primary care, study of the week

Choose…But Choose Wisely. Part Deux.

Yesterday I discussed the American College of Physicians’ Choosing Wisely list- a list of five tests that should be questioned.

Today, I’ll discuss the recommendations from the American Academy of Family Physicians.
1. Don’t do imaging for low back pain within the first six weeks, unless

red flags are present. 
Obviously, this is quite similar to the ACP’s recommendation of not doing imaging for non-specific back pain.  What are these “red flags?”  In general, they refer to specific neurological symptoms.  Imaging of the back does not improve outcomes in routine low back pain.

2.Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.
Read this again.  And again.  And again.  It’s the truth.

3.  Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
I’ll add my own, additional recommendation to this.  Don’t do repeated DEXA screening on patients with normal bone density.  I read the bone density tests that are done in my hospital.  I can’t believe how many people have a bone density test every two years no matter what, despite them consistently being normal and unchanged.

4.  Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

Again, similar to the ACP’s recommendation to not order stress tests on low-risk patients.  This takes it a bit further and includes not doing annual ECGs, with which I whole-heartedly agree.

5.  Don’t perform Pap smears on women younger than 21 or who havehad a hysterectomy for non-cancer disease.

Yup.  Agreed.  See my blog post here.  And please, please, no more Pap smears on people without a cervix!

More to come tomorrow!

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