Editorials

Choosing Wisely: More Good Clinical Recommendations to Improve Health Care Quality and Reduce Harm

Am Fam Physician. 2013 Aug 1;88(3):164-168.

Published online ahead of print March 19, 2013.

The Choosing Wisely campaign provides key clinical recommendations for physicians and patients that promote best practices and help avoid unnecessary medical interventions. This campaign is sponsored by the American Board of Internal Medicine Foundation, and initially nine medical specialty societies participated by providing a list of their top five recommendations. We previously published the lists from the three primary care specialty societies in American Family Physician (AFP),1 and maintain the lists on our website. Now, another 16 medical specialty organizations have joined the campaign, with more to come. In addition, Consumer Reports, AARP, and a dozen other consumer-oriented groups have partnered with the Choosing Wisely campaign to help provide information and resources to patients on making wise decisions about health care. This is an unprecedented collaborative project in the house of medicine. Hopefully, it will have far-reaching implications for improving practice and patient outcomes, lowering costs, and reducing harm.

Although the Choosing Wisely campaign is calling long overdue attention to the use of unnecessary diagnostic tests and treatments, this is hardly a new problem. A review of 172 studies performed between 1980 and 2009 found that a large proportion of physicians provide inappropriate interventions, such as antibiotics for upper respiratory tract infections, and perform inappropriate tests, such as Papanicolaou smears in women without a cervix, prostate-specific antigen testing in elderly men, and imaging for acute low back pain.2 Rather than improving over time, rates of unnecessary services have stayed the same or worsened. Compared with 10 years ago, physicians today are equally likely to perform a complete blood count, electrocardiography, and chest radiography as part of routine health maintenance examinations, and more likely to screen men 75 years or older for prostate cancer.3 Not only do these tests offer no health benefits and expose patients to harm, but even normal results don't make patients feel better.4

In the accompanying table, we have included the recommendations from the Choosing Wisely campaign that we consider especially relevant to primary care, and have organized them by discipline/body system. With nearly 100 recommendations on the list, and more to come, we thought this display would help readers more easily find these useful practice pointers. The complete list of recommendations relevant to primary care, including the rationale, comments, and references, is maintained on our website at http://www.aafp.org/afp/choosingwisely. To help highlight these valuable tips, we also will be featuring them on Twitter (https://twitter.com/AFPJournal), Facebook (https://www.facebook.com/AFPJournal), and the AFP home page (http://www.aafp.org/afp).

More information about the Choosing Wisely campaign is available at http://choosingwisely.org.

Table.

Interventions to Improve Health Care Quality and Reduce Harm: Consolidated Items Relevant to Primary Care from the Choosing Wisely Campaign

RecommendationSource

Allergy and immunologic

Don't routinely do diagnostic testing in patients with chronic urticaria.1

AAAAI guideline

Cardiovascular

Don't order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients.2,3*

USPSTF

Don't perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.4*

ACC/AHA guidelines

Don't order coronary artery calcium scoring for screening purposes on low-risk asymptomatic individuals except for those with a family history of premature CAD.5

AHA guideline

Don't routinely order coronary CT angiography for screening asymptomatic individuals.5

USPSTF, ACC/AHA guideline

Don't use coronary artery calcium scoring for patients with known CAD (including stents and bypass grafts).5

ACC/AHA guidelines

Avoid using stress echocardiograms on asymptomatic patients who meet “low-risk” scoring criteria for coronary disease.6

ACC/AHA guidelines

Don't repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no significant pathology.6

ACC/AHA guideline

Don't order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram.6

ACC/AHA guidelines

Avoid transesophageal echocardiography to detect cardiac sources of embolization, if a source has been identified and patient management will not change.6

ACC/AHA guideline

Don't order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation.7

ACC/AHA guidelines

Don't perform routine annual stress testing after coronary artery revascularization.8

ACC/AHA/ACR guideline

Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care.9

Expert consensus

Emergency medicine

Don't do CT for evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.10*

ACR Appropriateness Criteria

Don't use coronary CT angiography in high-risk emergency department patients presenting with acute chest pain.5

RCTs

NOTE: Risk defined by the Thrombolysis In Myocardial Infarction risk score for unstable angina/acute coronary syndromes.

Endocrinologic

Don't medicate to achieve tight glycemic control in older adults. Moderate control is generally better.11

RCTs

Don't use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.8

Expert consensus

Gastroenterologic

Long-term acid suppression therapy for GERD should be titrated to the lowest effective dose.12*

AGA position statement

Don't treat gastroesophageal reflux in infants routinely with acid suppression therapy.13

Systematic review of RCTs

For a patient with functional abdominal pain syndrome, CT scans should not be repeated unless there is a major change in clinical findings or symptoms.12*

U.S. Food and Drug Administration

CT scans are not necessary in the routine evaluation of abdominal pain.14

Expert consensus

Don't prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications.7

Expert consensus

Don't recommend percutaneous feeding tubes in patients with advanced dementia.9,11

RCT

Don't use topical lorazepam (Ativan), diphenhydramine (Benadryl), and haloperidol (Haldol) (“ABH”) gel for nausea.9

Expert consensus

Geriatric

Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.11

AGS guideline

Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.11

AGS, NICE guidelines

Don't delay palliative care for patients with a serious illness who have physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment. 9

RCTs

Gynecologic

Don't perform low-risk HPV testing.15

ACS/ASCCP/ASCP guideline

Don't treat patients who have mild cervical dysplasia of less than two years' duration.16

ASCCP, ACOG guidelines

Hematologic

Don't perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.7

Prospective studies

Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke.7

AABB guideline

Don't do workup for clotting disorder (order hypercoagulable testing) for patients who develop first episode of DVT in the setting of a known cause.17

Prospective cohort studies

Don't reimage DVT in the absence of a clinical change.17

ACCP guideline

Infectious disease

Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).14

AAP, IDSA guidelines

Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. 11

IDSA guideline

Nephrologic

Avoid NSAIDs in individuals with hypertension or heart failure or chronic kidney disease of all causes, including diabetes.18*

National Kidney Foundation KDQI

Don't screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.17

ACC/AHA guideline

Neurologic

Don't do imaging for uncomplicated headache.10

AAN, ACR guidelines

Don't perform electroencephalography for headaches.19

AAN guideline

CT scans are not necessary in the evaluation of minor head injuries.14

Systematic review and meta-analysis

Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.14

AAP guideline

In the evaluation of simple syncope and a normal neurologic examination, don't obtain brain imaging studies (CT or MRI).3

ACR, NICE guidelines

Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.19

AHA, NICE guidelines

Don't use opioids or butalbital for migraine except as a last resort.19

ICSI, U.S. Headache Consortium guidelines

Obstetric

Don't schedule non–medically-indicated (elective) inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.2,16

California Department of Public Health

Avoid elective, non–medically-indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.2,16

AAP/ACOG guidelines, Cochrane Database of Systematic Reviews

Ophthalmologic

Don't order antibiotics for adenoviral conjunctivitis.20

Cochrane Database of Systematic Reviews

Don't perform preoperative medical tests for eye surgery unless there are specific medical indications.20

Cochrane Database of Systematic Reviews

Orthopedic

Don't perform imaging for low back pain within the first six weeks unless red flags are present.2,3*

Agency for Health Care Policy and Research, Cochrane Database of Systematic Reviews

NOTE: Red flags include, but are not limited to, severe or progressive neurologic deficits or when serious underlying conditions such as osteomyelitis are suspected.

Otolaryngologic

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 at least seven days or symptoms worsen after initial clinical improvement.1,2,21*

Annals of Internal Medicine, Cochrane Database of Systematic Reviews

Don't routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.21

AAO-HNSF practice guideline

Don't prescribe oral antibiotics for uncomplicated external otitis.21

AAO-HNSF practice guideline

Don't prescribe oral antibiotics for uncomplicated tympanostomy tube otorrhea.21

RCT

Don't order CT scan of the head/brain for sudden hearing loss.21

AAO-HNSF practice guideline

Don't obtain CT or MRI in patients with a primary complaint of hoarseness prior to examining the larynx.21

AAO-HNSF practice guideline

Pediatric

Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children younger than four years.14

ACCP guideline

Preventive medicine

Don't perform routine annual cervical cytology screening (Pap tests) in women 30 to 65 years of age.16

ACS/ASCCP/ASCP, ACOG guidelines

Don't screen women younger than 30 years for cervical cancer with HPV testing, alone or in combination with cytology.2

USPSTF

Don't screen women older than 65 years for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.2

USPSTF

Don't perform Pap tests in patients younger than 21 years or in women after hysterectomy for benign disease.2*

ACOG (for age), USPSTF (for hysterectomy)

Don't screen for ovarian cancer in asymptomatic women at average risk.16

USPSTF

Don't use positron emission tomography/CT for cancer screening in healthy individuals.8

Expert consensus

Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.18*

American Society of Nephrology

Don't repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.12*

U.S. Multi-Society Task Force on Colorectal Cancer

Don't use DEXA to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors.2*

American Association of Clinical Endocrinologists, American College of Preventive Medicine, NOF, USPSTF

NOTE: Risk factors include, but are not limited to, fractures after 50 years of age, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, and thin/small build.

Don't routinely repeat DEXA scans more often than once every two years.22

USPSTF, NOF

Don't perform population-based screening for 25-OH-vitamin D deficiency.15

Endocrine Society guideline

Don't screen for carotid artery stenosis in asymptomatic adult patients.2

USPSTF

Pulmonary medicine

Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.13

AAP, NHLBI guidelines

Don't routinely use bronchodilators in children with bronchiolitis.13

AAP guideline, Cochrane Database of Systematic Reviews

Don't use systemic corticosteroids in children younger than two years with an uncomplicated lower respiratory tract infection.13

AAP guideline, Cochrane Database of Systematic Reviews

Don't use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.13

AAP guideline

Don't diagnose or manage asthma without spirometry.1*

NAEPP Expert Panel report

In patients with a low pretest probability of venous thromboembolism, obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don't obtain imaging studies as the initial diagnostic test.3

ACEP, AAFP, American College of Physicians guidelines

Don't image for suspected PE without moderate or high pretest probability.10*

ACEP, European Society of Cardiology guidelines

Avoid using a CT angiogram to diagnose PE in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.8

Expert consensus

Rheumatologic

Don't test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.22

Centers for Disease Control and Prevention, IDSA guidelines

Don't test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease.22

American College of Rheumatology guidelines

Don't prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic DMARDs).22

American College of Rheumatology guidelines

Surgical

Avoid routine preoperative testing for low-risk surgeries without a clinical indication.15

Cochrane Database of Systematic Reviews

Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.3,10 *

ACR Appropriateness Criteria

Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.23

ACC/AHA, European Society of Cardiology guidelines

Avoid cardiovascular stress testing for patients undergoing low-risk surgery.17

ACC/AHA guideline

Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.6

ACC/AHA guidelines

Don't order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.5

ACC/AHA guideline

Don't initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.23

ACC/AHA guideline

Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.23

Expert consensus

Urologic

Don't perform ultrasound on boys with cryptorchidism.24

Systematic review and meta-analysis

Don't prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.24

AUA guideline

Don't order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia.24

AUA guideline

Don't treat an elevated PSA with antibiotics for patients not experiencing other symptoms.24

RCT

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).7

IDSA guideline, Joint Commission


NOTE: This table is organized alphabetically by primary discipline. The sponsoring organizations of each recommendation are listed in the footnotes. Rationale, comments, and references can be found online at http://www.aafp.org/afp/choosingwisely

1–American Academy of Allergy, Asthma and Immunology

2–American Academy of Family Physicians

3–American College of Physicians

4–American College of Cardiology

5–Society of Cardiovascular Computed Tomography

6–American Society of Echocardiography

7–Society of Hospital Medicine (Adult)

8–Society of Nuclear Medicine and Molecular Imaging

9–American Academy of Hospice and Palliative Medicine

10–American College of Radiology

11–American Geriatrics Society

12–American Gastroenterological Association

13–Society of Hospital Medicine (Pediatric)

14–American Academy of Pediatrics

15–American Society for Clinical Pathology

16–American College of Obstetricians and Gynecologists

17–Society for Vascular Medicine

18–American Society of Nephrology

19–American Academy of Neurology

20–American Academy of Ophthalmology

21–American Academy of Otolaryngology–Head and Neck Surgery Foundation

22–American College of Rheumatology

23–Society of Thoracic Surgeons

24–American Urological Association

*—From Phase 1 of the Choosing Wisely initiative (2012).

AAAAI = American Academy of Allergy, Asthma and Immunology; AAFP = American Academy of Family Physicians; AAN = American Academy of Neurology; AAO-HNSF = American Academy of Otolaryngology–Head and Neck Surgery Foundation; AAP = American Academy of Pediatrics; ACC = American College of Cardiology; ACCP = American College of Chest Physicians; ACEP = American College of Emergency Physicians; ACOG = American College of Obstetricians and Gynecologists; ACR = American College of Radiology; ACS = American Cancer Society; AGA = American Gastroenterological Association; AGS = American Geriatrics Society; AHA = American Heart Association; ANA = antinuclear antibody; ASCCP = American Society for Colposcopy and Cervical Pathology; ASCP = American Society for Clinical Pathology; AUA = American Urological Association; CAD = coronary artery disease; CT = computed tomography; DEXA = dual-energy x-ray absorptiometry; DMARD = disease-modifying antirheumatic drug; DVT = deep vein thrombosis; GERD = gastroesophageal reflux disease; HPV = human papillomavirus; ICSI = Institute for Clinical Systems Improvement; IDSA = Infectious Diseases Society of America; KDQI = Kidney Disease Outcomes Quality Initiative; MRI = magnetic resonance imaging; NAEPP = National Asthma Education and Prevention Program; NHLBI = National Heart, Lung and Blood Institute; NICE = National Institute for Health and Clinical Excellence; NOF = National Osteoporosis Foundation; NSAID = nonsteroidal anti-inflammatory drug; Pap = Papanicolaou; PE = pulmonary embolism; PSA = prostate-specific antigen; RCT = randomized controlled trial; USPSTF = U.S. Preventive Services Task Force; V/Q = ventilation/perfusion.

Table.   Interventions to Improve Health Care Quality and Reduce Harm: Consolidated Items Relevant to Primary Care from the Choosing Wisely Campaign

View Table

Table.

Interventions to Improve Health Care Quality and Reduce Harm: Consolidated Items Relevant to Primary Care from the Choosing Wisely Campaign

RecommendationSource

Allergy and immunologic

Don't routinely do diagnostic testing in patients with chronic urticaria.1

AAAAI guideline

Cardiovascular

Don't order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients.2,3*

USPSTF

Don't perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.4*

ACC/AHA guidelines

Don't order coronary artery calcium scoring for screening purposes on low-risk asymptomatic individuals except for those with a family history of premature CAD.5

AHA guideline

Don't routinely order coronary CT angiography for screening asymptomatic individuals.5

USPSTF, ACC/AHA guideline

Don't use coronary artery calcium scoring for patients with known CAD (including stents and bypass grafts).5

ACC/AHA guidelines

Avoid using stress echocardiograms on asymptomatic patients who meet “low-risk” scoring criteria for coronary disease.6

ACC/AHA guidelines

Don't repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no significant pathology.6

ACC/AHA guideline

Don't order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram.6

ACC/AHA guidelines

Avoid transesophageal echocardiography to detect cardiac sources of embolization, if a source has been identified and patient management will not change.6

ACC/AHA guideline

Don't order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation.7

ACC/AHA guidelines

Don't perform routine annual stress testing after coronary artery revascularization.8

ACC/AHA/ACR guideline

Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care.9

Expert consensus

Emergency medicine

Don't do CT for evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.10*

ACR Appropriateness Criteria

Don't use coronary CT angiography in high-risk emergency department patients presenting with acute chest pain.5

RCTs

NOTE: Risk defined by the Thrombolysis In Myocardial Infarction risk score for unstable angina/acute coronary syndromes.

Endocrinologic

Don't medicate to achieve tight glycemic control in older adults. Moderate control is generally better.11

RCTs

Don't use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.8

Expert consensus

Gastroenterologic

Long-term acid suppression therapy for GERD should be titrated to the lowest effective dose.12*

AGA position statement

Don't treat gastroesophageal reflux in infants routinely with acid suppression therapy.13

Systematic review of RCTs

For a patient with functional abdominal pain syndrome, CT scans should not be repeated unless there is a major change in clinical findings or symptoms.12*

U.S. Food and Drug Administration

CT scans are not necessary in the routine evaluation of abdominal pain.14

Expert consensus

Don't prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications.7

Expert consensus

Don't recommend percutaneous feeding tubes in patients with advanced dementia.9,11

RCT

Don't use topical lorazepam (Ativan), diphenhydramine (Benadryl), and haloperidol (Haldol) (“ABH”) gel for nausea.9

Expert consensus

Geriatric

Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.11

AGS guideline

Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.11

AGS, NICE guidelines

Don't delay palliative care for patients with a serious illness who have physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment. 9

RCTs

Gynecologic

Don't perform low-risk HPV testing.15

ACS/ASCCP/ASCP guideline

Don't treat patients who have mild cervical dysplasia of less than two years' duration.16

ASCCP, ACOG guidelines

Hematologic

Don't perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability.7

Prospective studies

Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke.7

AABB guideline

Don't do workup for clotting disorder (order hypercoagulable testing) for patients who develop first episode of DVT in the setting of a known cause.17

Prospective cohort studies

Don't reimage DVT in the absence of a clinical change.17

ACCP guideline

Infectious disease

Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).14

AAP, IDSA guidelines

Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. 11

IDSA guideline

Nephrologic

Avoid NSAIDs in individuals with hypertension or heart failure or chronic kidney disease of all causes, including diabetes.18*

National Kidney Foundation KDQI

Don't screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.17

ACC/AHA guideline

Neurologic

Don't do imaging for uncomplicated headache.10

AAN, ACR guidelines

Don't perform electroencephalography for headaches.19

AAN guideline

CT scans are not necessary in the evaluation of minor head injuries.14

Systematic review and meta-analysis

Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.14

AAP guideline

In the evaluation of simple syncope and a normal neurologic examination, don't obtain brain imaging studies (CT or MRI).3

ACR, NICE guidelines

Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.19

AHA, NICE guidelines

Don't use opioids or butalbital for migraine except as a last resort.19

ICSI, U.S. Headache Consortium guidelines

Obstetric

Don't schedule non–medically-indicated (elective) inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.2,16

California Department of Public Health

Avoid elective, non–medically-indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.2,16

AAP/ACOG guidelines, Cochrane Database of Systematic Reviews

Ophthalmologic

Don't order antibiotics for adenoviral conjunctivitis.20

Cochrane Database of Systematic Reviews

Don't perform preoperative medical tests for eye surgery unless there are specific medical indications.20

Cochrane Database of Systematic Reviews

Orthopedic

Don't perform imaging for low back pain within the first six weeks unless red flags are present.2,3*

Agency for Health Care Policy and Research, Cochrane Database of Systematic Reviews

NOTE: Red flags include, but are not limited to, severe or progressive neurologic deficits or when serious underlying conditions such as osteomyelitis are suspected.

Otolaryngologic

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 at least seven days or symptoms worsen after initial clinical improvement.1,2,21*

Annals of Internal Medicine, Cochrane Database of Systematic Reviews

Don't routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.21

AAO-HNSF practice guideline

Don't prescribe oral antibiotics for uncomplicated external otitis.21

AAO-HNSF practice guideline

Don't prescribe oral antibiotics for uncomplicated tympanostomy tube otorrhea.21

RCT

Don't order CT scan of the head/brain for sudden hearing loss.21

AAO-HNSF practice guideline

Don't obtain CT or MRI in patients with a primary complaint of hoarseness prior to examining the larynx.21

AAO-HNSF practice guideline

Pediatric

Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children younger than four years.14

ACCP guideline

Preventive medicine

Don't perform routine annual cervical cytology screening (Pap tests) in women 30 to 65 years of age.16

ACS/ASCCP/ASCP, ACOG guidelines

Don't screen women younger than 30 years for cervical cancer with HPV testing, alone or in combination with cytology.2

USPSTF

Don't screen women older than 65 years for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.2

USPSTF

Don't perform Pap tests in patients younger than 21 years or in women after hysterectomy for benign disease.2*

ACOG (for age), USPSTF (for hysterectomy)

Don't screen for ovarian cancer in asymptomatic women at average risk.16

USPSTF

Don't use positron emission tomography/CT for cancer screening in healthy individuals.8

Expert consensus

Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.18*

American Society of Nephrology

Don't repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.12*

U.S. Multi-Society Task Force on Colorectal Cancer

Don't use DEXA to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors.2*

American Association of Clinical Endocrinologists, American College of Preventive Medicine, NOF, USPSTF

NOTE: Risk factors include, but are not limited to, fractures after 50 years of age, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, and thin/small build.

Don't routinely repeat DEXA scans more often than once every two years.22

USPSTF, NOF

Don't perform population-based screening for 25-OH-vitamin D deficiency.15

Endocrine Society guideline

Don't screen for carotid artery stenosis in asymptomatic adult patients.2

USPSTF

Pulmonary medicine

Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.13

AAP, NHLBI guidelines

Don't routinely use bronchodilators in children with bronchiolitis.13

AAP guideline, Cochrane Database of Systematic Reviews

Don't use systemic corticosteroids in children younger than two years with an uncomplicated lower respiratory tract infection.13

AAP guideline, Cochrane Database of Systematic Reviews

Don't use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.13

AAP guideline

Don't diagnose or manage asthma without spirometry.1*

NAEPP Expert Panel report

In patients with a low pretest probability of venous thromboembolism, obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don't obtain imaging studies as the initial diagnostic test.3

ACEP, AAFP, American College of Physicians guidelines

Don't image for suspected PE without moderate or high pretest probability.10*

ACEP, European Society of Cardiology guidelines

Avoid using a CT angiogram to diagnose PE in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.8

Expert consensus

Rheumatologic

Don't test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.22

Centers for Disease Control and Prevention, IDSA guidelines

Don't test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease.22

American College of Rheumatology guidelines

Don't prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic DMARDs).22

American College of Rheumatology guidelines

Surgical

Avoid routine preoperative testing for low-risk surgeries without a clinical indication.15

Cochrane Database of Systematic Reviews

Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.3,10 *

ACR Appropriateness Criteria

Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery.23

ACC/AHA, European Society of Cardiology guidelines

Avoid cardiovascular stress testing for patients undergoing low-risk surgery.17

ACC/AHA guideline

Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.6

ACC/AHA guidelines

Don't order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.5

ACC/AHA guideline

Don't initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.23

ACC/AHA guideline

Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.23

Expert consensus

Urologic

Don't perform ultrasound on boys with cryptorchidism.24

Systematic review and meta-analysis

Don't prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.24

AUA guideline

Don't order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia.24

AUA guideline

Don't treat an elevated PSA with antibiotics for patients not experiencing other symptoms.24

RCT

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).7

IDSA guideline, Joint Commission


NOTE: This table is organized alphabetically by primary discipline. The sponsoring organizations of each recommendation are listed in the footnotes. Rationale, comments, and references can be found online at http://www.aafp.org/afp/choosingwisely

1–American Academy of Allergy, Asthma and Immunology

2–American Academy of Family Physicians

3–American College of Physicians

4–American College of Cardiology

5–Society of Cardiovascular Computed Tomography

6–American Society of Echocardiography

7–Society of Hospital Medicine (Adult)

8–Society of Nuclear Medicine and Molecular Imaging

9–American Academy of Hospice and Palliative Medicine

10–American College of Radiology

11–American Geriatrics Society

12–American Gastroenterological Association

13–Society of Hospital Medicine (Pediatric)

14–American Academy of Pediatrics

15–American Society for Clinical Pathology

16–American College of Obstetricians and Gynecologists

17–Society for Vascular Medicine

18–American Society of Nephrology

19–American Academy of Neurology

20–American Academy of Ophthalmology

21–American Academy of Otolaryngology–Head and Neck Surgery Foundation

22–American College of Rheumatology

23–Society of Thoracic Surgeons

24–American Urological Association

*—From Phase 1 of the Choosing Wisely initiative (2012).

AAAAI = American Academy of Allergy, Asthma and Immunology; AAFP = American Academy of Family Physicians; AAN = American Academy of Neurology; AAO-HNSF = American Academy of Otolaryngology–Head and Neck Surgery Foundation; AAP = American Academy of Pediatrics; ACC = American College of Cardiology; ACCP = American College of Chest Physicians; ACEP = American College of Emergency Physicians; ACOG = American College of Obstetricians and Gynecologists; ACR = American College of Radiology; ACS = American Cancer Society; AGA = American Gastroenterological Association; AGS = American Geriatrics Society; AHA = American Heart Association; ANA = antinuclear antibody; ASCCP = American Society for Colposcopy and Cervical Pathology; ASCP = American Society for Clinical Pathology; AUA = American Urological Association; CAD = coronary artery disease; CT = computed tomography; DEXA = dual-energy x-ray absorptiometry; DMARD = disease-modifying antirheumatic drug; DVT = deep vein thrombosis; GERD = gastroesophageal reflux disease; HPV = human papillomavirus; ICSI = Institute for Clinical Systems Improvement; IDSA = Infectious Diseases Society of America; KDQI = Kidney Disease Outcomes Quality Initiative; MRI = magnetic resonance imaging; NAEPP = National Asthma Education and Prevention Program; NHLBI = National Heart, Lung and Blood Institute; NICE = National Institute for Health and Clinical Excellence; NOF = National Osteoporosis Foundation; NSAID = nonsteroidal anti-inflammatory drug; Pap = Papanicolaou; PE = pulmonary embolism; PSA = prostate-specific antigen; RCT = randomized controlled trial; USPSTF = U.S. Preventive Services Task Force; V/Q = ventilation/perfusion.

Address correspondence to Jay Siwek, MD, at siwekj@georgetown.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


EDITOR'S NOTE: Dr. Siwek is editor of AFP and Dr. Lin is associate deputy editor for AFP Online.

REFERENCES

1. Siwek J. Choosing Wisely: Top interventions to improve health and reduce harm, while lowering costs. Am Fam Physician. 2012;86(2):128–133.

2. Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med. 2012;172(2):171–178.

3. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142–148.

4. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pre-test probability of serious disease: systematic review and meta-analysis. JAMA Intern Med. 2013;173(6):407–416.


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