Choosing Wisely – Reducing Inappropriate Use

Contributed by John Øvretveit, PhD, Karolinska Institutet Medical University, Stockholm Sweden. 

“Choosing Wisely" - is a more effective way to enlist physicians into more appropriate testing and treatments than "de-implementation" or "stop using ineffective interventions".

Below are common high cost “think twice” recommendations from www.choosingwisely.org.

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.

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.

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.

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.

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.

Don’t do imaging for uncomplicated headache.
Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

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.

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.

Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.

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 less than 5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.