV testing in patients with certain abnormal Pap smears and in other select clinical indications. The presence of high risk HPV leads to more frequent examination or more aggressive investigation (e.g., colposcopy and biopsy). There is no medical indication for low risk HPV testing (HPV types that cause genital warts or very minor cell changes on the cervix) because the infection is not associated with disease progression and there is no treatment or therapy change indicated when low risk HPV is identified. Avoid routine preoperative testing for low risk surgeries without a clinical indication. 3 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. 4 Only order Methylated Septin 9 (SEPT9) to screen for colon cancer on patients for whom conventional diagnostics are not possible. Methylated Septin 9 (SEPT9) is a plasma test to screen patients for colorectal cancer. Its sensitivity and specificity are similar to commonly ordered stool guaiac or fecal immune tests. It offers an advantage over no testing in patients that refuse these tests or who, despite aggressive counseling, decline to have recommended colonoscopy. The test should not be considered as an alternative to standard diagnostic procedures when those procedures are possible. 5 Don’t use bleeding time test to guide patient care. The bleeding time test is an older assay that has been replaced by alternative coagulation tests. The relationship between the bleeding time test and the risk of a patient’s actually bleeding has not been established. Further, the test leaves a scar on the forearm. There are other reliable tests of coagulation available to evaluate the risks of bleeding in appropriate patient populations. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Society for Clinical Pathology (ASCP) list was developed under the leadership of the chair of ASCP’s Institute Advisory Committee and Past President of ASCP. Subject matter and test utilization experts across the fields of pathology and laboratory medicine were included in this process for their expertise and guidance. The review panel examined hundreds of options based on both the practice of pathology and evidence available through an extensive review of the literature. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is harmful; use of the test is costly and it does not provide higher quality care; and, eliminating it or changing to another test is within the control of the clinician. The final list is not exhaustive (many other tests/procedures were also identified and were also worthy of consideration), but the recommendations, if instituted, would result in higher quality care, lower costs, and more effective use of our laboratory resources and personnel. ASCPs’ disclosure and conflict of interest policy can be found at www.ascp.org. Sources Sattar N, Welsh P, Panarelli M, Forouchi NG. Increasing requests for vitamin D measurement: Costly, confusing, and without credibility. Lancet [Internet]. 2012 Jan 14 [cited 2012 Oct 12];379:95-96. 1 Bilinski K, Boyages S. The rising cost of vitamin D testing in Australia: time to establish guidelines for testing. Med J Aust [Internet]. 2012 Jul 16 [cited 2012 Oct 12];197 (2):90. Lu CM. Pathology consultation on vitamin D testing: Clinical indications for 25(OH) vitamin D measurement [Letter to the editor]. Am J Clin Pathol [Internet]. 2012 May [cited 2012 Oct 12];137:831. Holick M, Binkely N, Bischoll-Ferrari H, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab [Internet]. 2011 Jul [cited 2012 Oct 12];96(7):1911-1930. Lee JW, Berkowitz Z, Saraiya M. Low-risk human papillomavirus testing and other non recommended human papillomavirus testing practices among U.S. health care providers. Obstet Gynecol. 2011 Jul;118(1):4-13. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FA, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and early Detection of Cervical Cancer. Am J Clin Pathol [Internet]. 2012 May-Jun [cited 2012 Oct 12];137:516-542. Zhao C, Chen X, Onisko A, Kanbour A, Austin RM. Follow-up outcomes for a large cohort of U.S. women with negative imaged liquid-based cytology findings and positive high risk human papillomavirus test results. Gynecol Oncol [Internet]. 2011 Aug [cited 2012 Oct 12];122:291–296. American Society for Colposcopy and Cervical Pathology. Descriptions of new FDA-approved HPV DNA tests. HPV Genotyping Clinical Update.[Internet]. Frederick (MD): American Society for Colposcopy and Cervical Pathology. 2009. [Cited 2012 Oct 12]. Available from: www.asccp.org/ConsensusGuidelines/HPVGenotypingClinicalUpdate/tabid/5963/Default.aspx. Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database of Systematic Reviews. 2012, Issue 3. Art. No.: CD007293. DOI: 10.1002/14651858.CD007293.pub3. Katz R, Dexter F, Rosenfeld K, Wolfe L, Redmond V, Agarwal D, Salik I, Goldsteen K, Goodman M, Glass PS. Survey study of anesthesiologists’ and surgeons’ ordering of unnecessary preoperative laboratory tests. Anesth Analg. 2011 Jan;112(1). 2 3 Munro J, Booth A, Nicholl J. Routine preoperative testing: A systematic review of the evidence. Health Technol Assessmen. 1997;1(12). Reynolds TM. National Institute for Health and Clinical Excellence guidelines on preoperative tests: The use of routine preoperative tests for elective surgery. Ann Clin Biochem [Internet]. 2006 Jan [cited 2012 Oct 12];43:13-16. Capdenat Saint-Martin E, Michel P, Raymond JM Iskandar H, Chevalier C, Petitpierre MN, Daubech L, Amouretti M, Maurette P. Description of local adaptation of national guidelines and of active feedback for rationalizing preoperative screening in patients at low risk from anaesthetics in a French university hospital. Qual Health Care [Internet]. 1998 Mar [cited 2012 Oct 12];7:5-11. Rösch T, Church T, Osborn N, Wandell M, Lofton-Day C, Mongin S, Blumenstein BA, Allen JI, Snover D, Day R, Ransohoff DF. Prospective clinical validation of an assay for methylated SEPT9 DNA for colorectal cancer screening in plasma of average risk men and women over the age of 50. Gut. 2010;59(suppl III):A307. Ahlquist DA, Taylor WR, Mahoney DW, Zou H, Domanico M, Thibodeau SN, Boardman LA, Berger BM, Lidgard GP. The stool DNA test is more accurate than the plasma septin 9 test in detecting colorectal neoplasia. Clin Gastroenterol Hepatol. [Internet]. 2012 Mar [cited 2012 Oct 12];10(3):272-7. Lehman CM, Blaylock RC, Alexander DP, Rodges GM. Discontinuation of the bleeding time test without detectable adverse clinical impact. Clin Chem [Internet]. 2001;47(7) [cited 2012 Oct 12]:1204-1211. 4 5 Peterson P, Hayes TE, Arkin CF, Bovill EG, Fairweather RB, Rock WA Jr, Triplett DA, Brandt JT. The preoperative bleeding time test lacks clinical benefit. Arch Surg [Internet]. 1998 Feb [cited 2012 Oct 20];133(2):134-139. Lind SE. The bleeding time does not predict surgical bleeding. Blood [Internet]. 1991 Jun [cited 2012 Oct 20]; 77(12):2547-52. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Society for Clinical Pathology Founded in 1922 in Chicago, the American Society for Clinical Pathology (ASCP) is a medical professional society with more than 100,000 member board-certi ed anatomic and clinical pathologists, residents and fellows, laboratory professionals, and students. ASCP provides excellence in education, certi cation, and advocacy on behalf of patients, pathologists, and laboratory professionals. For more information, visit www.ascp.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Society of Echocardiography Five Things Physicians and Patients Should Question 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. 1 2 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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Society of Echocardiography (ASE) identified these interventions after careful review of evidence and clinical guidelines. In particular, ASE’s cardiovascular care experts reviewed the ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriateness Use Criteria for Echocardiography (AUC), which was published in March 2011. ASE’s cardiovascular care scenarios were chosen based on the highest likelihood of improving patient care and reducing inappropriate test use. Leaders in the organization transformed the scenarios into plain language and produced the clinical explanations for each procedure. ASE’s disclosure and conflict of interest policy can be found at www.asecho.org. Sources 1 Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol 2008;52:e1–142. Available from: content.onlinejacc.org/article.aspx?articleid=1139232. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009;54:e13–118. Available from: content.onlinejacc.org/article.aspx?articleid=1140211. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67. 2 3 4 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr., Fihn SD, Fraker TD Jr., Gardin JM, O’Rourke RA, Pasternak RC,Williams SV. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. Available from: www.cardiosource.org/~/media/Images/ACC/Science%20and%20Quality/Practice%20Guidelines/s/stable_clean.ashx. Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JMcB, Kushner FG, Lauer MS, Shaw LJ, Smith SC, Jr., Taylor AJ, Weintraub WS, Wenger NK. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010;56:e50–103. Available from: content.onlinejacc.org/article.aspx?articleid=1143997. Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67. 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Society of Echocardiography As the largest global organization for cardiovascular ultrasound imaging, the American Society of Echocardiography (ASE) is the leader and advocate, setting clinical standards and guidelines with a commitment to improving the practice for better patient outcomes. ASE is devoted to ensuring patient access to excellence in the practice of Echocardiography around the world. Echocardiography provides an exceptional view of the cardiovascular system to safely and cost-effectively enhance patient care. Full text of ASE’s guidelines is available at www.asecho.org/guidelines. For more information about ASE, visit www.asecho.org. For patient-speci c information on the practice of echocardiography, visit www.seemyheart.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. American Society of Nephrology Five Things Physicians and Patients Should Question Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. 1 Due to high mortality among end-stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen (PSA) and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost e ective 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. 2 Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia. Administering ESAs to CKD patients with the goal of normalizing hemoglobin levels has no demonstrated survival or cardiovascular disease benefit, and may be harmful in comparison to a treatment regimen that delays ESA administration or sets relatively conservative targets (9–11 g/dL). ESAs should be prescribed to maintain hemoglobin at the lowest level that both minimizes transfusions and best meets individual patient needs. 3 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 e ective, 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 e ective as NSAIDs. 4 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. 5 Don’t initiate chronic dialysis without ensuring a shared decisionmaking 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 di er substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Society of Nephrology (ASN) maintains a Quality and Patient Safety (QPS) Task Force that advances ASN’s commitment to providing high-quality care to patients and to raising awareness of patient safety issues for all professionals administering care to kidney patients. Each of ASN’s 10 advisory groups contributes expertise to the task force to ensure it addresses all areas of nephrology practice, and the society’s president, public policy board and council also provide insights. The QPS task force centered its focus on five items most likely to positively impact and influence optimal patient care. The final list of five items was unanimously approved by the ASN public policy board and council. ASN’s disclosure and conflict of interest policy can be found at www.asn-online.org. Sources 1 2 U.S. Renal Data System, American Society of Nephrology, American Society of Transplantation, Archives of Internal Medicine, Seminars in Dialysis. U.S. Food and Drug Administration, The New England Journal of Medicine (multiple publications). National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Chronic Kidney Disease; Chronic Kidney Disease in Adults: UK Guidelines for Identification, Management and Referral; American Heart Association; Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; Scottish Intercollegiate Guidelines Network on Management of Chronic Heart Failure. Fistula First Breakthrough Initiative – National Coalition Recommendation for the Minimal Use of PICC Lines, American Society of Diagnostic and interventional Nephrology: Guidelines for Venous Access in Patients with Chronic Kidney Disease, Seminars in Dialysis, National Kidney Foundation Clinical Practice Guidelines for Vascular Access, The Renal Network, Inc. PICC Line Resource Toolkit, Clinical and Experimental Nephrology. 3 4 & colors 5 Renal Physicians’ Association End-of-Life Care Guidelines, Pediatric Nephrology, Clinical Journal of the American Society of Nephrology, Journal of Pediatrics, Nephrology Dialysis Transplantation, Archives of Internal Medicine, Nephrology Dialysis and Transplant, New England Journal of Medicine, and the ABIM Foundation logos and Palliative Medicine. ® he basic building blocks of each n’s graphic identity and are the Approved 2006 properly and consistently, a unique ual symbols presented to the public. ve visual style can be established and sion on the public will be clear and . PaNTONe 301 c hexadecimal 005B99 traditional color for ABIM logos. To or consistency, ABIM has chosen the olor palettes (pictured on the right) R: 0, G: 82 , B: 145 C: 100, M: 69, Y: 24, K: 7 M and ABIM Foundation logos, based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American Society of Nephrology: ApprovedThe American Society of Nephrology (ASN) represents nearly 14,000 professionals 2006 medical professionalism to improve the health care system. We achieve ch as RGB and Hexadecimal, this by collaborating with physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® ation of these specific colors will PaNTONe 3155 c hexadecimal 006d75 committed to curing kidney disease. The Choosing Wisely campaign reflects ASN’s commitment to the highest quality care for the millions of kidney patients worldwide. ASN provides the most highly regarded education in kidney medicine, supports key kidney research, and advocates daily for policies that improve patients’ lives and equip professionals to help those with kidney disease achieve the highest quality of life. For more information or questions, please visit www.asn-online.org. ong and consistent identity for both nd the ABIM Foundation. ABIM ations should approve all materials For more information or BIM or the ABIM Foundation logos. to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. C: 100, M: 44, Y: 43, K: 15 R: 0, G: 101, B: 120 BIM Communications for reproduction– American Society of Nuclear Cardiology Five Things Physicians and Patients Should Question 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 percent of inappropriate stress testing. Testing should be performed only when the following findings are present: diabetes in patients older than 40 years old, peripheral arterial disease, and greater than 2 percent yearly coronary heart disease event rate. 1 Don’t perform cardiac imaging for patients who are at low risk. 2 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. 3 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. 4 Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery. Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery or with no cardiac symptoms or clinical risk factors undergoing intermediate-risk non-cardiac surgery. These types of testing do not change the patient’s clinical management or outcomes and will result in increased costs. Therefore, it is not appropriate to perform cardiac imaging procedures for non-cardiac surgery risk assessment in patients with no cardiac symptoms, clinical risk factors or who have moderate to good functional capacity. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Society of Nuclear Cardiology (ASNC) appointed a writing group of content experts to identify five areas in which to make recommendations. Areas were selected for the evidence-based data available to direct provider decision-making and the potential for improving patient selection and care by eliminating inappropriate testing. Specific recommendations were drafted for each subject area, accompanied by peer-reviewed literature citations. These recommendations were reviewed by the ASNC Quality Assurance Committee and Board of Directors prior to submission to the Choosing Wisely campaign. ASNC’s disclosure and conflict of interest policy can be found at www.asnc.org. Sources 1 Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. Hendel RC, Abbott BG, Bateman TM, et al. Role of radionuclide myocardial perfusion imaging for asymptomatic individuals. J Nucl Cardiol. 2011;18:3-15. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. 2 Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94. Anderson JL, Adams CD, Antman EM, Bridges CR, Cali RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Linco AM, Peterson ED, Theroux P, Wenger NK, Wright RS. ACC/ AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:e1-157. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. & colors 3 and the ABIM Foundation RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac Hendel logos and radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. ® 4 n’s graphic identity and are the he basic building blocks of each of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic ual symbols properly and consistently, a unique Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation presented to the public. and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines (Writing Committee to Approved 2006 Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007;50:e159-242. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American PaNTONe Heart Association, the American Society of Echocardiography, the American Societyhexadecimal of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society for 005B99 301 c Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94. ve visual style can be established and of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College radionuclide imaging: a report sion on the public will be clear and Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. . 5 traditional color for ABIM logos. ToKC, Ficaro EP, Hansen CL, Nichols KJ, Thompson RC, Van Decker WA, Yakovlevitch M. ASNC information statement: Recommendations for reducing radiation exposure in Cerqueira MD, Allman Douglas PS, Carr JJ, Cerqueira MD, Cummings JE, Gerber TC, C: 100, M: Taylor AJ. Developing an action plan for patient radiation safety in adult cardiovascular medicine: proceedings from Mukherjee D, 69, Y: 24, K: 7 (Published online March 22, 2012.) myocardial perfusion imaging. J Nucl Cardiol 2010;17:709-18. R: 0, G: 82 , B: 145 or consistency, ABIM has chosen the olor palettes (pictured on the right) the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association Think Tank held on February 28, 2011. J Am Coll Cardiol 2012;59:In Press. M and ABIM Foundation logos, based on the Pantone Matching MS), the preferred standard used About the ABIM Foundation: by graphic artists and printers. The mission of the ABIM can be converted into many Foundation is to advance About the American Society of Nuclear Cardiology: ApprovedThe American Society of Nuclear Cardiology (ASNC) is the voice of more than 4,500 2006 medical professionalism to improve the health ch as RGB and Hexadecimal, this by collaborating with care system. We achieve physicians and physician leaders, medical trainees, e preferred color format for systems, payers, policymakers, health care delivery Web consumer organizations and uter programs, such as Microsoft patients to foster a shared understanding of professionalism and how they can werPoint. adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. ® physicians, technologists and scientists dedicated to the science and practice of nuclear cardiology. Since 1993, ASNC has been establishing the standard for excellence in cardiovascular imaging through the development of clinical guidelines, professional education and research development. For more information or questions, please visit www.asnc.org. ation of these specific colors will PaNTONe 3155 c hexadecimal 006d75 ong and consistent identity for both nd the ABIM Foundation. ABIM ations should approve all materials For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. R: 0, G: 101, B: 120 C: 100, M: 44, Y: 43, K: 15 BIM or the ABIM Foundation logos. American Urological Association Five Things Physicians and Patients Should Question A routine bone scan is unnecessary in men with low-risk prostate cancer. 1 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. 2 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 order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia (BPH). 3 When an initial evaluation shows only the presence of lower urinary tract symptoms (LUTS), if the symptoms are not significantly bothersome to the patient or if the patient doesn’t desire treatment, no further evaluation is recommended. Such patients are unlikely to experience significant health problems in the future due to their condition and can be seen again if necessary. [While the patient can often tell the provider if the symptoms are bothersome enough that he desires additional therapy, another possible option is to use a validated questionnaire to assess symptoms. For example, if the patient completes the International Prostate Symptom Scale (IPSS) and has a symptom score of 8 or greater, this is considered to be “clinically” bothersome.] 4 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. Don’t perform ultrasound on boys with cryptorchidism. 5 Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The American Urological Association (AUA) established a committee to review evidence from the association’s guidelines and identify potential topics for nomination to the AUA’s Choosing Wisely list. The committee reviewed a number of recommendations and through a consensus process identified the five tests or procedures that should be questioned. These recommendations were reviewed and approved by the AUA Board of Directors. AUA’s disclosure and conflict of interest policy can be found at www.auanet.org. Sources 1 American Urological Association. Prostate-Specific Antigen Best Practice Statement. Revised 2009. [Internet]. Linthicum (MD): AUA; 2009 [cited 2012 Oct 16]. Available from: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf. National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): prostate cancer. Revised 2012 April. Fort Washington (PA): NCCN;2012. American Urological Association. Management of Erectile Dysfunction Clinical Practice Guideline. Updated 2006. [Internet]. Linthicum (MD):AUA;2005 [cited 2012 Oct 16]. Available from: www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=ed. American Urological Association. Management of the Benign Prostatic Hyperplasia Clinical Practice Guideline. [Internet]. Linthicum (MD):AUA;2010[cited 2012 Oct 16]. Available from: www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines.cfm?sub=bph. Heldwein FL, Teloken PE, Hartmann AA, Rhoden EL, Teloken C. Antibiotics and observation have a similar impact on asymptomatic patients with a raised PSA. BJU Int [Internet]. 2011;107(10):1576-81. Stopiglia RM, Ferreira U, Silva Jr. MM, Matheus WE, Denardi F, Reis LO. Prostate specific antigen decrease and prostate cancer diagnosis: Antibiotic versus placebo prospective randomized clinical trial. J Urol [Internet]. 2010 3;183(3):940-5. Tasian G and Copp H: Diagnostic performance of ultrasound in Nonpalpable Cryptorchidism: A systematic review and meta-analysis. Pediatrics [Internet]. 2011 Jan: 127(1): 119–128. 2 3 4 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the American Urological Association Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is a leading advocate for the specialty of urology, and has more than 18,000 members throughout the world. The AUA is a premier urologic association, providing invaluable support to the urologic community as it fosters the highest standards of urologic care through education, research and formulation of health policy. For information, visit www.auanet.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Society of Cardiovascular Computed Tomography Five Things Physicians and Patients Should Question Don’t use coronary artery calcium scoring for patients with known coronary artery disease (including stents and bypass grafts). Coronary artery calcium scoring is used for evaluation of individuals without known coronary artery disease and offers limited incremental prognostic value for individuals with known coronary artery disease, such as those with stents and bypass grafts. 1 2 Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk. No evidence exists to support the diagnostic or prognostic potential of coronary artery calcium scoring in individuals in the preoperative setting. This practice may add costs and confound professional guideline-based evaluations. 3 Don’t order coronary artery calcium scoring for screening purposes on low risk asymptomatic individuals except for those with a family history of premature coronary artery disease. Net reclassification of risk by coronary artery calcium scoring, when added to clinical risk scoring, is least effective in low risk individuals. 4 Don’t routinely order coronary computed tomography angiography for screening asymptomatic individuals. Coronary computed tomography angiography findings of coronary artery disease stenosis severity rarely offer incremental discrimination over coronary artery calcium scoring in asymptomatic individuals. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The Society of Cardiovascular Computed Tomography (SCCT) formed a committee panel made up of expert members of its existing Guidelines Committee and Publications and Statements Committee that would be dedicated to recommending between five and 10 questions that should be considered when ordering Coronary CT angiography and coronary artery calcium scoring. The panel reviewed and referred to SCCT’s existing and published guidelines, appropriate use criteria and support statements. Once questions were chosen, the list was referred to the SCCT Board of Directors, which then reviewed the draft list, offered feedback and narrowed the questions down to the five most important consideration points through online voting. The draft was returned to the working group panel, which fleshed out the chosen recommendations and cited its supporting evidence from currently published literature. The SCCT’s Board of Directors and Executive Board each then reviewed the final five items and implemented another round of edits before voting for final review and approval. SCCT’s bylaws and its disclosure and conflict of interest policy can be found at www.scct.org. Sources Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima JAC, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE. Assessment of coronary artery disease by cardiac computed tomography: A scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. [Internet]. Circulation. 2006 [cited 2012 Nov 9]. p. 1761–91. Available from: www.ncbi.nlm.nih.gov/pubmed/17015792. 1 Greenland P, Bonow RO, Brundage BH, Budoff MJ, Eisenberg MJ, Grundy SM, Lauer MS, Post WS, Raggi P, Redberg RF, Rodgers GP, Shaw LJ, Taylor AJ, Weintraub WS. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: A report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Amer Coll Cardio [Internet]. 2007 Jan 23 [cited 2012 Nov 19];49(3):378–402. Available from: www.ncbi.nlm.nih.gov/pubmed/17239724. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AC, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Mishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation [Internet]. 2007 Oct 23 [cited 2012 Oct 26];116(17):e418–99. Available from: www.ncbi.nlm.nih.gov/pubmed/17901357. Budoff MJ, Achenbach S, Blumenthal RS, Carr JJ, Goldin JG, Greenland P, Guerci AD, Lima JAC, Rader DJ, Rubin GD, Shaw LJ, Wiegers SE. Assessment of coronary artery disease by cardiac computed tomography: A scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. [Internet]. Circulation. 2006 [cited 2012 Nov 9]. p. 1761–91. Available from: www.ncbi.nlm.nih.gov/pubmed/17015792. Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology [Internet]. 2003 Sep;228(3):826–33. Available from: www.ncbi.nlm.nih.gov/pubmed/12869688. Choi EK, Choi S, Rivera JJ, Nasir K, Chang SA, Chun EJ, Kim HK, Choi DJ, Blumenthal RS, Chang HJ. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol [Internet]. 2008;52:357-365. Available from: content.onlinejacc.org/article.aspx?articleid=1139078. 2 3 4 Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, Rubin JD. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Amer Coll Cardio [Internet]. 2010 Nov 23 [cited 2012 Nov 5];56(22):1864–94. Available from: www.ncbi.nlm.nih.gov/pubmed/2108772. Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, Hoffmann U, Lesser JR, Mikati IA, O’Neil BJ, Shaw LJ, Shen MYH, Valeti US, Raff GL. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Amer Coll Cardio [Internet]. 2011 Sep 27 [cited 2012 Nov 28];58(14):1414–22. Available from: www.ncbi.nlm.nih.gov/pubmed/21939822. 5 Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE. Coronary CT angiography versus standard evaluation in acute chest pain. N Eng J Med [Internet]. [cited 2012 Dec 7]. Available from: www.nejm.org/doi/full/10.1056/NEJMoa1201161. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Eng J Med [Internet]. 2012 Apr 12;366(15):1393–403. Available from: www.ncbi.nlm.nih.gov/pubmed/22449295. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the Society of Cardiovascular Computed Tomography The Society of Cardiovascular Computed Tomography (SCCT) is the professional society devoted exclusively to cardiovascular computed tomography (CCT), representing physicians, scientists and technologists advocating for research, education and clinical excellence in the use of CCT. With an expanding global membership, it is acknowledged and recognized as the representative and advocate for research, education, and clinical excellence in the use of cardiovascular computed tomography. SCCT’s mission includes fostering optimal clinical effectiveness of CCT through professional education, establishment of standards for quality assurance and professional training, and development of evidence-based guidelines for its use to enhance patient care and improve the quality of cardiovascular medical practice. SCCT also serves as an advocate for cardiovascular CT in all interactions with the health care industry, medical policy development and reimbursement organizations. Learn more at: www.SCCT.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Society of Hospital Medicine – Adult Hospital Medicine Five Things Physicians and Patients Should Question 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. 1 2 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-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. 3 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. 4 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The Society of Hospital Medicine (SHM) created a Choosing Wisely® subcommittee comprised of representatives of the Hospital Quality and Patient Safety committee and included diverse representation of academic, community and adult hospitalists. SHM committee members submitted 150 recommendations for consideration, which were discussed for frequency of occurrence, the uniqueness of the tests and treatments and whether the cost burden for a specific test or treatment proved to be significant, narrowing the list to 65 items. The Choosing Wisely subcommittee ranked these items and a survey was sent to all SHM members to arrive at 11 recommendations, of which the final five were determined utilizing the Delphi method. SHM’s Board approved the final recommendations. SHM’s disclosure and conflict of interest policy can be found at www.hospitalmedicine.org/industry. Sources Hooton TM, Bradley SF, Cardena DD, Colgan R, Geerlings SR, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Clin Infect Dis [Internet]. 2010 [cited 2012 Sep 4];50(5): 625-663. 1 Saint S, Meddings JA, Calfee D, Kowalski CP, Krien SL. Catheter-associated Urinary Tract Infection and the Medicare Rule Changes. Ann Intern Med [Internet]. 2009 Jun 16 [cited 2012 Sep 4];150(12): 877–884. Centers for Medicare & Medicaid Services, Joint Commission. Standards for hospital care, surgical care improvement project (SCIP), SCIP-Inf-9; Performance Measure Name: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero. 2013. 2013 Joint Commission National Hospital Inpatient Quality Measures Specification Manual, version 4.11. 2 American Society of Health System Pharmacists. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis ASHP therapeutic guidelines on stress ulcer prophylaxis: ASHP commission on therapeutics and approved by the ASHP Board of Directors on November 14, 1998. AmJ Health Syst Pharm [Internet]. 1999 Feb 1 [cited 2012 Sep 4];56: 347–379. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB.Red blood cell transfusion: A clinical practice guideline from the AABB. Ann Intern Med [Internet]. 2012 Jul 3 [cited 2012 Sep 4];157(1):49-58. Consensus conference. Perioperative red blood cell transfusion. JAMA. 1988 Nov 11; 260(18):2700-3. Advancing Transfusion and Cellular Therapies Worldwide. AABB name change. [Internet]. 2012 [Cited 2012 Oct 15]. Available from: www.aabb.org/about/who/Pages/namechange.aspx. Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MW, Macfarlane PW, Sommargren C, Swiryn S. Van Hare GF. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circ. [Internet]. 2004 [cited 2012 Sep 4];110:2721–2746. Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM, Gibbons RJ, Alpert JS, Eagle KA, Gardner TJ, Gregoratos G, Russell RO, Ryan TJ, Smith SC. ACC/AHA guidelines for ambulatory electrocardiography: Executive summary and recommendations a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography) developed in collaboration with the North American Society for Pacing and Electrophysiology. Circ [Internet]. 1999 Aug 24 [cited 2012 Sep 4];100(8):886-93. 3 4 Snider A, Papaleo M, Beldner S, Park C, Katechis D, Galinkin D, Fein A. Is telemetry monitoring necessary in low-risk suspected acute chest pain syndromes? Chest [Internet]. 2002 Aug [cited 2012 Sep 4];122(2):517–523. Henriques-Forsythe MN, Ivonye CC Jamched U, Kamuguisha LKK, Onwuanyi AE. Is telemetry overused? Is it as helpful as thought? Cleve Clin J Med [Internet]. 2009 Jun [cited 2012 Sep 4];368-372. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM, American Heart Association, American Stroke Association Stroke Council, Clinical Cardiology Council. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke [Internet]. 2007 May [cited 2012 Sep 4];38(5):1655-711. Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during Acute Myocardial Infarction. Arch Intern Med [Internet]. 2011 Oct 10 [cited 2012 Sep 4];171(18):1646-1653. 5 Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients?: The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med [Internet]. 2005 June [cited 2012 Sep 4];20(6):520–524. Stuebing EA, Miner TJ. Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy. Arch Surg [Internet]. 2011 May [cited 2012 Sep 4];146(5):524-7. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the Society of Hospital Medicine Representing the fastest growing specialty in modern healthcare, the Society of Hospital Medicine (SHM) is the leading medical society for more than 34,000 hospitalists and their patients. SHM is dedicated to promoting the highest quality care for all hospitalized patients and overall excellence in the practice of hospital medicine through quality improvement, education, advocacy and research. Over the past decade, studies have shown that hospitalists can contribute to decreased patient lengths of stay, reductions in hospital costs and readmission rates, and increased patient satisfaction. For more information about SHM and hospital medicine, visit www.hospitalmedicine.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Society of Hospital Medicine – Pediatric Hospital Medicine Five Things Physicians and Patients Should Question 1 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. 2 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. 3 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. 4 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 grastroesophageal 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created A Delphi panel of pediatric hospital medicine physicians with wide geographic representation was convened by the Society of Hospital Medicine (SHM). The panel developed an initial list of 20 items with input from colleagues at each of the panelists’ home institutions, which was then discussed and reduced to 11 items via consensus of the panel. A comprehensive literature review was undertaken for these 11 items, while they were concurrently circulated on the electronic listservs of SHM’s Pediatric Committee and the American Academy of Pediatrics’ Section on Hospital Medicine. The collated comments along with the results of the evidence review were then presented to the members of the panel. Two rounds of Delphi voting took place via electronic submission of votes by the panel. Validity and feasibility of each item was assessed by the Delphi panel on a nine-point scale for each of the 11 items and the mean of each item was obtained. The aggregate score of the means of validity and feasibility decided the final five items. These recommendations were then submitted to the SHM Board for review and approval. SHM’s disclosure and conflict of interest policy can be found at www.hospitalmedicine.org/industry. Sources American Academy of Pediatrics, Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis, Pediatrics. 2006 Oct; 118(4):1774-93. 1 National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health; 2007 Aug. 417 p. Report No.: 07-4051. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. 1990 26(4): 209-211. Roback MG, Dreitlein DA. Chest radiograph in the evaluation of first time wheezing episodes: review of current clinical efficacy. Pediatr Emerg Care. 1998 Jun;14(3):181-4. 2 American Academy of Pediatrics. Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;(12):CD001266. American Academy of Pediatrics. Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. Klassen TP, Sutcliffe T, Watters LK, Wells GA, Allen UD, Li MM. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: A randomized, controlled trial. J Pediatr. 1997 Feb;130(2):191-6. Patel H, Platt R, Lozano JM, Wang EE. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2004;(3):CD004878. De Boeck K, Van der Aa N, Van Lierde S, Corbeel L, Eeckels R. Respiratory syncytial virus bronchiolitis: a double-blind dexamethasone efficacy study. J Pediatr. 1997 Dec;131(6):919-21. Von Woensel JB, van Aalderen WM, Kimpen JL. Viral lower respiratory tract infection in infants and young children. BMJ 2003 Jul 5;327(7405):36–40. Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, Grigg J. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009 Jan 22;360(4):329-38. Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M, Veereman-Wauters G, Wenzl TG, North American Society for Pediatric Gastroenterology Hepatology and Nutrition, European Society for Pediatric Gastroenterology Hepatology and Nutrition. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49:498–547. 3 4 van der Pol RJ, Smits MJ, van Wijk MP, Omari TI, Tabbers MM, Benninga MA. Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. Gibbons TE, Gold BD. The use of proton pump inhibitors in children: a comprehensive review. Paediatr Drugs. 2003;5(1):25-40. Orenstein SR, Hassall E. Infants and proton pump inhibitors: tribulations, no trials. J Pediatr Gastroenterol Nutr. 2007;45:395–8. Khoshoo V, Edell D, Thompson A, Rubin M. Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007 Nov;120:946–9. American Academy of Pediatrics. Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. 5 Schroeder AR, Marmor AK, Pantell RH, Newman TB. Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Ped Adolesc Med. 2004 Jun;158(6):527-530. Hunt CE, Corwin MJ, Lister G, Weese-Mayer DE, Neuman MR, Tinsley L, Baird TM, Keens TG, Cabral HJ. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999 Nov;135(5):580-6. Alverson BK, McCulloh RJ, Koehn KL. Continuous versus intermittent pulse oximetry monitoring of children hospitalized for bronchiolitis. Abstract presented at IDWeek 2012. Sand Diego (CA). 2012 Oct 19. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the Society of Hospital Medicine Representing the fastest growing specialty in modern healthcare, the Society of Hospital Medicine (SHM) is the leading medical society for more than 34,000 hospitalists and their patients. SHM is dedicated to promoting the highest quality care for all hospitalized patients and overall excellence in the practice of hospital medicine through quality improvement, education, advocacy and research. Over the past decade, studies have shown that hospitalists can contribute to decreased patient lengths of stay, reductions in hospital costs and readmission rates, and increased patient satisfaction. For more information about SHM and hospital medicine, visit www.hospitalmedicine.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Society of Nuclear Medicine and Molecular Imaging Five Things Physicians and Patients Should Question 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. 1 2 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. 3 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. 4 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. Don’t use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in this field. 5 • 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The president of the Society of Nuclear Medicine and Molecular Imaging (SNMMI) appointed a Steering Committee, led by the president-elect, to develop the “Top 5” list. This committee solicited input from five SNMMI clinical specialty councils (cardiovascular, brain, nuclear oncology, general nuclear medicine, pediatric) and our PET Center of Excellence. A task force made up of the Steering Committee and specialty council/center leadership convened, and its members also provided recommendations. The Steering Committee reviewed and ranked the submissions and presented the five highest-ranked statements to the SNMMI Board of Directors and House of Delegates. SNMMI’s disclosure and conflict of interest policy can be obtained by contacting the organization ([email protected]). Sources 1 Lee JW, Kang KW, Paeng JC, Lee SM, Jang SJ, Chung JK, Lee MC, Lee DS. Cancer screening using 18F-FDG PET/CT in Korean asymptomatic volunteers: a preliminary report. Ann Nucl Med [Internet]. 2009 Sep [cited 2012 Oct 19];23(7):685-91. Minamimoto R, Senda M, Terauchi T, Jinnouchi S, Inoue T, Iinuma T, Inoue T, Ito K, Iwata H, Uno K, Oku S, Oguchi K, Tsukamoto E, Nakashima R, Nishizawa S, Fukuda H, Murano T, Yoshida T. Analysis of various malignant neoplasms detected by FDG-PET cancer screening program: based on a Japanese Nationwide Survey. Ann Nucl Med [Internet]. 2011 Jan[cited 2012 Oct 19] ;25(1):45-54. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol [Internet]. 2009 Feb[cited 2012 Oct 19] ;53:2201–29. Welker MJ, Orlov D. Thyroid Nodules. Am Fam Physician [Internet]. 2003 Feb 1 [cited 2012 Oct 19]; 67(3):559-567. 2 3 Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM, American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid [Internet]. 2009 Nov[cited 2012 Oct 19];19(11):1167-214. Lee JC, Harris AM, Khafagiminimum FA. Thyroid Scans. Aust Fam Physician [Internet]. 2012 [cited 2012 Oct 19];41(8): 586. International Commission on Radiological Protection. Radiation dose to patients from radiopharmaceuticals (Addendum to ICRP Publication 53). ICRP Publication 80. 1998. Ann. ICRP 28 (3). McCollough CH, Primak AN, Braun N, Kofler J, Yu L, Christner J. Strategies for reducing radiation dose in CT. Radiol Clin North Am [Internet]. 2009 Jan[cited 2012 Oct 19] ;47:27-40. McCollough CH, Primak AH, Braun N, Kofler J, Yu L, Christner J. Strategies for reducing radiation dose in CT. Radiol Clin North Am. 2009;47:27-40. Hurwitz LM, Yoshizumi TT, Goodman PC, Nelson RC, Toncheva G, Nguyen GB, Lowry C, Anderson-Evans C. Radiation dose savings for adult pulmonary embolus 64-MDCT using bismuth breast shields, lower peak kilovoltage, and automatic tube current modulation. AJR Am J Roentgenol [Internet]. 2009 Jan [cited 2012 Oct 19];192(1):244-53. Stein EG, Haramati LB, Chamarthy M, Sprayregen S, Davitt MM, Freeman LM. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol [Internet]. 2010 Feb[cited 2012 Oct 19];194:392-397. 4 Parker MS, Hui FK, Camacho MA, Chung JK, Broga DW, Sethi NN. Female breast radiation exposure during CT pulmonary angiography. AJR Am J Roentgenol [Internet]. 2005 Nov [cited 2012 Oct 19];185:1228-1233. Niemann T, Nicolas G, Roser HW, Müller-Brand J, Bongartz G. Imaging for suspected pulmonary embolism in pregnancy-what about the fetal dose? A comprehensive review of the literature. Insights Imaging [Internet]. 2010 Nov[cited 2012 Oct 19];1:361-372. Freeman LM, Haramati LB. V/Q scintigraphy: alive, well and equal to the challenge of CT angiography. Eur J Nucl Med Mol [Internet]. Imaging. 2009 Mar [cited 2012 Oct 19];36:499-504. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med [Internet]. 2007 Nov 29 [cited 2012 Oct 19];357:2277-2284. Freeman LM, Stein EG, Spraregen S, Chamarthy M, Haramati LB. The current and continuing role of ventilation-perfusion scintigraphy in evaluating patients with suspected pulmonary embolism. Semin Nucl Med [Internet]. 2008 Nov [cited 2012 Oct 19]. 38(6):432-440. Burns SK, Haramati LB. Diagnostic imaging and risk stratification of patients with acute pulmonary embolism. Cardiol Rev [Internet]. 2012 Jan-Feb[cited 2012 Oct 19];20(1):15-24. Herholz K, Carter SF, Jones M. Positron emission tomography imaging in dementia. Br J Radiol [Internet]. 2007 Dec [cited 2012 Oct 19]; 80:S160-7. Drzezga A. Amyloid-plaque imaging in early and differential diagnosis of dementia. Ann Nucl Med [Internet]. 2010 Feb [cited 2012 Oct 19];24:55-66. Drzezga, A. Basic pathologies of neurodegenerative dementias and their relevance for state-of-the-art molecular imaging studies. Eur J Nucl Med Mol Imaging [Internet]. 2008 Mar [cited 2012 Oct 19] ;35 (Suppl 1):S4-S11. Schroeter ML, Raczka K, Neumann J, Yves von Cramon D. Towards a nosology for frontotemporal lobar degenerations-a meta-analysis involving 267 subjects. Neuroimage [Internet]. 2007 Jul 1 [cited 2012 Oct 19];36(3):497-510. Vlassenko AG, Mintun MA, Xiong C, Sheline YI, Goate AM, Benzinger TL, Morris JC. Amyloid-beta plaque growth in cognitively normal adults: longitudinal [11C]Pittsburgh compound B data. Ann Neurol [Internet]. 2011 Nov [cited 2012 Oct 19];70(5):857-61. 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the Society of Nuclear Medicine and Molecular Imaging The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is a nonpro t scienti c and professional organization dedicated to the science, technology and practical application of nuclear medicine and molecular imaging, with the ultimate goal of improving human health. Founded in 1960, SNMMI represents more than 19,000 nuclear medicine and molecular imaging professionals worldwide. For more information about nuclear medicine and molecular imaging, please visit SNMMI’s consumer website, www.discoverMI.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. The Society of Thoracic Surgeons Five Things Physicians and Patients Should Question Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery. 1 • Functional status has been shown to be reliable for prediction of perioperative and long-term cardiac events. In highly functional asymptomatic patients, management is rarely changed by preoperative stress testing. It is therefore appropriate to proceed with the planned surgery without it. Unnecessary stress testing can be harmful because it increases the cost of care and delays treatment without altering surgical or perioperative management in a meaningful way. Furthermore, low-risk patients who undergo preoperative stress testing are more likely to obtain additional invasive testing with risks of complications. Cardiac complications are significant contributors to morbidity and mortality after non-cardiac thoracic surgery, and it is important to identify patients preoperatively who are at risk for these complications. The most valuable tools in this endeavor include a thorough history, physical exam and resting EKG. Cardiac stress testing can be an important adjunct in this evaluation, but it should only be used when clinically indicated. 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. 2 • 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/AHA 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. 3 • 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. Patients with suspected or biopsy proven Stage I NSCLC do not require brain imaging prior to definitive care in the absence of neurologic symptoms. • The incidence of occult brain metastasis in Stage I lung cancer is low (<3%) and so routine brain imaging results in increased costs, delays in therapy and rarely changes patient management. • False-positive studies occur in up to 11% of patients resulting in further invasive testing or incorrect over staging, with potentially tragic effects on treatment decisions and outcomes. Some clinicians perform routine screening by brain magnetic resonance imaging (MRI) or computed tomography (CT) scans to rule out occult brain metastasis in asymptomatic patients prior to surgical resection of early stage lung cancer. This practice of routine screening for occult brain metastases has not been evaluated by a randomized clinical trial and may not be cost-effective or medically necessary. Pooled data from retrospective studies that included a comprehensive clinical evaluation demonstrated that only 3% of patients who have a negative neurologic evaluation present with intracranial metastasis. One study, limited to Stage I patients, reported a prevalence of 1.3%. The joint statement of the American Thoracic Society and the European Respiratory Society did not advocate preoperative imaging of the brain in patients with NSCLC who present without neurologic symptoms, and the current National Comprehensive Cancer Network (NCCN) non-small cell lung cancer guidelines do not recommend preoperative brain imaging for asymptomatic patients with Stage IA non-small cell lung carcinoma. 4 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. 5 • 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 FEV1 and 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. How This List Was Created The Society of Thoracic Surgeons (STS) list development process was led by the First Vice-President, and involved input from multiple workforces, including the Workforce on Adult Cardiac and Vascular Surgery, Workforce on General Thoracic Surgery, and Workforce on Evidence Based Surgery, and was staffed by STS’ Director of Quality. The initial 17 recommendations from these Workforces were narrowed down to eight based upon frequency, clinical guidelines and potential impact. STS leadership approved these eight recommendations for presentation to members in an online survey. The results of the survey, as well as research and systematic literature review by the Workforce on Evidence Based Surgery, were presented to the STS Executive Committee, which approved the five final recommendations. Sources Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Non-cardiac Surgery). Circulation. 2007 Oct 23;116:e418-99. 1 Poldermans D, Bax JJ, Boersma E, De Hert S, Euckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Per Kjeldsen K, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid J-P, Sellevold OFM, Sicari R, Van den Berghe G, Vermassen F. Guidelines for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The task force for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery of the European Society of Cardiology and endorsed by the European Society of Anaesthesiology. Eur Heart J. 2009;30:2769–812. Brunelli A, Varela G, Salati M, Jimenez MF, Pompili C, Novoa N, Sabbatini A. Recalibration of the revised cardiac risk index in lung resection candidates. Ann Thorac Surg. 2010;90:199–203. Wijeysundera DN, Beattie WS, Elliot RF, Austin PC, Hux JE, Laupacis A. Non-invasive cardiac stress testing before elective major non-cardiac surgery: Population based cohort study. BMJ. 2010;340:b5526. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Circulation. 2011;124(23):e652-e735. Stansby G, Macdonald S, Allison R, de Belder M, Brown MM, Dark J, Featherstone R, Flather M, Ford GA, Halliday A, Malik I, Naylor R, Pepper J, Rothwell PM. Asymptomatic carotid disease and cardiac surgery consensus. Angiology. 2011;62:457-460. 2 Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305:381-390. Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: An updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;41:607-624. Cournot M, Boccalon H, Cambou JP, Guilloux J, Taraszkiewicz D, Hanaire-Broutin H, Chamontin B, Galinier M, Ferrières J. Accuracy of the screening physical examination to identify subclinical atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg. 2007 Dec;46:1215-21. Ratchford EV, Jin Z, Di Tullio MR, Salameh MJ, Homma S, Gan R, Boden-Albala B, Sacco RL, Rundek T. Carotid bruit for detection of hemodynamically significant carotid stenosis: The Northern Manhattan Study. Neurol Res. 2009;31:748–752. Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, Khandheria BK, Levine RA, Marx GR, Miller FA Jr, Nakatani S, Quiñones MA, Rakowski H, Rodriguez LL, Swaminathan M, Waggoner AD, Weissman NJ, Zabalgoitia M. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: A report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2009 Sep;22(9):975-1014. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Developed in collaboration with the Society of Cardiovascular Anesthesiologists: Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2006 Aug 1;114(5):e84-231. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008 Oct 7;118(15):e523-661. American College of Cardiology Foundation Appropriate Use Criteria Task Force; American Society of Echocardiography; American Heart Association; American Society of Nuclear Cardiology; Heart Failure Society of America; Heart Rhythm Society; Society for Cardiovascular Angiography and Interventions; Society of Critical Care Medicine; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; American College of Chest Physicians. ACCF/ASE/AHA/ ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011 Mar;24(3):229-267. 3 Silvestri GA, Gould MK, Margolis ML, Tanoue LT, McCrory D, Toloza E, Detterbeck F. Noninvasive staging of non-small cell lung cancer. ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3suppl):178S-201S. Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for non-small-cell lung cancer with clinical stage T1–2 N0. Ann Thorac Surg. 1999 Sep;68(3):1039-1042. 4 American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small cell lung cancer. Am J Respir Crit Care Med 1997;156:320-332. Toloza EM. Harpole L, and McCory DC. Noninvasive staging of non-small cell lung cancer: A review of the current evidence. Chest. 2003;123;(1 Sppl):137S-146S. National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): Non-small cell lung cancer. Fort Washington (PA): NCCN;2012. Colice GL, Birkmeyer JD, Black WC, Littenberg B, Silvestri G. Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases. Chest. 1995;108(5):1264-1271. Shahian DM, O’Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand SL, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP. The society of thoracic surgeons 2008 cardiac surgery risk models: Part 1--coronary artery bypass grafting surgery. Ann Thorac Surg. 2009 Jul;88:S2-22. 5 O’Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand SL, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP. The society of thoracic surgeons 2008 cardiac surgery risk models: Part 2--isolated valve surgery. Ann Thorac Surg. 2009 Jul;88:S23-42. Ried M, Unger P, Puehler T, Haneya A, Schmid C, Diez C. Mild-to-moderate copd as a risk factor for increased 30-day mortality in cardiac surgery. Thorac Cardiovasc Surg. 2010 Oct;58:387-391. Adabag AS, Wassif HS, Rice K, Mithani S, Johnson D, Bonawitz-Conlin J, Ward HB, McFalls EO, Kuskowski MA, Kelly RF. Preoperative pulmonary function and mortality after cardiac surgery. Am Heart J. 2010 Apr;159(4):691-697. About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About The Society of Thoracic Surgeons Founded in 1964, The Society of Thoracic Surgeons (STS) is an international not-forpro t organization representing more than 6,500 cardiothoracic surgeons, researchers and other health care professionals who are part of the cardiothoracic surgery team. STS members are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung and esophagus, as well as other surgical procedures within the chest. For more information about cardiothoracic surgery procedures, visit www.sts.org/patients. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org. Society for Vascular Medicine Five Things Physicians and Patients Should Question Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause. Lab tests to look for a clotting disorder will not alter treatment of a venous blood clot, even if an abnormality is found. DVT is a very common disorder, and recent discoveries of clotting abnormalities have led to increased testing without proven benefit. 1 2 3 4 Don’t reimage DVT in the absence of a clinical change. Repeat ultrasound images to evaluate “response” of venous clot to therapy does not alter treatment. Avoid cardiovascular testing for patients undergoing low-risk surgery. Pre-operative stress testing does not alter therapy or decision-making in patients facing low-risk surgery. 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. 5 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. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician. How This List Was Created The Society for Vascular Medicine (SVM) looked to the leadership of its Board of Trustees and input from its members to develop the list of five things physicians and patients should question. Suggestions from SVM members were solicited through an e-mail blast, and a second e-mail was sent to the SVM Board of Trustees seeking volunteers and suggestions. A committee, consisting of four members of the Board of Trustees, narrowed an initial list down to seven recommendations. The full Board of Trustees voted on the recommendations using the Delphi method of choice, arriving at the five that became SVM’s list as part of the Choosing Wisely® campaign. SVM’s disclosure and conflict of interest policy can be found at www.vascularmed.org. Sources Dalen JE. Should patients with venous thromboembolism be screened for thrombophilia? Am J Med [Internet]. 2008 Jun [cited 2012 Oct 18]; 121:6;458–463. Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet [Internet]. 2003 Aug 16 [cited 2012 Oct 18];362:523–526. 1 Ho WK, Hankey GJ, Quinlan DJ, Eikelboom JW. Risk of recurrent venous thromboembolism in patients with common thrombophilia. Arch Intern Med [Internet]. 2006 Apr 10 [cited 2012 Oct 18];166:729–736. Baglin T, Gray E, Greaves M, Hunt BJ, Keelin D, Machin S, Mackie I, Makris M, Nokes T, Perry D, Tait RC, Walker I, Watson H. Clinical guidelines for testing for heritable thrombophilia; Br J Haematol [Internet]. 2010 Apr [cited 2012 Oct 18];149:209–220. 2 Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Practice Guidelines. Chest. [Internet]. 2012 Feb [cited 2012 Oct 18];141(2)(Suppl):e351S–e418S. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol [Internet]. 2007 Oct 23 [cited 2012 Oct 18];50:e159 –241. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): Executive summary. Circ [Internet]. 2006 Mar 21[cited 2012 Oct 18]113;1474-1547. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): Executive summary. Circ [Internet]. 2006 Mar 21[cited 2012 Oct 18]113;1474-1547. 3 4 5 About the ABIM Foundation The mission of the ABIM Foundation is to advance medical professionalism to improve the health care system. We achieve this by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org. About the Society for Vascular Medicine The Society for Vascular Medicine (SVM) is a nonpro t medical society comprised of physicians, surgeons, nurses, physician assistants, nurse practitioners, and vascular interventionists. For nearly 25 years, one of the goals of the Society has been to maintain high standards of clinical vascular medicine. The Society believes that optimal vascular care is best accomplished by the collegial interaction of a community of vascular professionals working with the patient. The Society recognizes the importance of individuals with diverse backgrounds in achieving ideal standards of research and clinical practice. The society believes that partnerships between patients and health care providers are crucial to improving vascular health, achieving better outcomes and lowering health care costs. For more information, visit www.vascularmed.org. ® For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www.choosingwisely.org.