This document outlines the objectives and content of a presentation on evidence-based medicine and good stewardship. The presentation discusses how unnecessary medical care increases costs and risks harming patients. It describes specialty-specific recommendations from the Choosing Wisely campaign to reduce unnecessary care. These recommendations include limiting imaging for back pain, reducing antibiotic prescriptions for sinus infections, and restricting osteoporosis screening to high-risk patients. The goals are to have conversations with patients about care decisions using evidence-based guidelines and avoiding overtreatment.

1. VAFP 2013
Annual
Meeting
CHOOSING WISELY:
EVIDENCE-BASED MEDICINE
AND GOOD STEWARDSHIP

2.  Mark Ryan, MD, FAAFP
 Assistant Clinical Professor, VCU DFMPH
 VP Communications, National Physicians Alliance

3.  1. Participants will describe how medical treatment decisions
increase healthcare costs and risk patient harm.
 2. Participants will describe specialty-specific evidence-based
recommendations to reduce medical care that may not benefit
patients.
 3. Participants will propose how to use these guidelines in
discussing care decisions with patients.
OBJECTIVES

4.  American medical care is expensive.
 A large amount of medical care provided in the US is
unnecessary.
 Overtreatment and excess testing risks harm.
 We can do something to avoid unnecessary testing and excess
costs, and potentially avoid harming patients.
THE BOTTOM LINE

5. AMERICAN HEALTHCARE IS EXPENSIVE

6. AMERICAN HEALTHCARE IS EXPENSIVE

7. WE DO NOT GET GOOD RETURN ON OUR
INVESTMENT
 WHO rankings in 2000 ranked the US 37th.
 IOM "U.S. Health in International Perspectives” report in 2013
showed that Americans had poorer health than 16 other
wealthy nations.
 (U.S. Health in International Perspective: Shorter Lives, Poorer Health)

8. WE DO NOT GET GOOD RETURN ON OUR
INVESTMENT

9. WE DO NOT GET GOOD RETURN ON OUR
INVESTMENT

10. WE DO NOT GET GOOD RETURN ON OUR
INVESTMENT

11. WE DO NOT GET GOOD RETURN ON OUR
INVESTMENT

12.  “The costs of the system's current inefficiency underscore the
urgent need for a systemwide transformation. About 30 percent
of health spending in 2009--roughly $750 billion--was wasted on
unnecessary services, excessive administrative costs, fraud, and
other problems.”
 There were 6 categories of excess healthcare costs.
Unnecessary services accounted for $210 billion (28% of excess
costs and 8% of all healthcare costs).
 Other categories: Inefficiently delivered services ($130 billion), excess
administrative costs ($190 billion), prices that are too high ($105
billion), missed prevention opportunities ($55 billion), fraud ($75 billion).
 (Best Care at Lower Cost: The Path to Continuously Learning
Health Care in America)
1/3 OF HEALTHCARE SPENDING IN THE
UNITED STATES IS WASTED

13.  Overuse—beyond evidence-established levels
 Discretionary use beyond benchmarks
 Unnecessary choice of higher-cost services
 (Best Care at Lower Cost: The Path to Continuously Learning Health
Care in America)
UNNECESSARY SERVICES

14.  Medical care is not necessarily safe
 An estimated 13.5 percent of hospitalized Medicare beneficiaries
experienced adverse events during their hospital stays -- HHS Office
of the Inspector General report Adverse Events in Hospitals: National
Incidence Among Medicare Beneficiaries)
 1 in 20 hospitalized patients risk a hospital-associated infection --
(CDC data)
 In 1999, the IOM estimated between 44,000 and 98,000 Americans
died yearly from medical errors, while a 2009 investigation by Hearst
newspapers suggested 200,000 annual deaths.
 There is increasing attention being paid to the risk of excess
radiation exposure and cancer due to advanced imaging.
 High-profile concerns about adverse effects from medications (e.g.
Vioxx, Avandia, etc.)
HARMS OF EXCESS MEDICAL CARE

15.  Primum non nocere
 More care is not necessarily better care or safer care.
 The right care for every person every time.
 Safe
 Effective
 Efficient
 Patient-centered
 Timely
 Equitable
 (CMS Quality Improvement Roadmap Executive Summary)
OUR RESPONSIBILITY

16.  Triple Aim: “a framework developed by the Institute for
Healthcare Improvement that describes an approach to
optimizing health system performance”
 Elements of the Triple Aim:
 Improving the patient experience of care (including quality and
satisfaction);
 Improving the health of populations; and
 Reducing the per capita cost of health care.
 Clinical decisions made by patients and physicians can help
attain the Triple Aim.
OUR RESPONSIBILITY

17.  In 2009, the American Board of Internal Medicine (ABIM)
Foundation launched its “Putting the Charter into Practice”
grants, with a goal to “advance professional values and
behaviors among practicing physicians”.
 National Physicians Alliance was one of 5 grant recipients.
 Dr. Stephen Smith (Brown Alpert Medical School Department
of Family Medicine) was the lead physician on the project.
PUTTING THE CHARTER INTO PRACTICE

18.  National Physicians Alliance (NPA) is a multi-specialty
physician organization with several areas of
interest, including limiting the impact of pharmaceutical and
medical device companies on medical practice, ensuring
access to healthcare for all Americans, and good stewardship
of limited resources.
 NPA sought the grant with the intent to “identify five steps
primary care physicians could take in their daily practices to
achieve the highest goals of doctors and patients alike:
excellent care that we can afford together”
 The focus was on primary care specialties: family
medicine, internal medicine, and pediatrics.
PUTTING THE CHARTER INTO PRACTICE

19.  “Working groups of NPA members in each of the 3 primary
care specialties agreed that an ideal activity would be one
that was common in primary care practice, that was strongly
supported by the evidence, and that would lead to significant
health benefits and reduce risks, harms, and costs. A
modification of nominal group process was used to generate a
preliminary list of activities. A first round of field testing was
conducted with 83 primary care physicians, and a second
round of field testing with an additional 172 physicians.”
 The “Top 5” Lists in Primary Care: Meeting the Responsibility
of Professionalism
GOOD STEWARDSHIP

20.  “The first round of field testing resulted in 1 activity being
deleted from the family medicine list. Support for the
remaining activities was strong. The second round of field
testing showed strong support for all activities. The family
medicine and internal medicine groups independently
selected 3 activities that were the same, so the final lists
reflect 12 unique activities that could improve clinical care.”
 Lists were released in 2010, and included a short summary
and discussion of the evidence-based recommendations.
 The “Top 5” Lists in Primary Care: Meeting the Responsibility
of Professionalism
GOOD STEWARDSHIP

21.  Family Medicine:
1. Don't do imaging for low back pain within the first 6 weeks unless
red flags are present.
2. Don't routinely prescribe antibiotics for acute mild to moderate
sinusitis unless symptoms (which must include purulent nasal
secretions AND maxillary pain or facial or dental tenderness to
percussion) last for 7 or more days OR symptoms worsen after initial
clinical improvement.
3. Don't order annual ECGs or any other cardiac screening for
asymptomatic, low-risk patients.
4. Don't perform Pap tests on patients younger than 21 years or in
women status post hysterectomy for benign disease.
5. Don't use DEXA screening for osteoporosis in women under age 65
years or men under 70 years with no risk factors.
 The “Top 5” Lists in Primary Care: Meeting the Responsibility of
Professionalism
GOOD STEWARDSHIP

22.  Internal Medicine:
1. Don't do imaging for low back pain within the first 6 weeks
unless red flags are present.
2. Don't obtain blood chemistry panels (eg, basic metabolic
panel) or urinalyses for screening in asymptomatic, healthy
adults.
3. Don't order annual ECGs or any other cardiac screening for
asymptomatic, low-risk patients.
4. Use only generic statins when initiating lipid-lowering drug
therapy.
5. Don't use DEXA screening for osteoporosis in women under age
65 years or men under 70 years with no risk factors.
 The “Top 5” Lists in Primary Care: Meeting the Responsibility of
Professionalism
GOOD STEWARDSHIP

23.  Pediatrics
1. Don't prescribe antibiotics for pharyngitis unless the patient
tests positive for streptococcus.
2. Don't obtain diagnostic images for minor head injuries
without loss of consciousness or other risk factors.
3. Don't refer OME early in the course of the problem.
4. Advise patients not to use cough and cold medications.
5. Use inhaled corticosteroids to control asthma appropriately.
 The “Top 5” Lists in Primary Care: Meeting the Responsibility
of Professionalism
GOOD STEWARDSHIP

24.  Analysis using the 2009 National Ambulatory Medical Care
Survey (NAMCS) and the National Hospital Ambulatory Medical
Care Survey (NHAMCS) suggested that adoption of the Top 5
lists could save approximately $6.7 billion.
 (Kale MS, Bishop TF, Federman AD, Keyhani S. “Top 5” Lists
Top $5 Billion. Arch Intern Med. 2011;171(20):1858-1859.
doi:10.1001/archinternmed.2011.501)
GOOD STEWARDSHIP

25. Date of download: 7/5/2013
Copyright © 2012 American Medical
Association. All rights reserved.
From: “Top 5” Lists Top $5 Billion
Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed.2011.501

26.  Routine CBCs were done in 56% of eligible visits and
accounted for $32 million in costs.
 Prescribing name brand instead of generic statins (before
atorvastatin went generic) accounted for $5.8 billion in excess
costs.
 Bone density scans in women under 65 happened rarely (1.4%
of visits) but accounted for $527 million in excess costs.
 41% of children seen for non-strep, non-febrile pharyngitis
were given antibiotics ($116 million)
GOOD STEWARDSHIP

27.  The ABIM Foundation awarded NPA a second grant to select 3
practices to serve as demonstration sites for implementing
the Top 5 lists.
 A training video was created to help physicians discuss these
issues with patients.
 The ABIM Foundation used the approach piloted by the Good
Stewardship project to launch their ongoing Choosing Wisely
initiative.
 The AAFP endorsed the Good Stewardship list for family
medicine.
GOOD STEWARDSHIP

28.  “Choosing Wisely® aims to promote conversations between
physicians and patients by helping patients choose care that
is:
 Supported by evidence
 Not duplicative of other tests or procedures already received
 Free from harm
 Truly necessary”
 “national organizations representing medical specialists have
been asked to “choose wisely” by identifying five tests or
procedures commonly used in their field, whose necessity
should be questioned and discussed”
 (ABIMF Choosing Wisely website)
CHOOSING WISELY

29.  Choosing Wisely is a collaboration between the ABIM
Foundation and Consumer Reports.
 In 2013, the National Research Center for Women and
Families honored NPA, the ABIM Foundation, and Consumer
Reports as 2013 Health Policy Heroes.
CHOOSING WISELY

30.  Thus far there have been two rounds of lists generate by
specialty societies, and 35 specialty organizations have
submitted lists.
 The lists include evidence-based discussions backing the
recommendations, and are referred to as “Five Things
Physicians and Patients Should Question”
 The AAFP has submitted lists in both rounds, meaning that
there are 10 interventions that the AAFP considers as good
opportunities to reduce costs and unnecessary medical care.
 The AAFP’s first Choosing Wisely list was the endorsement of
the Good Stewardship list.
CHOOSING WISELY

31.  1. Don’t do imaging for low back pain within the first six
weeks, unless red flags are present.
 Red flags include, but are not limited to, severe or progressive
neurological deficits or when serious underlying conditions such as
osteomyelitis are suspected. Imaging of the lower spine before six
weeks does not improve outcomes, but does increase costs. Low
back pain is the fifth most common reason for all physician visits.
CHOOSING WISELY: AAFP

32.  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.
(Also listed by AAAAI and AAP)
 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.
CHOOSING WISELY: AAFP

33.  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.
 DEXA is not cost effective in younger, low-risk patients, but is cost
effective in older patients.
CHOOSING WISELY: AAFP

34.  4. Don’t order annual electrocardiograms (EKGs) or any other
cardiac screening for low-risk patients without symptoms.
(Also listed by ACP)
 There is little evidence that detection of coronary artery stenosis in
asymptomatic patients at low risk for coronary heart disease
improves health outcomes. False-positive tests are likely to lead to
harm through unnecessary invasive procedures, over-treatment and
misdiagnosis. Potential harms of this routine annual screening
exceed the potential benefit.
CHOOSING WISELY: AAFP

35.  5. Don’t perform Pap smears on women younger than 21 or
who have had a hysterectomy for non-cancer disease.
 Most observed abnormalities in adolescents regress spontaneously,
therefore Pap smears for this age group can lead to unnecessary
anxiety, additional testing and cost. Pap smears are not helpful in
women after hysterectomy (for non-cancer disease) and there is little
evidence for improved outcomes.
CHOOSING WISELY: AAFP

36.  6. Don’t schedule elective, non-medically indicated
inductions of labor or Cesarean deliveries before 39 weeks, 0
days gestational age. (Collaborative with ACOG)
 Delivery prior to 39 weeks, 0 days has been shown to be associated
with an increased risk of learning disabilities and a potential
increase in morbidity and mortality. There are clear medical
indications for delivery prior to 39 weeks and 0 days based on
maternal and/or fetal conditions. A mature fetal lung test, in the
absence of appropriate clinical criteria, is not an indication for
delivery.
CHOOSING WISELY: AAFP

37.  7. Avoid elective, non-medically indicated inductions of labor
between 39 weeks, 0 days and 41 weeks, 0 days unless the
cervix is deemed favorable. (Collaborative with ACOG)
 Ideally, labor should start on its own initiative whenever possible.
Higher Cesarean delivery rates result from inductions of labor when
the cervix is unfavorable. Health care clinicians should discuss the
risks and benefits with their patients before considering inductions of
labor without medical indications.
CHOOSING WISELY: AAFP

38.  8. Don’t screen for carotid artery stenosis (CAS) in
asymptomatic adult patients.
 There is good evidence that for adult patients with no symptoms of
carotid artery stenosis, the harms of screening outweigh the benefits.
Screening could lead to non-indicated surgeries that result in serious
harms, including death, stroke and myocardial infarction.
CHOOSING WISELY: AAFP

39.  9. 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.
 There is adequate evidence that screening women older than 65
years of age for cervical cancer who have had adequate prior
screening and are not otherwise at high risk provides little to no
benefit.
CHOOSING WISELY: AAFP

40.  10. Don’t screen women younger than 30 years of age for
cervical cancer with HPV testing, alone or in combination with
cytology.
 There is adequate evidence that the harms of HPV testing, alone or in
combination with cytology, in women younger than 30 years of age
are moderate. The harms 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.
CHOOSING WISELY: AAFP

41.  The central role of primary care—especially family medicine—
includes forming long-term relationships with our patients to
be able to discuss these recommendations with them.
 We must also work to improve communication within
medicine in order to avoid duplicating tests. If an in
integrated system, remember to check the EHR before
ordering anything!
THE ROLE OF PRIMARY CARE

42.  Consumer Reports involvement allows outreach to patients via
a trusted organization.
 Many common medical tests and treatments are unnecessary
 Choosing Wisely: How to avoid unnecessary tests and treatments
 Video outlining the purpose and goal of Choosing Wisely
 Patient-friendly resources and campaign promotional
materials from Choosing Wisely and Consumer Reports.
 Focus on various recommendations and areas of interest.
 English and Spanish
 Training videos from the Good Stewardship project.
ENGAGING PATIENTS IN CHOOSING WISELY

43.  The concept of patient-centered care places the patient at the
center of the decision-making process. Good
Stewardship/Choosing Wisely should allow us to move further
in those directions.
 Patients increasingly want a voice in their treatment
decisions. We should continue to encourage this, both to
avoid patient harm and to be good stewards of precious
resources.
ENGAGING PATIENTS IN CHOOSING WISELY

44. YOUR NEXT STEPS?
 This year, at NPA’s National Conference the pilot projects from
the Good Stewardship project will be presenting their findings.
 This is a great opportunity to get involved:
 http://www.npalliance.org
 mryan2@mcvh-vcu.edu
 mark.ryan@npalliance.org

45. EXTRA CREDIT

46.  In total, 35 specialty groups have submitted
recommendations, many of which will be relevant to family
medicine.
 My quick review of these recommendations follows. This if
based somewhat on how relevant the different
recommendations are for my practice, and is not
comprehensive.
CHOOSING WISELY: OTHER ORGANIZATIONS

47.  Don’t order sinus computed tomography (CT) or
indiscriminately prescribe antibiotics for uncomplicated acute
rhinosinusitis. (Aligns with AAFP, AAP)
 Don’t diagnose or manage asthma without spirometry.
CHOOSING WISELY: AAAAI

48.  Don’t recommend percutaneous feeding tubes in patients with
advanced dementia; instead, offer oral assisted feeding.
(Aligns with AGS)
 Don’t delay palliative care for a patient with serious illness
who has physical, psychological, social or spiritual distress
because they are pursuing disease-directed treatment.
CHOOSING WISELY: AAHPM

49.  Don’t perform imaging of the carotid arteries for simple
syncope without other neurologic symptoms. (Aligns with
ACP)
 Don’t use opioid or butalbital treatment for migraine except
as a last resort.
 Don’t recommend CEA for asymptomatic carotid stenosis
unless the complication rate is low (<3%).
CHOOSING WISELY: AAN

50.  Don’t perform preoperative medical tests for eye surgery
unless there are specific medical indications.
 Don’t order antibiotics for adenoviral conjunctivitis (pink eye).
CHOOSING WISELY: AAO

51.  Don’t prescribe oral antibiotics for uncomplicated acute
external otitis.
 Don’t routinely obtain radiographic imaging for patients who
meet diagnostic criteria for uncomplicated acute
rhinosinusitis. (Also listed by AAAAI)
 Don’t obtain computed tomography (CT) or magnetic
resonance imaging (MRI) in patients with a primary complaint
of hoarseness prior to examining the larynx.
CHOOSING WISELY: AAO-HNS (ENT)

52.  Antibiotics should not be used for apparent viral respiratory
illnesses (sinusitis, pharyngitis, bronchitis). (Aligns with AAFP,
AAAAI)
 Cough and cold medicines should not be prescribed or
recommended for respiratory illnesses in children under four
years of age.
 Neuroimaging (CT, MRI) is not necessary in a child with simple
febrile seizure.
 Computed tomography (CT) scans are not necessary in the
routine evaluation of abdominal pain. (Aligns with ACR)
CHOOSING WISELY: AAP

53.  Don’t perform stress cardiac imaging or advanced non-
invasive imaging in the initial evaluation of patients without
cardiac symptoms unless high-risk markers are present.
(Aligns with ACP)
 Don’t perform annual stress cardiac imaging or advanced non-
invasive imaging as part of routine follow-up in asymptomatic
patients.
 Don’t perform stress cardiac imaging or advanced non-
invasive imaging as a pre-operative assessment in patients
scheduled to undergo low-risk non-cardiac surgery.
CHOOSING WISELY: ACC

54.  Don’t schedule elective, non-medically indicated inductions of
labor or Cesarean deliveries before 39 weeks 0 days
gestational age. (Collaborative with AAFP)
 Don’t schedule elective, non-medically indicated inductions of
labor between 39 weeks 0 days and 41 weeks 0 days unless
the cervix is deemed favorable. (Collaborative with AAFP)
 Don’t perform routine annual cervical cytology screening (Pap
tests) in women 30–65 years of age.
 Don’t screen for ovarian cancer in asymptomatic women at
average risk.
CHOOSING WISELY: ACOG

55.  Don’t obtain screening exercise electrocardiogram testing in
individuals who are asymptomatic and at low risk for coronary heart
disease. (Aligns with ACC)
 Don’t obtain imaging studies in patients with non-specific low back
pain. (Aligns with AAFP)
 In the evaluation of simple syncope and a normal neurological
examination, don’t obtain brain imaging studies (CT or MRI) . (Similar to
AAN)
 In patients with low pretest probability of venous thromboembolism
(VTE), obtain a high-sensitive D-dimer measurement as the initial
diagnostic test; don’t obtain imaging studies as the initial diagnostic
test. (Aligns with ACR)
 Don’t obtain preoperative chest radiography in the absence of a clinical
suspicion for intrathoracic pathology.
CHOOSING WISELY: ACP

56.  Don’t do imaging for uncomplicated headache.
 Don’t image for suspected pulmonary embolism (PE) without
moderate or high pre-test probability. (Aligns with ACP)
 Avoid admission or preoperative chest x-rays for ambulatory
patients with unremarkable history and physical exam. (Similar
to ACP)
 Don’t do computed tomography (CT) for the evaluation of
suspected appendicitis in children until after ultrasound has
been considered as an option. (Aligns with AAP)
 Don’t recommend follow-up imaging for clinically
inconsequential adnexal cysts.
CHOOSING WISELY: ACR

57.  Don’t test for Lyme disease as a cause of musculoskeletal
symptoms without an exposure history and appropriate exam
findings.
 Don’t routinely repeat DXA scans more often than once every
two years.
CHOOSING WISELY: ACR (RHEUM)

58.  For pharmacological treatment of patients with
gastroesophageal reflux disease (GERD), long-term acid
suppression therapy (proton pump inhibitors or histamine2
receptor antagonists) should be titrated to the lowest
effective dose needed to achieve therapeutic goals.
 Do not repeat colorectal cancer screening (by any method) for
10 years after a high-quality colonoscopy is negative in
average-risk individuals.
 Do not repeat colonoscopy for at least five years for patients
who have one or two small (< 1 cm) adenomatous polyps,
without high-grade dysplasia, completely removed via a high-
quality colonoscopy.
CHOOSING WISELY: AGA

59.  Don’t recommend percutaneous feeding tubes in patients with
advanced dementia; instead offer oral assisted feeding. (Also
listed by AAHPM)
 Don’t use antipsychotics as first choice to treat behavioral and
psychological symptoms of dementia.
 Avoid using medications to achieve hemoglobin A1c <7.5% in
most adults age 65 and older; moderate control is generally
better.
 Don’t use benzodiazepines or other sedative-hypnotics in older
adults as first choice for insomnia, agitation or delirium.
 Don’t use antimicrobials to treat bacteriuria in older adults
unless specific urinary tract symptoms are present.
CHOOSING WISELY: AGS

60.  Don’t perform population based screening for 25-OH-Vitamin
D deficiency.
 Avoid routine preoperative testing for low risk surgeries
without a clinical indication.
CHOOSING WISELY: ASCP

61.  Don’t perform routine cancer screening for dialysis patients
with limited life expectancies without signs or symptoms.
 Don’t administer erythropoiesis-stimulating agents (ESAs) to
chronic kidney disease (CKD) patients with hemoglobin levels
greater than or equal to 10 g/dL without symptoms of
anemia.
 Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in
individuals with hypertension or heart failure or CKD of all
causes, including diabetes.
CHOOSING WISELY: ASN

62.  Don’t prescribe testosterone to men with erectile dysfunction
who have normal testosterone levels.
CHOOSING WISELY: AUA

63.  Don’t do work up for clotting disorder (order hypercoagulable
testing) for patients who develop first episode of deep vein
thrombosis (DVT) in the setting of a known cause.
 Don’t reimage DVT in the absence of a clinical change.
 Avoid cardiovascular testing for patients undergoing low -risk
surgery. (Aligns with ACC)
CHOOSING WISELY: SVM

64.  Don’t place, or leave in place, urinary catheters for incontinence
or convenience or monitoring of output for non-critically ill
patients (acceptable indications: critical illness, obstruction,
hospice, perioperatively for <2 days for urologic procedures; use
weights instead to monitor diuresis).
 Don’t prescribe medications for stress ulcer prophylaxis to
medical inpatients unless at high risk for GI complications.
 Avoid transfusions of red blood cells for arbitrary hemoglobin or
hematocrit thresholds and in the absence of symptoms of active
coronary disease, heart failure or stroke.
 Don’t perform repetitive CBC and chemistry testing in the face of
clinical and lab stability.
CHOOSING WISELY: SHM-ADULT

65.  Don’t order chest radiographs in children with uncomplicated
asthma or bronchiolitis.
 Don’t routinely use bronchodilators in children with
bronchiolitis.
 Don’t treat gastroesophageal reflux in infants routinely with
acid suppression therapy.
CHOOSING WISELY: SHM-PEDS

66.  Don’t perform stress cardiac imaging or coronary angiography
in patients without cardiac symptoms unless high-risk
markers are present. (ASNC)
 Use methods to reduce radiation exposure in cardiac imaging,
whenever possible, including not performing such tests when
limited benefits are likely. (ASNC)
 Avoid using a computed tomography angiogram to diagnose
pulmonary embolism in young women with a normal chest
radiograph; consider a radionuclide lung study (“V/Q study”)
instead. (SNMMI)
CHOOSING WISELY: ADVANCED IMAGING

67.  Don’t use coronary artery calcium scoring for patients with
known coronary artery disease (including stents and bypass
grafts).
 Don’t order coronary artery calcium scoring for preoperative
evaluation for any surgery, irrespective of patient risk.
 Don’t order coronary artery calcium scoring for screening
purposes on low risk asymptomatic individuals except for
those with a family history of premature coronary artery
disease.
 Don’t routinely order coronary computed tomography
angiography for screening asymptomatic individuals.
CHOOSING WISELY: SCCT