10 treatments or procedures to avoid, according to AAFP

The American Academy of Family Physicians has released five new things to avoid as part of the ABIM Foundation’s Choosing Wisely campaign, adding to the existing list of five tests, medical procedures, or treatments that have been deemed to possibly do more harm than good.

The American Academy of Family Physicians, along with other medical specialty societies, have released additional lists of tests, procedures, or therapies that they say physicians should question before ordering.

The newest lists, released today, are an addition to the more than 130 tests and procedures that have been identified as not always necessary and the possible cause of undue harm. The release of the lists are part of the ABIM Foundation’s Choosing Wisely campaign, which aims to spur conversations between physicians and their patients about the necessity of certain medical treatments, procedures, or tests.

The five new recommendations for things to question as released by the ABIM Foundation and the AAFP include:

• Scheduling elective, non-medically necessary inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age. Delivery before 39 weeks and 0 days is associated with increased risk of developmental disabilities, as well as morbidity and mortality. Clear medical indications exist for delivery before 39 weeks and 0 days based on maternal and/or fetal conditions, the AAFP says, and a mature fetal lung test-in the absence of appropriate clinical criteria-is not an indication for delivery.

• Elective inductions should also be avoided between 39 weeks and 41 weeks unless the cervix is deemed favorable, the AAFP adds. Labor should start on its own whenever possible. Unfavorable cervical conditions lead to higher Cesarean delivery rates.

• Screening for carotid artery stenosis (CAS) in asymptomatic adult patients. For adult patients with no symptoms of CAS, screening outweighs the benefits and could lead to non-indicated surgeries that result in serious harm like death, stroke and myocardial infarction.

• Screening 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. Women older than 65 who have had adequate prior screening and are not otherwise at high risk reap little to no benefit from such screenings, says AAFP.

• Screening women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology. The harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate, and include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety and distress, says AAFP.

Those new recommendations join five previously released by AAFP:

• Imaging for low back pain within the first six weeks. Red flag exceptions to this recommendation include severe or progressive neurological deficits or when serious underlying conditions like osteomyelitis are suspected. Lower spine imaging before six weeks does not improve outcomes, AAFP says, but increases costs and is the fifth most common reason for all physician visits.

• Routinely prescribing antibiotics for acute mild-to-moderate sinusitis unless symptoms persist for seven or more days, or if symptoms worsen after initial clinical improvement. More sinusitis cases in the ambulatory setting are caused by viral infections that will resolve on their own. Despite recommendations to the contrary, antibiotics are prescribed in more than 80% of outpatient visits for sinusitis, which accounts for 16 million office visits and $5.8 billion in annual healthcare costs, says AAFP.

• Using dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. AAFP says DEXA is not cost-effective in younger, low-risk patients, but is cost-effective in older patients.

• Ordering annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. False positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis, despite the fact that there is little evidence that the detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. Potential harms of this routine annual screening exceed the potential benefit, according to AAFP.

• Performing Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, so Pap smears for this group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy for non-cancer diseases and there is little evidence for improved outcomes, says AAFP.

Each specialty society participating in the Choosing Wisely campaign identified five commonly performed procedures, tests or treatments from their profession that should be questioned. The first set of lists was introduced in April 2012, and the second set was released today at a press conference in Washington, DC.

“Twenty-five of the nation’s leading medical specialty societies have now spoken up and shown leadership by identifying what tests and treatments are common to their profession, but not always beneficial,” says Christine K. Cassel, MD, president and chief executive officer of the ABIM Foundation. “Millions of Americans are increasingly realizing that when it comes to health care, more is not necessarily better. Through these lists of tests and procedures, we hope to encourage conversations between physicians and patients about what care they truly need.”

The lists released today were compiled by the specialty medical organizations representing more than 350,000 physicians. The organizations releasing lists today represent more than 350,000 physicians. All of the recommendations were developed by the individual specialty societies after months of careful consideration and review, says ABIM. The societies collectively believe the recommendations can make a significant impact on patient care, safety and quality.

The 25 specialty societies that have now released lists are working to share the recommendations with their collective membership of more than 725,000 physicians, and consumer campaigns have been launched to reach millions of patients. Consumer Reports-the world’s largest independent product-testing organization-has used its website and magazine to amplify the campaign’s key messages. In a Consumer Reports survey of 2,669 consumers who received Choosing Wisely information, 72% say it changed their opinion of the topic, taught them new information, or prompted them to ask more questions of their health provider. More than 80% of consumers reporting interest in a Choosing Wisely topic say they are likely to have a conversation with their physician about what they had read.

Additionally, the campaign announced that the Robert Wood Johnson Foundation has given a $2.5 million, 28-month grant to the ABIM Foundation to advance Choosing Wisely. The grant will fund medical specialty societies and regional health improvement collaboratives to work in specific communities to raise awareness of potential overuse of medical care, and stress the importance of conversations between physicians and patients about appropriate care.

“Reducing the overuse of health care resources is a critical part of improving quality of health care in America,” said Risa Lavizzo-Mourey, M.D., president and chief executive officer of the Robert Wood Johnson Foundation. “We want to see what can happen when this work is targeted in specific geographic regions and are pleased to help increase the tangible impact of the Choosing Wisely campaign.”

More lists will be released later this year, with plans for additional recommendations from 15 specialty organizations, including the Society of General Internal Medicine and AAFP-which will release its third list.

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