Choosing Wisely: 10 practices to stop—or adopt—to reduce overuse in health care

,

doi:10.12788/jfp.0085

Applied Evidence

Choosing Wisely: 10 practices to stop—or adopt—to reduce overuse in health care

J Fam Pract. 2020 October;69(8):396-400 | 10.12788/jfp.0085

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References

1. Miyakis S, Karamanof G, Liontos M, et al. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82:823-829.

2. Morgan DJ, Dhruva SS, Wright SM, et al. Update on medical overuse: a systematic review. JAMA Intern Med. 2016;176:1687-1692.

3. Durante C, Costante G, Lucisano G, et al. The natural history of benign thyroid nodules. JAMA. 2015;313:926-935.

4. Choosing Wisely. Society of Hospital Medicine—Pediatric hospital medicine. Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. www.choosingwisely.org/clinician-lists/society-hospital-medicine-pediatric-continuous-pulse-oximetry-in-children-with-acute-respiratory-illness/. Accessed September 28, 2020.

5. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135:e1044-e1051.

6. Kravitz RL, Bell RA, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Arch Intern Med. 2003;163:1673-1681.

7. Kravitz RL, Bell RA, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Serv Res. 2002;37:217-238.

8. Choosing Wisely. American Academy of Family Physicians. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-imaging-low-back-pain/. Accessed September 28, 2020.

9. Choosing Wisely. American Society of Anesthesiologists–Pain Medicine. Avoid imaging studies (MRI, CT or X-rays) for acute low back pain without specific indications. www.choosingwisely.org/clinician-lists/american-society-anesthesiologists-imaging-studies-for-acute-low-back-pain/. Accessed September 28, 2020.

10. Choosing Wisely. American College of Emergency Physicians. Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis). www.choosingwisely.org/clinician-lists/acep-lumbar-spine-imaging-in-the-ed/. Accessed September 28, 2020.

11. Choosing Wisely. American Academy of Family Physicians. Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-pelvic-or-physical-exams-to-prescribe-oral-contraceptives/. Accessed September 28, 2020.

12. Over-the-counter access to hormonal contraception. ACOG Committee Opinion, Number 788. Obstet Gynecol. 2019;134:e96-e105. https://journals.lww.com/greenjournal/Fulltext/2019/10000/Over_the_Counter_Access_to_Hormonal_Contraception_.46.aspx. Accessed September 28, 2020.

13. Choosing Wisely. American Academy of Family Physicians. Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin. www.choosingwisely.org/clinician-lists/aafp-daily-home-glucose-monitoring-for-patients-with-type-2-diabetes. Accessed September 28, 2020.

14. Choosing Wisely. Society of General Internal Medicine. Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin. www.choosingwisely.org/clinician-lists/society-general-internal-medicine-daily-home-finger-glucose-testing-type-2-diabetes-mellitus/. Accessed September 28, 2020.

15. Malanda UL, Welschen LM, Riphagen II, et al. Self‐monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev. 2012(1):CD005060.

16. Peel E, Douglas M, Lawton J. Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients’ perspectives. BMJ. 2007;335:493.

17. Choosing Wisely. American Academy of Family Physicians. Don’t screen for genital herpes simplex virus infection (HSV) in asymptomatic adults, including pregnant women. www.choosingwisely.org/clinician-lists/aafp-genital-herpes-screening-in-asymptomatic-adults/. Accessed September 28, 2020.

18. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Serologic screening for genital herpes infection: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:2525-2530.

19. Choosing Wisely. American Academy of Family Physicians. Don’t screen for testicular cancer in asymptomatic adolescent and adult males. www.choosingwisely.org/clinician-lists/aafp-testicular-cancer-screening-in-asymptomatic-adolescent-and-adult-men/. Accessed September 28, 2020.

20. Lin K, Sharangpani R. Screening for testicular cancer: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:396-399.

21. Choosing Wisely. American Academy of Pediatrics. Cough and cold medicines should not be prescribed, recommended or used for respiratory illnesses in young children. www.choosingwisely.org/clinician-lists/american-academy-pediatrics-cough-and-cold-medicines-for-children-under-four/. Accessed September 28, 2020.

22. Schaefer MK, Shehab N, Cohen AL, et al. Adverse events from cough and cold medications in children. Pediatrics. 2008;121:783-787.

23. Carr BC. Efficacy, abuse, and toxicity of over-the-counter cough and cold medicines in the pediatric population. Curr Opin Pediatr. 2006;18:184-188.

24. Oduwole O, Udoh EE, Oyo‐Ita A, et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2018(4):CD007094.

25. Choosing Wisely. American Academy of Allergy, Asthma & Immunology. Don’t perform unproven diagnostic tests, such as immunoglobulin G(lgG) testing or an indiscriminate battery of immunoglobulin E(lgE) tests, in the evaluation of allergy. www.choosingwisely.org/clinician-lists/american-academy-allergy-asthma-immunology-diagnostic-tests-for-allergy-evaluation/. Accessed September 28, 2020.

26. Cox L, Williams B, Sicherer S, et al. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and Immunology Specific IgE Test Task Force. Ann Allergy Asthma Immunol. 2008;101:580-592.

27. Choosing Wisely. American Epilepsy Society. Do not routinely order electroencephalogram (EEG) as part of initial syncope work-up. www.choosingwisely.org/clinician-lists/aes-eeg-as-part-of-initial-syncope-work-up/. Accessed September 28, 2020.

28. Choosing Wisely. American College of Emergency Physicians. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/. Accessed September 28, 2020.

29. Choosing Wisely. American College of Physicians. In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). www.choosingwisely.org/clinician-lists/american-college-physicians-brain-imaging-to-evaluate-simple-syncope/. Accessed September 28, 2020.

30. Choosing Wisely. American Academy of Neurology. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. www.choosingwisely.org/clinician-lists/american-academy-neurology-carotid-artery-imaging-for-simple-syncope/. Accessed September 28, 2020.

31. Josephson CB, Rahey S, Sadler RM. Neurocardiogenic syncope: frequency and consequences of its misdiagnosis as epilepsy. Can J Neurol Sci. 2007;34:221-224.

32. Mendu ML, McAvay G, Lampert R, et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299-1305.

33. Choosing Wisely. American Academy of Pediatrics–Section on Surgery. Avoid referring most children with umbilical hernias to a pediatric surgeon until around age 4-5 years. www.choosingwisely.org/clinician-lists/aap-sosu-avoid-surgery-referral-for-umbilical-hernias-until-age-4-5/. Accessed September 28, 2020.

34. Antonoff MB, Kreykes NS, Saltzman DA, et al. American Academy of Pediatrics Section on Surgery hernia survey revisited. J Pediatr Surg. 2005;40:1009-1014.

35. Choosing Wisely. American Geriatrics Society. Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations. www.choosingwisely.org/clinician-lists/american-geriatrics-society-prescription-appetite-stimulants-to-treat-anorexia-cachexia-in-elderly/. Accessed September 28, 2020.

36. Milne AC, Potter J, Vivanti A, et al. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Sys Rev. 2009(2):CD003288.

37. Fox CB, Treadway AK, Blaszczyk AT, et al. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy. 2009;29:383-397.

Improve your practice with these 10 primary care recommendations

1 Avoid imaging studies in early acute low back pain without red flags.

Both the AAFP and the American Society of Anesthesiologists recommend against routine X-rays, magnetic resonance imaging, and computed tomography (CT) scans in the first 6 weeks of acute low back pain (LBP).^8,9 The American College of Emergency Physicians (ACEP) recommends against routine lumbar spine imaging for emergency department (ED) patients.¹⁰ In all cases, imaging is indicated if the patient has any signs or symptoms of neurologic deficits or other indications, such as signs of spinal infection or fracture. However, as ACEP notes, diagnostic imaging does not typically help identify the cause of acute LBP, and when it does, it does not reduce the time to symptom improvement.¹⁰

2 Prescribe oral contraceptives on the basis of a medical history and a blood pressure measurement. No routine pelvic exam or other physical exam is necessary.

This AAFP recommendation¹¹ is based on clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG) and other research.¹²The ACOG practice guideline supports provision of hormonal contraception without a pelvic exam, cervical cancer (Pap) testing, urine pregnancy testing, or testing for sexually transmitted infections. ACOG guidelines also support over-the-counter provision of hormonal contraceptives, including combined oral contraceptives.¹²

3 Stop recommending daily self-glucose monitoring for patients with diabetes who are not using insulin.

Both the AAFP and the Society for General Internal Medicine recommend against daily blood sugar checks for people who do not use insulin.^13,14 A Cochrane review of 9 trials (3300 patients) found that after 6 months, hemoglobin A1C was reduced by 0.3% in people who checked their sugar daily compared with those who did not, but this difference was not significant after a year.¹⁵ Hypoglycemic episodes were more common in the “checking” group, and there were no differences in quality of life. A qualitative study found that blood sugar results had little impact on patients’ motivation to change behavior.¹⁶

4 Don’t screen for herpes simplex virus (HSV) infection in asymptomatic adults, even those who are pregnant.

This AAFP recommendation¹⁷ comes from a US Preventive Services Task Force (USPSTF) Grade D recommendation.18 Most people with positive HSV-2 serology have had an outbreak; even those who do not think they have had one will realize that they had the symptoms once they hear them described.18 With available tests, 1 in 2 positive results for HSV-2 among asymptomatic people will be a false-positive.¹⁸

A 2006 analysis of inpatient lab studies found that doctors ordered an average of 2.96 studies per patient per day, but only 29% of these tests contributed to management.

There is no known cure, intervention, or reduction in transmission for infected patients who do not have symptoms.¹⁸ Also, serologically detected HSV-2 does not reliably predict genital herpes; and HSV-1 has been found to cause an increasing percentage of genital infection cases.¹⁸

Continue to: 5 Don't screen for testicular cancer in asymptomatic individuals

References

1. Miyakis S, Karamanof G, Liontos M, et al. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82:823-829.

2. Morgan DJ, Dhruva SS, Wright SM, et al. Update on medical overuse: a systematic review. JAMA Intern Med. 2016;176:1687-1692.

3. Durante C, Costante G, Lucisano G, et al. The natural history of benign thyroid nodules. JAMA. 2015;313:926-935.

4. Choosing Wisely. Society of Hospital Medicine—Pediatric hospital medicine. Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. www.choosingwisely.org/clinician-lists/society-hospital-medicine-pediatric-continuous-pulse-oximetry-in-children-with-acute-respiratory-illness/. Accessed September 28, 2020.

5. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135:e1044-e1051.

6. Kravitz RL, Bell RA, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Arch Intern Med. 2003;163:1673-1681.

7. Kravitz RL, Bell RA, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Serv Res. 2002;37:217-238.

8. Choosing Wisely. American Academy of Family Physicians. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-imaging-low-back-pain/. Accessed September 28, 2020.

9. Choosing Wisely. American Society of Anesthesiologists–Pain Medicine. Avoid imaging studies (MRI, CT or X-rays) for acute low back pain without specific indications. www.choosingwisely.org/clinician-lists/american-society-anesthesiologists-imaging-studies-for-acute-low-back-pain/. Accessed September 28, 2020.

10. Choosing Wisely. American College of Emergency Physicians. Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis). www.choosingwisely.org/clinician-lists/acep-lumbar-spine-imaging-in-the-ed/. Accessed September 28, 2020.

11. Choosing Wisely. American Academy of Family Physicians. Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications. www.choosingwisely.org/clinician-lists/american-academy-family-physicians-pelvic-or-physical-exams-to-prescribe-oral-contraceptives/. Accessed September 28, 2020.

12. Over-the-counter access to hormonal contraception. ACOG Committee Opinion, Number 788. Obstet Gynecol. 2019;134:e96-e105. https://journals.lww.com/greenjournal/Fulltext/2019/10000/Over_the_Counter_Access_to_Hormonal_Contraception_.46.aspx. Accessed September 28, 2020.

13. Choosing Wisely. American Academy of Family Physicians. Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes mellitus and are not using insulin. www.choosingwisely.org/clinician-lists/aafp-daily-home-glucose-monitoring-for-patients-with-type-2-diabetes. Accessed September 28, 2020.

14. Choosing Wisely. Society of General Internal Medicine. Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin. www.choosingwisely.org/clinician-lists/society-general-internal-medicine-daily-home-finger-glucose-testing-type-2-diabetes-mellitus/. Accessed September 28, 2020.

15. Malanda UL, Welschen LM, Riphagen II, et al. Self‐monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev. 2012(1):CD005060.

16. Peel E, Douglas M, Lawton J. Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients’ perspectives. BMJ. 2007;335:493.

17. Choosing Wisely. American Academy of Family Physicians. Don’t screen for genital herpes simplex virus infection (HSV) in asymptomatic adults, including pregnant women. www.choosingwisely.org/clinician-lists/aafp-genital-herpes-screening-in-asymptomatic-adults/. Accessed September 28, 2020.

18. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Serologic screening for genital herpes infection: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:2525-2530.

19. Choosing Wisely. American Academy of Family Physicians. Don’t screen for testicular cancer in asymptomatic adolescent and adult males. www.choosingwisely.org/clinician-lists/aafp-testicular-cancer-screening-in-asymptomatic-adolescent-and-adult-men/. Accessed September 28, 2020.

20. Lin K, Sharangpani R. Screening for testicular cancer: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:396-399.

21. Choosing Wisely. American Academy of Pediatrics. Cough and cold medicines should not be prescribed, recommended or used for respiratory illnesses in young children. www.choosingwisely.org/clinician-lists/american-academy-pediatrics-cough-and-cold-medicines-for-children-under-four/. Accessed September 28, 2020.

22. Schaefer MK, Shehab N, Cohen AL, et al. Adverse events from cough and cold medications in children. Pediatrics. 2008;121:783-787.

23. Carr BC. Efficacy, abuse, and toxicity of over-the-counter cough and cold medicines in the pediatric population. Curr Opin Pediatr. 2006;18:184-188.

24. Oduwole O, Udoh EE, Oyo‐Ita A, et al. Honey for acute cough in children. Cochrane Database Syst Rev. 2018(4):CD007094.

25. Choosing Wisely. American Academy of Allergy, Asthma & Immunology. Don’t perform unproven diagnostic tests, such as immunoglobulin G(lgG) testing or an indiscriminate battery of immunoglobulin E(lgE) tests, in the evaluation of allergy. www.choosingwisely.org/clinician-lists/american-academy-allergy-asthma-immunology-diagnostic-tests-for-allergy-evaluation/. Accessed September 28, 2020.

26. Cox L, Williams B, Sicherer S, et al. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and Immunology Specific IgE Test Task Force. Ann Allergy Asthma Immunol. 2008;101:580-592.

27. Choosing Wisely. American Epilepsy Society. Do not routinely order electroencephalogram (EEG) as part of initial syncope work-up. www.choosingwisely.org/clinician-lists/aes-eeg-as-part-of-initial-syncope-work-up/. Accessed September 28, 2020.

28. Choosing Wisely. American College of Emergency Physicians. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. www.choosingwisely.org/clinician-lists/acep-avoid-head-ct-for-asymptomatic-adults-with-syncope/. Accessed September 28, 2020.

29. Choosing Wisely. American College of Physicians. In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). www.choosingwisely.org/clinician-lists/american-college-physicians-brain-imaging-to-evaluate-simple-syncope/. Accessed September 28, 2020.

30. Choosing Wisely. American Academy of Neurology. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. www.choosingwisely.org/clinician-lists/american-academy-neurology-carotid-artery-imaging-for-simple-syncope/. Accessed September 28, 2020.

31. Josephson CB, Rahey S, Sadler RM. Neurocardiogenic syncope: frequency and consequences of its misdiagnosis as epilepsy. Can J Neurol Sci. 2007;34:221-224.

32. Mendu ML, McAvay G, Lampert R, et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169:1299-1305.

33. Choosing Wisely. American Academy of Pediatrics–Section on Surgery. Avoid referring most children with umbilical hernias to a pediatric surgeon until around age 4-5 years. www.choosingwisely.org/clinician-lists/aap-sosu-avoid-surgery-referral-for-umbilical-hernias-until-age-4-5/. Accessed September 28, 2020.

34. Antonoff MB, Kreykes NS, Saltzman DA, et al. American Academy of Pediatrics Section on Surgery hernia survey revisited. J Pediatr Surg. 2005;40:1009-1014.

35. Choosing Wisely. American Geriatrics Society. Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations. www.choosingwisely.org/clinician-lists/american-geriatrics-society-prescription-appetite-stimulants-to-treat-anorexia-cachexia-in-elderly/. Accessed September 28, 2020.

36. Milne AC, Potter J, Vivanti A, et al. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Sys Rev. 2009(2):CD003288.

37. Fox CB, Treadway AK, Blaszczyk AT, et al. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy. 2009;29:383-397.

Choosing Wisely: 10 practices to stop—or adopt—to reduce overuse in health care

References

Improve your practice with these 10 primary care recommendations

1 Avoid imaging studies in early acute low back pain without red flags.

2 Prescribe oral contraceptives on the basis of a medical history and a blood pressure measurement. No routine pelvic exam or other physical exam is necessary.

3 Stop recommending daily self-glucose monitoring for patients with diabetes who are not using insulin.

4 Don’t screen for herpes simplex virus (HSV) infection in asymptomatic adults, even those who are pregnant.

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