Early imaging for lower back pain and Pap smears for women younger than 21 years are among eight common – but unnecessary – procedures that should be dropped from primary care physicians’ to-do lists, according to new recommendations from two primary care organizations.
The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) highlighted eight procedures and tests that are overused and unnecessary.
The recommendations are part of the ABIM (American Board of Internal Medicine) Foundation’s Choosing Wisely campaign, which targets commonly used yet ineffective procedures.
Physicians often stick with an ineffective practice (such as initially prescribing antibiotics for sinus infections) because it’s what they’re used to and it’s what patients expect, said AAFP President Glen R. Stream in an interview. The Choosing Wisely campaign is about empowering physicians and patients to break out of that cycle, Dr. Stream said.
"We have limited resources to provide health care to the people in this country, and we don’t want to waste them on things that don’t add any benefit to anyone’s health," he explained. "By focusing on these [procedures], we can avoid unnecessary x-ray exposure and medication side effects, and reserve limited medical resources to focus on things that we do know help people."
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As part of their "Five Things Physicians and Patients Should Question" fact sheets, AAFP and ACP made the following recommendations:
• Don’t perform imaging for lower back pain in the first 6 weeks unless there are red flags (AAFP). Red flags include a suspected underlying condition such as osteomyelitis or spinal abnormality, or severe or progressive neurologic deficits. ACP advises physicians not to perform imaging studies in patients who have nonspecific low back pain that can’t be attributed to a specific disease or spinal abnormality.
• When treating mild to moderate sinusitis, wait at least 7 days, or until symptoms worsen, before prescribing antibiotics (AAFP). Most sinusitis is cause by a viral infection and will resolve on its own. Despite that evidence, antibiotics are prescribed in 80% of cases of acute sinusitis.
• Don’t perform Pap smears on women younger than 21 years or in those who have had a hysterectomy (AAFP). Most abnormalities in young adults occur spontaneously, so a Pap smear could just cause unnecessary anxiety, according to the AAFP. In addition, there’s little evidence that Pap smears for those who have had a hysterectomy for a noncancer disease will result in improved outcomes.
• Don’t use DXA (dual-energy x-ray absorptiometry) screening for women younger than 65 years or men younger than 70 years with no risk factors (AAFP). DXA is most cost effective for elderly patients.
• Don’t order an EKG or any other cardiac screening for low-risk patients without symptoms (AAFP). False positives can lead to invasive procedures, overtreatment, and misdiagnosis. There’s little evidence that an EKG for low-risk patients improves outcomes. The ACP recommends against screening exercise EKGs in asymptomatic patients who are at low risk for coronary heart disease.
• Don’t use brain imaging for a patient with simple syncope and a normal neurologic exam (ACP). The likelihood of fainting caused by an issue in the central nervous system is low. Therefore, brain imaging (CT or MRI) would not improve outcomes for patients with simple syncope who don’t exhibit any signs of seizure or other neurologic symptoms.
• Start with high-sensitive d-dimer measurement, not imaging, for patients with low pretest probability of venous thromboembolism (ACP). A negative, high-sensitivity d-dimer measurement can eliminate the possibility of VTE and avoid costly imaging procedures.
• In the absence of cardiopulmonary symptoms, don’t order preoperative chest radiography (ACP). Without such symptoms, radiography rarely changes management or improves patient outcomes.
In addition to the AAFP and ACP, seven other physician organizations released their own recommendations as a part of the Choosing Wisely campaign, including the American Academy of Allergy, Asthma, and Immunology; the American Society of Clinical Oncology; the American Society of Nephrology; the American College of Cardiology; the American College of Radiology; the American Gastroenterological Association; and the American Society of Nuclear Cardiology.
"Physicians, working together with patients, can help ensure the right care is delivered at the right time for the right patient," said Dr. Christine Cassel, president and CEO of the ABIM Foundation, in a statement. Through its partnership with Consumer Reports, the foundation will release resources to 11 consumer-related organizations to provide patient education about the unnecessary procedures.
"By identifying tests and procedures that might warrant additional conversations between doctors and patients, we are able to help patients receive better care through easy-to-use and accessible information," said James Guest, president and CEO of Consumer Reports, in a statement.