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A second look at the 'choosing wisely' recommendations

October 26, 2013
By C. Paul Martin, M.D. , Marshall Independent

Earlier this month this column introduced and discussed a new program for patients and physicians called Choosing Wisely. In summary, it is a series of suggestions regarding present practices and concepts which may need modification in contemporary medical practices. A recent statement by Dr. Don Burwick, the founder of the Institute for Health Care Improvement and the head of CMS (Medicare and Medicaid Services), regarding "Health Care Monsters" and "Taming the Excess" indicated his views: "Everyone involved in health care, including patients and physicians, needs to rein in their desires for more" He cited Choosing Wisely as a good start to cut back on unnecessary procedures.

To clarify this statement, recent information published by the American Board of Family Medicine (AAFP) states: "The Choosing Wisely campaign was created as an initiative of the American Board of Internal Medicine Foundation to improve health care quality. More than 50 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused." In addition, the AAFP relates: "[that it] remains committed to supporting the Choosing Wisely campaign with the goal of ensuring high-quality, cost-effective care to patients. The AAFP has identified 15 tests and procedures that both doctors and patients should carefully consider and openly discuss before incorporating them into a treatment plan."

In summary of the above paragraphs, groups of physicians have published statements and recommendations regarding common medical conditions and the associated procedures and treatments which may lend themselves to new concepts and attitudes by physicians and patients. Notably, these comments by the specialty societies are general in nature, and specific illnesses and situations may often require specific or alternative directions. It should be emphasized that these thoughts are not laws, specific guidelines, or definitive answers to often puzzling patient illnesses or situations. The individual doctor-patient relationship ultimately determines the final action.

After reviewing our last column, an interested reader has asked me how these new ideas included in Choosing Wisely were formulated; how did they come to be? I believe these new thoughts about older concepts fall into two groups: screening tests and treatments or specific illnesses. Some examples will illustrate these points.

Until a few years ago, patients received a routine chest X-ray when entering the hospital for any reason as a screening test for underlying illness. A scientifically controlled study was performed at a prominent East Coast hospital where five thousand consecutive screening X-rays were reviewed for unknown illnesses; only 25 previously unknown illnesses were found! Thus, similar routine screening tests for carotid artery narrowing, cervical cancer, bone density, and scoliosis have been called into question.

For many years and presently, treatment for acute pharyngitis was thought by many patients to require "a shot of penicillin" or a similar oral dose of an antibiotic. Scientific studies have shown that most cases of acute pharyngitis are actually viral in origin and do not require antibiotic therapy.

A similar situation exists for recommendations for otitis media and sinusitis except in certain cases. The remarkable and very serious development of bacterial resistance related to antibiotic overuse has prompted these recommendations in Choosing Wisely.

In today's column, some of the recommendations of the Choosing Wisely program are listed. The AAFP states regarding the Choosing Wisely program: "To help reduce unnecessary or harmful treatments and tests, the AAFP recommends that family physicians have conversations with patients regarding the safety and efficacy of [the following]:

Antibiotics for Otitis Media (Ear Infections)- The recommendation suggests that antibiotics NOT be used for otitis media in children aged 2-12 with non-severe symptoms where the observation option is reasonable;

Prostate Cancer Screening- The recommendation is that NO routine screening tests such as the digital rectal exam or PSA blood test are to be performed;

Scoliosis in Adolescents- The recommendation is that NO screening is necessary;

Screening for Carotid Artery Stenosis in Asymptomatic Adult Patients- The recommendation is that NO screening is necessary;

The Prescription of Oral Conceptive Medications- The recommendation is that NO general or pelvic examinations are routinely required to prescribe oral contraceptive medications;

Recommendations for Pap Smears -No routine Pap Smears in women under 30, post-hysterectomy, or age 65 and older who have had adequate screening in the past are recommended;

Imaging for Low Back Pain - No imaging for low back pain within the first six weeks is recommended.

These recommendations may be surprising to our readers. However, they are the results of statistically significant studies of the value, costs, and possible harm to patients related to previous treatments and recommendations. Complications from aggressive screening procedures have been pragmatic considerations for patients and physicians. Consult your physician for further information about these concerns.

More information on general and specific topics related to Choosing Wisely is available on the Internet; check the website:



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