Choosing Wisely

Yesterday I mentioned that Doctors estimate our country spends $6.8 billion in unnecessary tests.  Who can fix this?  We all can, doctors, health systems, patients, and insurers.

In 2011 The National Physician’s Alliance (NPA) published work on the Good Stewardship Project, a pilot  which was developed with funding from the American Board of Internal Medicine Foundation.  The initial effort worked with physicians in three specialties to “define 5 things “you can do in your practice” to provide excellent patient care while appropriately conserving health care resources in the fields of internal medicine, family medicine, and pediatrics.”

Subsequent to that pilot the NPA continues to work with specialties to take on both looking at the evidence and the education of patients regarding tests that have no evidence and should be considered unnecessary.  The aim is to engage physicians in conversation with their patients to choose “care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary”

Consumer Reports is on board helping to develop materials for patients.  By 2014 more than 30 specialty organizations will have created evidence based lists of care that is not supported by evidence and/or may be unnecessary.  This represents over 500,000 physicians who are represented by these groups who commit to work with their patients to make wise choices. The link to all of the specialty organizations, with links to their lists is here.

The Family Medicine list, as an example, is below. The data and evidence is here.

1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
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.
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.
4. Don’t order annual electrocardiograms (EKGs) or any other cardiac
screening for low-risk patients without symptoms.
5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
6. Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.
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.
8. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.
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.
10. Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.
11. Don’t prescribe antibiotics for otitis media in children aged 2–12
years with non-severe symptoms where the observation option is
12. Don’t perform voiding cystourethrogram (VCUG) routinely in first
febrile urinary tract infection (UTI) in children aged 2–24 months.
13. Don’t routinely screen for prostate cancer using a prostate-specific
antigen (PSA) test or digital rectal exam.
14. Don’t screen adolescents for scoliosis.
15. Don’t require a pelvic exam or other physical exam to prescribe
oral contraceptive medication.

4 thoughts on “Choosing Wisely

  1. Roger Rosenblatt

    What a sensible and courageous list. At this juncture, implementing it feels a little like swimming uphill (probably impossible); but if we learn the rationale for one of these recommendations and start discussing it with our patients, we might find that the swimming pool is actually level.

    Great blog.

    1. sdobie Post author

      I agree. wonder if it is harder for some specialties, when you look at their lists. What is powerful? They are all buying in. Specialties agreeing we need to follow evidence, and thus save money for the health of the public. thanks for stopping by! come often. s


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