Overused Tests/Procedures in Family Medicine

An additional 90 tests and procedures were added the American Board of Internal Medicine Foundation’s list of what it considers possibly unnecessary or harmful. The purpose of the foundations Choosing Wisely campaign is to encourage physician and patient conversations to improve care and eliminate unnecessary tests and procedures.

The Choosing Wisely campaign has compiled lists from 25 specialty societies—including the American Academy of Cardiology, the American College of Physicians and the American Society of Clinical Oncology—of the top five things physicians and patients should question.

“These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation,” according to the Choosing Wisely website. “Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.”

The initiative includes lists for physicians as well as patient-friendly resources put together by the specialty societies and Consumer Reports.

In 2012 the American Academy of Family Physicians identified five tests and treatments that are commonly ordered but not always necessary in family medicine. This year, the AAFP added five clinical recommendations with the goal of identifying screenings and procedures in family medicine that evidence suggest might — in their overuse — lead to unnecessary risks, harms and costs.

“It has been estimated that nearly one-third of health care delivered in the United States is unnecessary,” Glen R. Stream, MD, MBI, board chair of the AAFP, said in a statement. “Tests and procedures that lack evidence of their effectiveness put our patients at risk and drive up the cost of care.”

The additions to the AAFP’s list lean heavily toward women’s health.

5. Cervical cancer and HPV testing

Recommendation: Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.

Reasoning: Evidence shows that the harms of using HPV testing in women younger than 30 are moderate. Using HPV testing can lead to more frequent testing and invasive diagnostic procedures while abnormal results can cause psychological harms, anxiety and distress.

4. Cervical cancer and women over 65

Recommendation: 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.

Reason: Evidence suggests there is little benefit for this group of women.

3. Carotid artery stenosis (CAS) screening

Recommendation: Don’t screen for CAS in asymptomatic adult patients.

Reason: Screening for CAS in adult patients with no symptoms could cause more harm than good as it can lead to non-indicated surgeries that can result in serious harms such as myocardial infarction, stroke and death.

2. Elective inductions of labor

Recommendation: Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.

Reason: Inductions of labor when the cervix is unfavorable leads to higher Cesarean delivery rates. Clinicians should discuss risks and benefits with patients before inductions of labor without medical indications are considered.

1. Scheduling labor/deliveries before 39 weeks

Recommendation: Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

Reason: Delivery prior to this age is associated with increased risk of learning disabilities and a potential increase in morbidity and mortality. While there are clear medical indications based on maternal and/or fetal conditions for delivery before 39 weeks, a mature fetal lung test is not one.

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Choosing Wisely campaign