Choosing Wisely

Encouraging conversations between physicians and patients to improve care.

The American Academy of Family Physicians (AAFP) remains committed to supporting the Choosing Wisely®(www.choosingwisely.org) campaign with the goal of ensuring high-quality, cost-effective care to patients. The AAFP has identified 10 tests and procedures(3 page PDF) that both doctors and patients should carefully consider and openly discuss before incorporating them into a treatment plan.

To help reduce unnecessary or harmful treatments and tests, the AAFP recommends that family physicians have conversations with patients regarding the safety and efficacy of:

Elective, Non-medically Indicated Inductions of Labor or Cesarean Deliveries Before 39 Weeks*

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

Elective Inductions of Labor Between 39 weeks and 41 weeks*

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

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.

Screening for Carotid Artery Stenosis in Asymptomatic Adult Patients

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.

Screening for Cervical Cancer in Women Older Than 65 Years of Age

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.

Screening for Cervical Cancer in Women Younger than 30 years of Age

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.

Imaging for Low Back Pain

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.)

Low back pain is the fifth most common reason for all physician visits.
Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs.

Sources: Agency for Health Care Research and Policy (AHCPR), Cochrane Reviews

Antibiotics for Sinusitis

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 to percussion.)

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 over 80% of outpatient visits for acute sinusitis.

Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care.

Sources: Center for Disease Control and Prevention (CDC), Cochrane, and Annals of Internal Medicine

DEXA for Osteoporosis

Don't use dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women under age 65 or men under 70 with no risk factors.

DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.

Sources: U.S. Preventive Services Task Force (USPSTF), American Association of Clinical Endocrinology (AACE), American College of Preventive Medicine (ACPM), National Osteoporosis Foundation (NOF)

Annual EKGs for Low-risk Patients

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

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.

Sources: US Preventive Services Task Force (USPSTF)

Pap Smears

Don't perform Pap smears on women under the age of 21 or women who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, therefore screening Pap smears done in 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.

Sources: US Preventive Services Task Force (USPSTF) (for hysterectomy), American College of Obstetrics and Gynecology (ACOG) (for age)

 

*The AAFP has collaborated with the American Academy of Obstetricians and Gynecologists to develop the first two recommendations listed above regarding induction of labor.

The recommendations listed above are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.