primary care, study of the week

Choose…But Choose Wisely

I am going to write a series posts on this topic, because I think that this is one of the most important issues  addressed by national specialty societies in a long time.  Readers of this blog and my patients know that I often talk about the problems associated with over-testing.  On this blog I’ve discussed the issues with mammography, pap smears, PSA, and MRIs for orthopedic complaints, to name a few.

It’s now nice to have some validation. Nine specialty societies have each created a list of five tests that should be questioned, rather than being ordered reflexively.  They have created an initiative called “Choosing Wisely.”  I am going to address each society’s list in its own post.  Keep in mind, no one is saying that these tests should NEVER be used.  They just need to be used in clinically appropriate circumstances.

Let’s start with my own specialty society- the American College of Physicians.  Its list can be found here.

1.  Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary  heart disease.

Otherwise known as a “stress test.”  There is no role for a “screening” stress test if you have a low risk for heart disease.  How do you know if you’re low risk?  Go here.  Plug in your numbers.  If they’re less than 10%, you’re low risk.  Oh, and there’s an app for that.  Really.

2.  Don’t obtain imaging studies in patients with non-specific low back pain.

  In other words, don’t get an MRI, X-ray, or CT scan for people with back pain in the absence of certain symptoms.  It does not provide useful information or improve outcomes.  Most low back is muscular in origin- it responds to exercise, weight loss, stretching, tincture of time, and judicious use of anti-inflammatories.

3.  In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). 
Syncope is a fancy word for fainting or “passing out.”  Most syncope is vasovagal- you know, that feeling of the blood leaving your head, the world going gray, tunnel vision, and then WHAM- you hit the floor.  Lots of stuff can cause it, and very few of those things are dangerous.  It’s almost never caused by a neurological issue, and there is no need for head imaging.  Even when it’s caused by something bad, that something bad is usually cardiac, meaning it’s caused by the heart, not the brain.

4.  In patients with low pretest probability of venous thromboembo- lism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
Hmmm.  This one requires a medical-ese to English translation, I think.  Pre-test probability = the likelihood that a person has a specific condition.  VTE = blood clot (either in the leg or as a pulmonary embolism.)  High-sensitive D-dimer measurement = a blood test for a particular protein in the blood that is elevated when there is a clot.
   This is an interesting one that I’m sure is going to instigate some debate.  There is tool called the Wells Criteria.  This takes into account various risk factors and signs and symptoms for pulmonary embolism (PE).  It allows a calculation of high, low, or medium probability of a PE.  This recommendation states that if someone has a low probability of a PE, you should do a D-dimer test rather than an imaging test (which is a CT scan of the chest) to rule out a PE.  If the D-dime test is negative, a PE is unlikely.
    While I agree with this recommendation, I can see a lot of doctors not following it.  First of all, some D-dimer assays are not that reliable, so it depends on how much faith you place in your lab’s assay.  PE’s can be deadly.  They can also be notoriously difficult to diagnose.  A CT angiogram is the “gold standard” to rule out a PE, but has the risk of a fairly large dose of radiation (directly to the breasts, in women).  

5.  Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. 
Hallelujah.  Now I just have to get my surgical colleagues to stop ordering them prior to surgeries!

More to follow tomorrow!

1 thought on “Choose…But Choose Wisely”

  1. I was trying to get into the Choosing Wisely website yesterday and they had so much traffic the server was down. I was hoping you would do just what you're doing here, in fact I was going to email you to suggest it,and here you are! Thank you.


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