Search recommendations from the Choosing Wisely campaign


Search by one or more of the following criteria.

Keyword:
Topic Areas:
Sponsors:
Source:
Show columns
Topic Areas Rationale Sponsoring Organizations Sources
To see supporting references, click on the Recommendation.
Recommendation Topic Areas Rationale Sponsoring Organizations Sources
Recommendation : Don’t routinely do diagnostic testing in patients with chronic urticaria. Topic Areas : • Allergy and immunologic
Rationale : In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost-effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • American Academy of Allergy, Asthma and Immunology guidelines
Recommendation : Don’t order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients. Topic Areas : • Cardiovascular
• Preventive Medicine
Rationale : There is little evidence that detection of coronary artery stenosis improves health outcomes in asymptomatic patients at low risk of coronary heart disease. False-positive test results are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis. Potential harms of routine annual screening exceed the potential benefit. Sponsoring organizations : •  American College of Physicians
•  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : 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. Topic Areas : • Cardiovascular
Rationale : Asymptomatic, low-risk patients account for up to 45% of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40 years; peripheral arterial disease; or greater than 2% yearly risk of coronary heart disease events. Sponsoring organizations : •  American College of Cardiology
Sources : • ACC/AHA guidelines
Recommendation : 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. Topic Areas : • Cardiovascular
• Preventive Medicine
Rationale : Net reclassification of risk by coronary artery calcium scoring, when added to clinical risk scoring, is least effective in low-risk individuals. Sponsoring organizations : •  Society of Cardiovascular Computed Tomography
Sources : • American Heart Association guidelines
Recommendation : Don’t routinely order coronary CT angiography for screening asymptomatic individuals. Topic Areas : • Cardiovascular
• Preventive Medicine
Rationale : Coronary CT angiography findings of coronary artery disease stenosis severity rarely offer incremental discrimination over coronary artery calcium scoring in asymptomatic individuals. Sponsoring organizations : •  Society of Cardiovascular Computed Tomography
Sources : • ACC/AHA guidelines
• U.S. Preventive Services Task Force
Recommendation : Don’t use coronary artery calcium scoring for patients with known coronary artery disease (CAD) (including stents and bypass grafts). Topic Areas : • Cardiovascular
Rationale : Coronary artery calcium scoring is used for evaluation of individuals without known CAD and offers limited incremental prognostic value for individuals with known CAD, such as those with stents and bypass grafts. Sponsoring organizations : •  Society of Cardiovascular Computed Tomography
Sources : • ACC/AHA guidelines
Recommendation : Avoid using stress echocardiograms on asymptomatic patients who meet "low-risk" scoring criteria for coronary disease. Topic Areas : • Cardiovascular
Rationale : Stress echocardiography is mostly used in symptomatic patients to assist in the diagnosis of obstructive coronary artery disease. There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors. Sponsoring organizations : •  American Society of Echocardiography
Sources : • ACC/AHA guidelines
Recommendation : Don’t repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no significant pathology. Topic Areas : • Cardiovascular
Rationale : Repeat imaging to address the same question, when no pathology has been previously found and there has been no clinical change in the patient’s condition, is not indicated. Sponsoring organizations : •  American Society of Echocardiography
Sources : • ACC/AHA guidelines
Recommendation : Don’t order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram. Topic Areas : • Cardiovascular
Rationale : Trace mitral, tricuspid, and pulmonic regurgitation can be detected in 70% to 90% of normal individuals and has no adverse clinical implications. The clinical significance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown. Sponsoring organizations : •  American Society of Echocardiography
Sources : • ACC/AHA guidelines
Recommendation : Avoid transesophageal echocardiography to detect cardiac sources of embolization if a source has been identified and patient management will not change. Topic Areas : • Cardiovascular
Rationale : Tests whose results will not alter management should not be ordered. Protocol-driven testing can be useful if it serves as a reminder not to omit a test or procedure, but should always be individualized to the particular patient. While transesophageal echocardiography is safe, even the small degree of risk associated with a procedure is not justified if there is no expected clinical benefit. Sponsoring organizations : •  American Society of Echocardiography
Sources : • ACC/AHA guidelines
Recommendation : Don’t order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. Topic Areas : • Cardiovascular
Rationale : Telemetric monitoring is of limited utility or measurable benefit in low-risk cardiac chest pain patients with normal electrocardiogram. Published guidelines provide clear indications for the use of telemetric monitoring in patients, which are contingent upon frequency, severity, duration, and conditions under which the symptoms occur. Inappropriate use of telemetric monitoring is likely to increase cost of care and produce false positives potentially resulting in errors in patient management. Sponsoring organizations : •  Society of Hospital Medicine (Adult)
Sources : • ACC/AHA guidelines
Recommendation : Don’t perform routine annual stress testing after coronary artery revascularization. Topic Areas : • Cardiovascular
Rationale : Routine annual stress testing in patients without symptoms does not usually change management. This practice may lead to unnecessary testing without any proven impact on patient management. Sponsoring organizations : •  Society of Nuclear Medicine and Molecular Imaging
Sources : • ACC/AHA/ACR guidelines
Recommendation : Don’t leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care. Topic Areas : • Geriatric Medicine
• Cardiovascular
Rationale : In about a quarter of patients with implantable cardioverter-defibrillators, the defibrillator fires within weeks preceding death. For patients with advanced irreversible diseases, defibrillator shocks rarely prevent death, may be painful to patients, and are distressing to caregivers/family members. Currently there are no formal practice protocols to address deactivation; fewer than 10% of hospices have official policies. Advance care planning discussions should include the option of deactivating the implantable cardioverter-defibrillator when it no longer supports the patient’s goals. Sponsoring organizations : •  American Academy of Hospice and Palliative Medicine
Sources : • Expert consensus
Recommendation : Don’t do CT for evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. Topic Areas : • Pediatric
• Surgical
• Emergency medicine
Rationale : Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks, and has excellent accuracy, with reported sensitivity and specificity of 94%. Sponsoring organizations : •  American College of Radiology
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t use coronary CT angiography in high-risk emergency department patients presenting with acute chest pain. note: Risk defined by the Thrombolysis In Myocardial Infarction risk score for unstable angina/acute coronary syndromes. Topic Areas : • Cardiovascular
• Emergency medicine
Rationale : To date, randomized control trials evaluating use of coronary CT angiography for individuals presenting with acute chest pain in the emergency department have been limited to low- or low-intermediate­­–risk individuals. Sponsoring organizations : •  Society of Cardiovascular Computed Tomography
Sources : • Randomized controlled trials
Recommendation : Don’t medicate to achieve tight glycemic control in older adults. Moderate control is generally better. Topic Areas : • Endocrinologic
• Geriatric Medicine
Rationale : There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among nonolder adults, except for reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Given the long time frame to achieve theorized microvascular benefits of tight control, glycemic goals should reflect patient goals, health status, and life expectancy. Sponsoring organizations : •  American Geriatrics Society
Sources : • Randomized controlled trials
Recommendation : Don’t use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function. Topic Areas : • Endocrinologic
Rationale : Nuclear medicine thyroid scanning does not conclusively determine whether thyroid nodules are benign or malignant. Cold nodules on thyroid scans will still require biopsy. Nuclear medicine thyroid scans are useful to evaluate the functional status of thyroid nodules in patients who are hyperthyroid. Sponsoring organizations : •  Society of Nuclear Medicine and Molecular Imaging
Sources : • Expert consensus
Recommendation : Long-term acid suppression therapy for gastroesophageal reflux disease should be titrated to the lowest effective dose. Topic Areas : • Gastroenterologic
Rationale : The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient’s quality of life rather than as a disease control measure. Sponsoring organizations : •  American Gastroenterological Association
Sources : • American Gastroenterological Association position statement
Recommendation : Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy. Topic Areas : • Pediatric
• Gastroenterologic
Rationale : Antireflux therapy has been demonstrated to have no effect in reducing the symptoms of gastroesophageal reflux disease (GERD) in children. Concerns regarding the use of proton pump inhibitor therapy in infants include an inability to definitively diagnose pediatric patients according to the established criteria of GERD, lack of documented efficacy of acid suppression therapy in infants, and the potential adverse effects associated with acid suppression therapy. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • Systematic review of RCTs
Recommendation : 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. Topic Areas : • Gastroenterologic
Rationale : There is a small, but measurable increase in one’s cancer risk from x-ray exposure. An abdominal CT scan is one of the higher radiation exposure x-rays — equivalent to three years of natural background radiation. Due to this risk and the high costs of this procedure, CT scans should be performed only when they are likely to provide useful information that changes patient management. Sponsoring organizations : •  American Gastroenterological Association
Sources : • U.S. Food and Drug Administration
Recommendation : CT scans are not necessary in the routine evaluation of abdominal pain. Topic Areas : • Pediatric
• Gastroenterologic
• Emergency medicine
Rationale : Utilization of CT imaging in the emergency department evaluation of children with abdominal pain is increasing. The increased lifetime risk of cancer due to excess radiation exposure is of special concern given the acute sensitivity of children’s organs. There also is the potential for radiation overdose with inappropriate CT protocols. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • Expert consensus
Recommendation : Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. Topic Areas : • Gastroenterologic
Rationale : According to published guidelines, medications for stress ulcer prophylaxis are not recommended for adult patients in non-intensive care unit settings. Histamine H2-receptor antagonists and proton pump inhibitors commonly used to treat stress ulcers are associated with adverse drug events and increased medication costs, and commonly enhance susceptibility to community-acquired nosocomial pneumonia and Clostridium difficile. Adherence to therapeutic guidelines will aid health care providers in reducing treatment of patients without clinically important risk factors for gastrointestinal bleeding. Sponsoring organizations : •  Society of Hospital Medicine (Adult)
Sources : • Expert consensus
Recommendation : Don’t recommend percutaneous feeding tubes in patients with advanced dementia. Topic Areas : • Geriatric Medicine
• Gastroenterologic
Rationale : Careful hand feeding for patients with severe dementia is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and patient comfort. Food is the preferred nutrient. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers. Sponsoring organizations : •  American Academy of Hospice and Palliative Medicine
•  American Geriatrics Society
Sources : • Randomized controlled trials
Recommendation : Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), and haloperidol (Haldol) (“ABH”) gel for nausea. Topic Areas : • Gastroenterologic
Rationale : Topical drugs can be safe and effective, such as topical nonsteroidal anti-inflammatory drugs for local arthritis symptoms. However, while topical gels are commonly prescribed in hospice practice, antinausea gels have not been proven effective in any large, well-designed or placebo-controlled trials. The active ingredients in ABH are not absorbed to systemic levels that could be effective. Only diphenhydramine (Benadryl) is absorbed via the skin, and then only after several hours and erratically at subtherapeutic levels. It is therefore not appropriate for “as needed” use. The use of agents given via inappropriate routes may delay or prevent the use of more effective interventions. Sponsoring organizations : •  American Academy of Hospice and Palliative Medicine
Sources : • Expert consensus
Recommendation : Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Topic Areas : • Geriatric Medicine
• Psychiatric and Psychologic
Rationale : Large-scale studies consistently show that the risk of motor vehicle accidents, falls, and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers, and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies. Sponsoring organizations : •  American Geriatrics Society
Sources : • American Geriatrics Society guidelines
Recommendation : Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. Topic Areas : • Geriatric Medicine
• Neurologic
• Psychiatric and Psychologic
Rationale : People with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary. Sponsoring organizations : •  American Geriatrics Society
Sources : • National Institute for Health and Clinical Excellence guidelines
• American Geriatrics Society guidelines
Recommendation : 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. Topic Areas : • Geriatric Medicine
Rationale : Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care, and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations. Sponsoring organizations : •  American Academy of Hospice and Palliative Medicine
Sources : • Randomized controlled trials
Recommendation : Don’t perform low-risk human papillomavirus (HPV) testing. Topic Areas : • Gynecologic
Rationale : National guidelines provide for HPV testing in patients with certain abnormal Pap smears and in other select clinical indications. The presence of high-risk HPV leads to more frequent examination or more aggressive investigation (e.g., colposcopy and biopsy). There is no medical indication for low-risk HPV testing (HPV types that cause genital warts or very minor cell changes on the cervix) because the infection is not associated with disease progression and there is no treatment or therapy change indicated when low-risk HPV is identified. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • ACS/ASCCP/ASCP guidelines
Recommendation : Don’t treat patients who have mild cervical dysplasia of less than two years’ duration. Topic Areas : • Gynecologic
• Oncologic
Rationale : Mild dysplasia (cervical intraepithelial neoplasia 1) is associated with the presence of human papillomavirus (HPV), which does not require treatment in average-risk women. Most women with cervical intraepithelial neoplasia 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment. Sponsoring organizations : •  American College of Obstetricians and Gynecologists
Sources : • American Society for Colposcopy and Cervical Pathology guidelines
• American College of Obstetricians and Gynecologists guidelines
Recommendation : Don’t perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability. Topic Areas : • Hematologic
Rationale : Hospitalized patients frequently have considerable volumes of blood drawn (phlebotomy) for diagnostic testing during short periods of time. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals. Sponsoring organizations : •  Society of Hospital Medicine (Adult)
Sources : • Prospective studies
Recommendation : 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. Topic Areas : • Hematologic
Rationale : The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients. The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration. According to a National Institutes of Health Consensus Conference, no single criterion should be used as an indication for red cell component therapy. Instead, multiple factors related to the patient’s clinical status and oxygen delivery needs should be considered. Sponsoring organizations : •  Society of Hospital Medicine (Adult)
Sources : • AABB guidelines
Recommendation : Don’t do workup for clotting disorder (order hyper-coagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause. Topic Areas : • Hematologic
Rationale : Lab tests to look for a clotting disorder will not alter treatment of a venous blood clot, even if an abnormality is found. DVT is a very common disorder, and recent discoveries of clotting abnormalities have led to increased testing without proven benefit. Sponsoring organizations : •  Society for Vascular Medicine
Sources : • Prospective cohort studies
Recommendation : Don’t reimage deep vein thrombosis in the absence of a clinical change. Topic Areas : • Hematologic
Rationale : Repeat ultrasound images to evaluate “response” of venous clot to therapy does not alter treatment. Sponsoring organizations : •  Society for Vascular Medicine
Sources : • American College of Chest Physicians guidelines
Recommendation : Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis). Topic Areas : • Infectious disease
Rationale : Although overall antibiotic subscription rates for children have fallen, they still remain alarmingly high. Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contributes to higher health care costs and the risks of adverse events. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American Academy of Pediatrics guidelines
• Infectious Diseases Society of America guidelines
Recommendation : Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Topic Areas : • Geriatric Medicine
• Urologic
• Infectious disease
Rationale : Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria have been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated. Sponsoring organizations : •  American Geriatrics Society
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in individuals with hypertension or heart failure or chronic kidney disease of all causes, including diabetes. Topic Areas : • Nephrologic
• Cardiovascular
Rationale : The use of NSAIDs, including cyclooxygenase type 2 inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention, and worsen kidney function in these individuals. Other agents such as acetaminophen or tramadol, or short-term use of narcotic analgesics, may be safer than and as effective as NSAIDs. Sponsoring organizations : •  American Society of Nephrology
Sources : • National Kidney Foundation Kidney Disease Outcomes Quality Initiative
Recommendation : Don’t screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present. Topic Areas : • Nephrologic
• Cardiovascular
Rationale : Performing surgery or angioplasty to improve circulation to the kidneys has no proven preventive benefit, and shouldn’t be considered unless there is evidence of symptoms, such as elevated blood pressure or decreased renal function. Sponsoring organizations : •  Society for Vascular Medicine
Sources : • ACC/AHA guidelines
Recommendation : Don’t do imaging for uncomplicated headache. Topic Areas : • Neurologic
Rationale : Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being. Sponsoring organizations : •  American College of Radiology
Sources : • American Academy of Neurology guidelines
• American College of Radiology guidelines
Recommendation : Don’t perform electro-encephalography for headaches. Topic Areas : • Neurologic
Rationale : Electroencephalography has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes, and increases cost. Recurrent headache is the most common pain problem, affecting 15% to 20% of people. Sponsoring organizations : •  American Academy of Neurology
Sources : • American Academy of Neurology guidelines
Recommendation : CT scans are not necessary in the evaluation of minor head injuries. Topic Areas : • Pediatric
• Neurologic
• Emergency medicine
Rationale : Head injuries occur commonly in children and adolescents. Approximately 50% of children who visit hospital emergency departments with a head injury are given a CT scan, a considerable number of which are unnecessary. Unnecessary exposure to x-rays poses considerable danger to children, including increasing the lifetime risk of cancer because a child’s brain tissue is more sensitive to ionizing radiation. They also impose undue costs to the health care system. Clinical observation prior to CT decision making for children with minor head injuries is an effective approach. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • Systematic review and meta-analysis
Recommendation : Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure. Topic Areas : • Pediatric
• Neurologic
• Emergency medicine
Rationale : CT scanning is associated with radiation exposure that may escalate future cancer risk. MRI also has associated risks from required sedation and high cost. The literature does not support the use of skull films in the evaluation of a child with a febrile seizure. Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child’s fever. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American Academy of Pediatrics guidelines
Recommendation : In the evaluation of simple syncope and a normal neurologic examination don’t obtain brain imaging studies (CT or MRI). Topic Areas : • Neurologic
Rationale : In patients with witnessed syncope, but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system cause of the event is extremely low and patient outcomes are not improved with brain imaging studies. Sponsoring organizations : •  American College of Physicians
Sources : • National Institute for Health and Clinical Excellence guidelines
• American College of Radiology guidelines
Recommendation : Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Topic Areas : • Neurologic
Rationale : Occlusive carotid artery disease does not cause fainting but rather causes focal neurologic deficits such as unilateral weakness. Thus, carotid imaging will not identify the cause of the fainting and increases cost. Fainting is a frequent complaint, affecting 40% of people during their lifetime. Sponsoring organizations : •  American Academy of Neurology
Sources : • National Institute for Health and Clinical Excellence guidelines
• American Heart Association guidelines
Recommendation : Don’t use opioids or butalbital for migraine except as a last resort. Topic Areas : • Neurologic
Rationale : Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioids and butalbital can worsen headaches. Opioids should be reserved for those with medical conditions precluding use of migraine-specific treatments or for those who fail these treatments. Sponsoring organizations : •  American Academy of Neurology
Sources : • U.S. Headache Consortium guidelines
• Institute for Clinical Systems Improvement
Recommendation : Don’t schedule non–medically-indicated (elective) inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age. Topic Areas : • Obstetrical
Rationale : 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. Sponsoring organizations : •  American Academy of Family Physicians
•  American College of Obstetricians and Gynecologists
Sources : • California Department of Public Health
Recommendation : Avoid elective, non–medically-indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. Topic Areas : • Obstetrical
Rationale : 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. Sponsoring organizations : •  American Academy of Family Physicians
•  American College of Obstetricians and Gynecologists
Sources : • AAP/ACOG guidelines
• Cochrane Database of Systematic Reviews
Recommendation : Don’t order antibiotics for adenoviral conjunctivitis. Topic Areas : • Ophthalmologic
• Infectious disease
Rationale : Adenoviral conjunctivitis and bacterial conjunctivitis are different forms of infection that can be diagnosed by the ophthalmologist by clinical signs and symptoms, and if needed, by cultures. Antibiotics are of use for patients with bacterial conjunctivitis, particularly with moderate to severe bacterial conjunctivitis. However, they are not useful for adenoviral conjunctivitis and the overuse of antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments. In cases of diagnostic uncertainty, patients may be followed closely to see if their condition resolves on its own or if further treatment is required. Sponsoring organizations : •  American Academy of Ophthalmology
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications. Topic Areas : • Surgical
• Ophthalmologic
Rationale : For many, preoperative tests are not necessary and add costs because eye surgeries are not lengthy and don’t pose serious risks. An electrocardiogram should be ordered if patients have heart disease. A blood glucose test should be ordered if patients have diabetes. A potassium test should be ordered if patients are on diuretics. In general, patients scheduled for surgery do not need medical tests unless the history or physical examination indicates the need for a test (e.g., like the existence of conditions noted above, heart disease, diabetes, use of diuretics, etc.). Institutional policies should consider these issues. Sponsoring organizations : •  American Academy of Ophthalmology
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t perform imaging for low back pain within the first six weeks unless red flags are present. note: Red flags include, but are not limited to, severe or progressive neurologic deficits or when serious underlying conditions such as osteomyelitis are suspected. Topic Areas : • Orthopedic
Rationale : Imaging of the lumbar 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. Sponsoring organizations : •  American College of Physicians
•  American Academy of Family Physicians
Sources : • Agency for Health Care Policy and Research
• Cochrane Database of Systematic Reviews
Recommendation : 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. Topic Areas : • Otolaryngologic
• Infectious disease
Rationale : Most cases of maxillary sinusitis in the ambulatory setting are caused by a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80% of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
•  American Academy of Family Physicians
•  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • Cochrane Database of Systematic Reviews
• Annals of Internal Medicine
Recommendation : Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis. Topic Areas : • Otolaryngologic
• Infectious disease
Rationale : Imaging of the paranasal sinuses, including plain film radiography, CT, and MRI, is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis. Acute rhino-sinusitis is defined as up to four weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both. Imaging is costly and may expose patients to radiation. Imaging may be appropriate in patients with a complication of acute rhinosinusitis, patients with comorbidities that predispose them to complications, and patients in whom an alternative diagnosis is suspected. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • American Academy of Otolaryngology–Head and Neck Surgery Foundation practice guidelines
Recommendation : Don’t prescribe oral antibiotics for uncomplicated external otitis. Topic Areas : • Otolaryngologic
• Infectious disease
Rationale : Oral antibiotics have significant adverse effects and have been shown to be no more effective than topical antibiotics. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • American Academy of Otolaryngology–Head and Neck Surgery Foundation practice guidelines
Recommendation : Don’t prescribe oral antibiotics for uncomplicated tympanostomy tube otorrhea. Topic Areas : • Otolaryngologic
• Pediatric
• Infectious disease
Rationale : Oral antibiotics have significant adverse effects and have been shown to be no more effective than topical antibiotics. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • Randomized controlled trials
Recommendation : Don’t order CT scan of the head/brain for sudden hearing loss. Topic Areas : • Otolaryngologic
Rationale : CT scanning is expensive, exposes the patient to radiation, and offers no useful information that would improve initial management. CT scanning may be appropriate in patients with focal neurologic findings, a history of trauma, or chronic ear disease. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • American Academy of Otolaryngology–Head and Neck Surgery Foundation practice guidelines
Recommendation : Don’t obtain CT or MRI in patients with a primary complaint of hoarseness prior to examining the larynx. Topic Areas : • Otolaryngologic
Rationale : Examination of the larynx with mirror or fiberoptic scope is the primary method for evaluating patients with hoarseness. Imaging is unnecessary in most patients and is both costly and has potential for radiation exposure. After laryngoscopy, evidence supports the use of imaging to further evaluate 1) vocal fold paralysis or 2) a mass or lesion of the larynx. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • American Academy of Otolaryngology–Head and Neck Surgery Foundation practice guidelines
Recommendation : Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children younger than four years. Topic Areas : • Pediatric
Rationale : Research has shown these products offer little benefit to young children, and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American College of Chest Physicians guidelines
Recommendation : Don’t perform routine annual cervical cytology screening (Pap tests) in women 30 to 65 years of age. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : In average-risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at three-year intervals. However, a well-woman visit should occur annually for patients with their health care provider to discuss concerns, problems, and have appropriate screening, with consideration of a pelvic examination. Sponsoring organizations : •  American College of Obstetricians and Gynecologists
Sources : • ACS/ASCCP/ASCP guidelines
• American College of Obstetricians and Gynecologists guidelines
Recommendation : Don’t screen women younger than 30 years for cervical cancer with human papillomavirus (HPV) testing, alone or in combination with cytology. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years 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. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : 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. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : There is adequate evidence that screening women older than 65 years for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t perform Pap tests in patients younger than 21 years or in women after hysterectomy for benign disease. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : Most dysplasia in adolescents regresses spontaneously; therefore, screening Pap tests in this age group can lead to unnecessary anxiety, morbidity, and cost. Pap tests have low yield in women after hysterectomy for benign disease, and there is poor evidence for improved outcomes. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
• American College of Obstetricians and Gynecologists guidelines
Recommendation : Don’t screen for ovarian cancer in asymptomatic women at average risk. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : In population studies, there is only fair evidence that screening of asymptomatic women with serum cancer antigen 125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits. Sponsoring organizations : •  American College of Obstetricians and Gynecologists
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t use positron emission tomography/CT for cancer screening in healthy individuals. Topic Areas : • Oncologic
• Preventive Medicine
Rationale : The likelihood of finding cancer in healthy adults is extremely low (around 1%), based on studies using positron emission tomography/CT for screening. Imaging without clear clinical indication is likely to identify harmless findings that lead to more tests, biopsy, or unnecessary surgery. Sponsoring organizations : •  Society of Nuclear Medicine and Molecular Imaging
Sources : • Expert consensus
Recommendation : Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. Topic Areas : • Oncologic
• Nephrologic
• Preventive Medicine
Rationale : Due to high mortality among end-stage renal disease patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen, and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost-effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis, and increased stress. An individualized approach to cancer screening incorporating patients’ cancer risk factors, expected survival, and transplant status is required. Sponsoring organizations : •  American Society of Nephrology
Sources : • American Society of Nephrology
Recommendation : Don’t repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals. Topic Areas : • Oncologic
• Gastroenterologic
• Preventive Medicine
Rationale : A screening colonoscopy every 10 years is the recommended interval for adults without increased risk of colorectal cancer, beginning at 50 years of age. Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population. Therefore, following a high-quality colonoscopy with normal results the next interval for any colorectal screening should be 10 years following that normal colonoscopy. Sponsoring organizations : •  American Gastroenterological Association
Sources : • U.S. Multi-Society Task Force on Colorectal Cancer
Recommendation : Don’t use dual energy x-ray absorptiometry (DEXA) to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors. 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. Topic Areas : • Rheumatologic
• Preventive Medicine
Rationale : Not cost-effective in younger, low-risk patients, but cost-effective in older patients. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
• National Osteoporosis Foundation
• American Association of Clinical Endocrinologists
• American College of Preventive Medicine
Recommendation : Don’t routinely repeat dual energy x-ray absorptiometry (DEXA) scans more often than once every two years. Topic Areas : • Rheumatologic
• Preventive Medicine
Rationale : Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation (NOF) recommendations. The optimal interval for repeating DEXA scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DEXA scanners, frequent testing (e.g., < 2 years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DEXA changes do not always correlate with probability of fracture. Therefore, DEXA should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women 67 years and older with normal bone mass may not need additional DEXA testing for up to 10 years provided osteoporosis risk factors do not significantly change. Sponsoring organizations : •  American College of Rheumatology
Sources : • U.S. Preventive Services Task Force
• National Osteoporosis Foundation
Recommendation : Don’t perform population-based screening for 25-OH-vitamin D deficiency. Topic Areas : • Endocrinologic
• Preventive Medicine
Rationale : Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months, and in those with limited sun exposure. Over-the-counter vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals). Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Endocrine Society guidelines
Recommendation : Don’t screen for carotid artery stenosis in asymptomatic adult patients. Topic Areas : • Neurologic
• Preventive Medicine
Rationale : 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 nonindicated surgeries that result in serious harms, including death, stroke, and myocardial infarction. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. Topic Areas : • Pediatric
• Pulmonary medicine
Rationale : National guidelines articulate a reliance on physical examination and patient history for diagnosis of asthma and bronchiolitis in the pediatric population. Multiple studies have established limited clinical utility of chest radiographs for patients with asthma or bronchiolitis. Omission of the use of chest radiography will reduce costs, but not compromise diagnostic accuracy and care. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • National Heart, Lung and Blood Institute guidelines
• American Academy of Pediatrics guidelines
Recommendation : Don’t routinely use bronchodilators in children with bronchiolitis. Topic Areas : • Pediatric
• Pulmonary medicine
Rationale : Published guidelines do not advocate the routine use of bronchodilators in patients with bronchiolitis. Comprehensive reviews of the literature have demonstrated that the use of bronchodilators in children admitted to the hospital with bronchiolitis has no effect or any important outcomes. There is limited demonstration of clear impact of bronchodilator therapy upon the course of disease. Additionally, providers should consider the potential impact of adverse events upon the patient. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • Cochrane Database of Systematic Reviews
• American Academy of Pediatrics guidelines
Recommendation : Don’t use systemic corticosteroids in children younger than two years with an uncomplicated lower respiratory tract infection Topic Areas : • Pediatric
• Pulmonary medicine
• Infectious disease
Rationale : Published guidelines recommend that corticosteroid medications not be used routinely in the management of bronchiolitis. Furthermore, additional studies in patients with other viral lower respiratory tract infections have failed to demonstrate any benefits. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • Cochrane Database of Systematic Reviews
• American Academy of Pediatrics guidelines
Recommendation : Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. Topic Areas : • Pediatric
• Pulmonary medicine
Rationale : The utility of continuous pulse oximetry in pediatric patients with acute respiratory illness is not well established. Use of continuous pulse oximetry has been previously associated with increased admission rates and increase length of stay. The clinical benefit of pulse oximetry is not validated or well documented. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • American Academy of Pediatrics guidelines
Recommendation : Don’t diagnose or manage asthma without spirometry. Topic Areas : • Pulmonary medicine
Rationale : Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore, spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or underestimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • National Asthma Education and Prevention Expert Panel report
Recommendation : In patients with a low pretest probability of venous thrombo-embolism, obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. Topic Areas : • Pulmonary medicine
Rationale : In patients with low pretest probability of venous thromboembolism as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes venous thromboembolism and the need for further imaging studies. Sponsoring organizations : •  American College of Physicians
Sources : • American College of Emergency Physicians guidelines
• American Academy of Family Physicians
• American College of Physicians
Recommendation : Don’t image for suspected pulmonary embolism (PE) without moderate or high pretest probability. Topic Areas : • Pulmonary medicine
Rationale : While deep venous thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood D-dimer levels and certain specific risk factors. Imaging, particularly CT pulmonary angiography, is a rapid, accurate, and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pretest probability of PE. Sponsoring organizations : •  American College of Radiology
Sources : • European Society of Cardiology guidelines
• American College of Emergency Physicians guidelines
Recommendation : Avoid using a CT angiogram to diagnose pulmonary embolism (PE) in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead. Topic Areas : • Pulmonary medicine
Rationale : When the clinical question is whether or not pulmonary emboli are present, a V/Q study can provide the answer with lower overall radiation dose to the breast than can CT angiography, even when performed with a breast shield. Sponsoring organizations : •  Society of Nuclear Medicine and Molecular Imaging
Sources : • Expert consensus
Recommendation : Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings Topic Areas : • Rheumatologic
Rationale : The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in one or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false-positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease. Sponsoring organizations : •  American College of Rheumatology
Sources : • CDC, IDSA guidelines
Recommendation : Don’t test antinuclear antibodies (ANA) subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Topic Areas : • Rheumatologic
Rationale : Tests for ANA subserologies (including antibodies to double-stranded DNA, Smith, RNP, SSA, SSB, Scl-70, centromere) are usually negative if the ANA is negative. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA, in the setting of lupus or Sjögren syndrome. Broad testing of autoantibodies should be avoided; instead, the choice of autoantibodies should be guided by the specific disease under consideration. Sponsoring organizations : •  American College of Rheumatology
Sources : • American College of Rheumatology guidelines
Recommendation : Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional nonbiologic disease-modifying antirheumatic drugs [DMARDs]). Topic Areas : • Rheumatologic
Rationale : High-quality evidence suggests that methotrexate and other conventional nonbiologic DMARDs are effective in many patients with rheumatoid arthritis. Initial therapy for rheumatoid arthritis should be a conventional nonbiologic DMARD unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other nonbiologic DMARDs during an initial three-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity AND poor prognostic features (functional limitations, disease outside the joints, seropositivity, or bony damage), where biologic therapy may be appropriate first-line treatment. Sponsoring organizations : •  American College of Rheumatology
Sources : • American College of Rheumatology guidelines
Recommendation : Avoid routine preoperative testing for low-risk surgeries without a clinical indication. Topic Areas : • Surgical
Rationale : Most preoperative tests (typically a complete blood count, prothrombin time and partial thromboplastin time, basic metabolic panel, and urinalysis) performed on elective surgical patients are normal. Findings influence management in under 3% of patients tested. In almost all cases, no adverse outcomes are observed when clinically stable patients undergo elective surgery, irrespective of whether an abnormal test is identified. Preoperative testing is appropriate in symptomatic patients and those with risks factors for which diagnostic testing can provide clarification of patient surgical risk. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. Topic Areas : • Surgical
Rationale : Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2% of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than 70 years who has not had chest radiography within six months. Sponsoring organizations : •  American College of Physicians
•  American College of Radiology
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to noncardiac thoracic surgery. Topic Areas : • Surgical
• Cardiovascular
Rationale : Functional status has been shown to be reliable for prediction of perioperative and long-term cardiac events. In highly functional asymptomatic patients, management is rarely changed by preoperative stress testing. It is therefore appropriate to proceed with the planned surgery without it. Preoperative stress testing should be reserved for patients with significant clinical risk factors for cardiac complications such as history, symptom, or signs of ischemic heart disease, heart failure, cerebrovascular disease, diabetes mellitus, or peripheral vascular disease. It may also be appropriate to perform preoperative cardiac testing on patients with a low functional status (unable to carry out anything more than minor physical activity) since inactivity in these patients may mask otherwise significant cardiac disease. Sponsoring organizations : •  Society of Thoracic Surgeons
Sources : • ACC/AHA, ESC guidelines
Recommendation : Avoid cardiovascular stress testing for patients undergoing low-risk surgery. Topic Areas : • Surgical
• Cardiovascular
Rationale : Preoperative stress testing does not alter therapy or decision making in patients facing low-risk surgery. Sponsoring organizations : •  Society for Vascular Medicine
Sources : • ACC/AHA guidelines
Recommendation : Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease. Topic Areas : • Surgical
• Cardiovascular
Rationale : Perioperative echocardiography is used to clarify signs or symptoms of cardiovascular disease, or to investigate abnormal heart tests. Resting left ventricular function is not a consistent predictor of perioperative ischemic events; even reduced left ventricular systolic function has poor predictive value for perioperative cardiac events. Sponsoring organizations : •  American Society of Echocardiography
Sources : • ACC/AHA guidelines
Recommendation : Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk. Topic Areas : • Surgical
• Cardiovascular
Rationale : No evidence exists to support the diagnostic or prognostic potential of coronary artery calcium scoring in individuals in the preoperative setting. This practice may add costs and confound professional guideline-based evaluations. Sponsoring organizations : •  Society of Cardiovascular Computed Tomography
Sources : • ACC/AHA guidelines
Recommendation : Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria. Topic Areas : • Surgical
• Cardiovascular
Rationale : Studies show that the presence of asymptomatic carotid disease in patients undergoing cardiac surgery does not justify preoperative screening in more than the subgroup of ”high-risk” patients. Carotid stenosis with symptoms (stroke or transient ischemic attacks) is a known risk for cardiovascular accident and appropriate for preoperative testing. High-risk patients have been defined as patients with left main coronary disease, peripheral artery disease, hypertension, smoking, diabetes mellitus, or age older than 65 years due to a higher rate of asymptomatic carotid stenosis in these patients. The presence a carotid bruit does not equate to an increased risk of stroke after cardiac surgery. Patients with carotid stenosis have a higher rate of cerebrovascular complications after cardiac surgery, but there is no evidence that prophylactic or concomitant carotid surgery decreases this rate of complications in asymptomatic patients. Although controversial, the cumulative risk of carotid surgery and cardiac surgery, either sequentially or concomitantly, may exceed the benefit in asymptomatic patients. Sponsoring organizations : •  Society of Thoracic Surgeons
Sources : • ACC/AHA guidelines
Recommendation : Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms. Topic Areas : • Pulmonary medicine
• Surgical
Rationale : Pulmonary function tests can be helpful in determining risk in cardiac surgery, but patients with no pulmonary disease are unlikely to benefit and do not justify testing. Symptoms attributed to cardiac disease that are respiratory in nature should be better characterized with pulmonary function tests. Sponsoring organizations : •  Society of Thoracic Surgeons
Sources : • Expert consensus
Recommendation : Don’t perform ultrasound on boys with cryptorchidism. Topic Areas : • Pediatric
• Urologic
Rationale : Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen. Sponsoring organizations : •  American Urological Association
Sources : • Systematic review and meta-analysis
Recommendation : Don’t prescribe testosterone to men with erectile dysfunction who have normal testosterone levels. Topic Areas : • Urologic
Rationale : While testosterone treatment is shown to increase sexual interest, there appears to be no significant influence on erectile function. The information available in studies to date is insufficient to fully evaluate testosterone’s efficacy in the treatment of men with erectile dysfunction who have normal testosterone levels. Sponsoring organizations : •  American Urological Association
Sources : • American Urological Association guidelines
Recommendation : Don’t order creatinine or upper-tract imaging for patients with benign prostatic hyper-plasia. Topic Areas : • Urologic
Rationale : When an initial evaluation shows only the presence of lower urinary tract symptoms, if the symptoms are not significantly bothersome to the patient or if the patient doesn’t desire treatment, no further evaluation is recommended. Such patients are unlikely to experience significant health problems in the future due to their condition and can be seen again if necessary. While the patient can often tell the provider if the symptoms are bothersome enough that he desires additional therapy, another possible option is to use a validated questionnaire to assess symptoms. For example, if the patient completes the International Prostate Symptom Scale and has a symptom score of 8 or greater, this is considered to be "clinically" bothersome. Sponsoring organizations : •  American Urological Association
Sources : • American Urological Association guidelines
Recommendation : Don’t treat an elevated prostate-specific antigen (PSA) with antibiotics for patients not experiencing other symptoms. Topic Areas : • Urologic
Rationale : It had previously been suggested that a course of antibiotics might lead to a decrease in an initially raised PSA and reduce the need for prostate biopsy; however, there is a lack of clinical studies to show that antibiotics actually decrease PSA levels. It should also be noted that a decrease in PSA does not indicate an absence of prostate cancer. There is no information available on the implications of deferring a biopsy following a decrease in PSA. Sponsoring organizations : •  American Urological Association
Sources : • Randomized controlled trials
Recommendation : 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 Topic Areas : • Urologic
Rationale : Catheter-associated urinary tract infections are the most common (frequently occurring) health care–acquired infection. Use of urinary catheters for incontinence or convenience without proper indication or specified optimal duration of use increases the likelihood of infection and is commonly associated with greater morbidity, mortality and health care costs. Published guidelines suggest that hospitals and long-term care facilities should develop, maintain, and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies, and replacement indications. Sponsoring organizations : •  Society of Hospital Medicine (Adult)
Sources : • IDSA guideline, Joint Commission
Recommendation : Don’t use systemic corticosteroids in children younger than two years with an uncomplicated lower respiratory tract infection Topic Areas : • Pediatric
• Pulmonary medicine
• Infectious disease
Rationale : Published guidelines recommend that corticosteroid medications not be used routinely in the management of bronchiolitis. Furthermore, additional studies in patients with other viral lower respiratory tract infections have failed to demonstrate any benefits. Sponsoring organizations : •  Society of Hospital Medicine (Pediatric)
Sources : • Cochrane Database of Systematic Reviews
• American Academy of Pediatrics guidelines
Recommendation : Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings. Topic Areas : • Geriatric Medicine
• Gastroenterologic
Rationale : Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems. Sponsoring organizations : •  American Medical Directors Association
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home. Topic Areas : • Endocrinologic
• Geriatric Medicine
Rationale : SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s insulin needs nor is it efficient in the long-term care setting. Use of SSI leads to greater patient discomfort and increased nursing time because patients’ blood glucose levels are usually monitored more frequently than may be necessary and more insulin injections may be given. With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake. Basal insulin, or basal plus rapid-acting insulin with one or more meals (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively. Sponsoring organizations : •  American Medical Directors Association
Sources : • Expert consensus
Recommendation : Don't obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract. Topic Areas : • Urologic
• Infectious disease
Rationale : Chronic asymptomatic bacteriuria is frequent in the long-term care setting, with prevalence as high as 50%. A positive urine culture in the absence of localized urinary tract infection (UTI) symptoms (i.e., dysuria, frequency, urgency) is of limited value in identifying whether a patient’s symptoms are caused by a UTI. Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in long-term care facilities that contributes to the overuse of antibiotic therapy in this setting, leading to an increased risk of diarrhea, resistant organisms and infection due to Clostridium difficile. An additional concern is that the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the more timely detection of the patient’s more serious underlying problem. A patient with advanced dementia may be unable to report urinary symptoms. In this situation, it is reasonable to obtain a urine culture if there are signs of systemic infection such as fever (increase in temperature of equal to or greater than 2°F [1.1°C] from baseline) leukocytosis, or a left shift or chills in the absence of additional symptoms (e.g., new cough) to suggest an alternative source of infection. Sponsoring organizations : •  American Medical Directors Association
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior. Topic Areas : • Geriatric Medicine
• Psychiatric and Psychologic
Rationale : Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress–not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning. If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent. Sponsoring organizations : •  American Medical Directors Association
Sources : • American Medical Directors Association guidelines and systematic reviews
Recommendation : Don't routinely prescribe lipid-lowering medications in individuals with a limited life expectancy. Topic Areas : • Geriatric Medicine
• Cardiovascular
Rationale : There is no evidence that hypercholesterolemia, or low high-density lipoprotein cholesterol is an important risk factor for all-cause mortality, coronary heart disease mortality, or hospitalization for myocardial infarction or unstable angina in persons older than 70 years. In fact, studies show that elderly patients with the lowest cholesterol have the highest mortality after adjusting other risk factors. In addition, a less favorable risk-benefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs more increased (cognitive impairment, falls, neuropathy and muscle damage). Sponsoring organizations : •  American Medical Directors Association
Sources : • Expert consensus
Recommendation : Avoid the routine use of “whole-body” diagnostic CT scanning in patients with minor or single system trauma. Topic Areas : • Emergency medicine
Rationale : Aggressive use of “whole-body” CT scanning improves early diagnosis of injury and may even positively impact survival in polytrauma patients. However, the significance of radiation exposure as well as costs associated with these studies must be considered, especially in patients with low energy mechanisms of injury and absent physical examination findings consistent with major trauma. Sponsoring organizations : •  American College of Surgeons
Sources : • Expert consensus
Recommendation : Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia. Topic Areas : • Geriatric Medicine
• Gastroenterologic
• Preventive Medicine
Rationale : Screening for colorectal cancer has been shown to reduce the mortality associated with this common disease; colonoscopy provides the opportunity to detect and remove adenomatous polyps, the precursor lesion to many cancers, thereby reducing the incidence of the disease later in life. However, screening and surveillance modalities are inappropriate when the risks exceed the benefit. The risk of colonoscopy increases with increasing age and comorbidities. The risk/benefit ratio of colorectal cancer screening or surveillance for any patient should be individualized based on the results of previous screening examinations, family history, predicted risk of the intervention, life expectancy, and patient preference. Sponsoring organizations : •  American College of Surgeons
Sources : • U.S. Multi-Society Task Force on Colorectal Cancer
• U.S. Preventive Services Task Force
Recommendation : Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. Topic Areas : • Surgical
Rationale : Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2% of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary diseases in patients older than age 70 who have not had chest radiography within six months. Sponsoring organizations : •  American College of Surgeons
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. Topic Areas : • Pediatric
• Surgical
• Emergency medicine
Rationale : Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94% in experienced hands. Recognizing that expertise may vary, strategies including improving diagnostic expertise in community-based ultrasound and the development of evidence-based clinical decision rules are realistic goals in improving diagnosis without the use of CT scan. Sponsoring organizations : •  American College of Surgeons
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee. Topic Areas : • Orthopedic
Rationale : Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee. Sponsoring organizations : •  American Academy of Orthopaedic Surgeons
Sources : • Randomized controlled trials
Recommendation : Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee. Topic Areas : • Orthopedic
Rationale : In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee. Sponsoring organizations : •  American Academy of Orthopaedic Surgeons
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t recommend daily home finger glucose testing in patients with type 2 diabetes mellitus not using insulin. Topic Areas : • Endocrinologic
Rationale : Self-monitoring of blood glucose (SMBG) is an integral part of patient self-management in maintaining safe and target-driven glucose control in type 1 diabetes. However, there is no benefit to daily finger glucose testing in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia, and there is negative economic impact and potential negative clinical impact of daily glucose testing. SMBG should be reserved for patients during the titration of their medication doses or during periods of changes in patients’ diet and exercise routines. Sponsoring organizations : •  Society of General Internal Medicine
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t perform routine general health checks for asymptomatic adults. Topic Areas : • Preventive Medicine
Rationale : Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the “health maintenance” annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing. Sponsoring organizations : •  Society of General Internal Medicine
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t perform routine preoperative testing before low-risk surgical procedures. Topic Areas : • Surgical
Rationale : Preoperative assessment is expected before all surgical procedures. This assessment includes an appropriately directed and sufficiently comprehensive history and physical examination, and, in some cases, properly includes laboratory and other testing to help direct management and assess surgical risk. However, preoperative testing for low-risk surgical procedures (such as cataract extraction) results in unnecessary delays and adds to significant avoidable costs and should be eliminated. Sponsoring organizations : •  Society of General Internal Medicine
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t recommend cancer screening in adults with life expectancy of less than 10 years. Topic Areas : • Geriatric Medicine
• Preventive Medicine
Rationale : Screening for cancer can be lifesaving in otherwise healthy at-risk patients. While screening tests lead to a mortality benefit, which emerges years after the test is performed, they expose patients to immediate potential harms. Patients with life expectancies of less than 10 years are unlikely to live long enough to derive the distant benefit from screening. However, these patients are in fact more likely to experience the harms since patients with limited life expectancy are more likely to be frail and more susceptible to complications of testing and treatments. Therefore, the balance of potential benefits and harms does not favor recommending cancer screening in patients with life expectancies of less than 10 years. Sponsoring organizations : •  Society of General Internal Medicine
Sources : • U.S. Preventive Services Task Force
Recommendation : Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience. Topic Areas : • Surgical
• Infectious disease
Rationale : Peripherally inserted central catheters (PICCs) are commonly used devices in contemporary medical practice that are associated with two costly and potentially lethal health care-acquired complications: central-line associated bloodstream infection and venous thromboembolism. Given the clinical and economic consequences of these complications, placement of PICCs should be limited to acceptable indications (long-term intravenous antibiotics, total parenteral nutrition, chemotherapy and frequent blood draws). PICCs should be promptly removed when acceptable indications for their use ends. Sponsoring organizations : •  Society of General Internal Medicine
Sources : • Systematic review and meta-analysis
Recommendation : Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring. Topic Areas : • Psychiatric and Psychologic
Rationale : Metabolic, neuromuscular, and cardiovascular side effects are common in patients receiving antipsychotic medications for any indication, so thorough initial evaluation to ensure that their use is clinically warranted, and ongoing monitoring to ensure that side effects are identified, are essential. “Appropriate initial evaluation” includes the following: (a) thorough assessment of possible underlying causes of target symptoms including general medical, psychiatric, environmental or psychosocial problems; (b) consideration of general medical conditions; and (c) assessment of family history of general medical conditions, especially of metabolic and cardiovascular disorders. “Appropriate ongoing monitoring” includes re-evaluation and documentation of dose, efficacy and adverse effects; and targeted assessment, including assessment of movement disorder or neurological symptoms; weight, waist circumference and/or body mass index; blood pressure; heart rate; blood glucose level; and lipid profile at periodic intervals. Sponsoring organizations : •  American Psychiatric Association
Sources : • American Psychiatric Association guidelines
Recommendation : Don’t routinely prescribe two or more antipsychotic medications concurrently. Topic Areas : • Psychiatric and Psychologic
Rationale : Research shows that use of two or more antipsychotic medications occurs in 4% to 35% of outpatients and 30% to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance, and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy. Sponsoring organizations : •  American Psychiatric Association
Sources : • American Psychiatric Association guidelines
Recommendation : Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. Topic Areas : • Geriatric Medicine
• Psychiatric and Psychologic
Rationale : Behavioral and psychological symptoms of dementia are defined as the noncognitive symptoms and behaviors, including agitation or aggression, anxiety, irritability, depression, apathy, and psychosis. Evidence shows that risks (e.g., cerebrovascular effects, mortality, parkinsonism or extrapyramidal signs, sedation, confusion and other cognitive disturbances, and increased body weight) tend to outweigh the potential benefits of antipsychotic medications in this population. Clinicians should limit the use of antipsychotic medications to cases where nonpharmacologic measures have failed and the patients’ symptoms may create a threat to themselves or others. This item is also included in the American Geriatric Society’s list of recommendations for “Choosing Wisely.” Sponsoring organizations : •  American Psychiatric Association
Sources : • Agency for Healthcare Research and Quality
• Cochrane Database of Systematic Reviews
Recommendation : Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults. Topic Areas : • Psychiatric and Psychologic
Rationale : There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results. Sponsoring organizations : •  American Psychiatric Association
Sources : • Agency for Healthcare Research and Quality
Recommendation : Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders. Topic Areas : • Pediatric
• Psychiatric and Psychologic
Rationale : Recent research indicates that use of antipsychotic medication in children has nearly tripled in the past 10 to 15 years, and this increase appears to be disproportionate among children with low family income, minority children, and children with externalizing behavior disorders (i.e., rather than schizophrenia, other psychotic disorders and severe tic disorders). Evidence for the efficacy and tolerability of antipsychotic medications in children and adolescents is inadequate and there are notable concerns about weight gain, metabolic side effects, and a potentially greater tendency for cardiovascular changes in children than in adults. Sponsoring organizations : •  American Psychiatric Association
Sources : • Cochrane Database of Systematic Reviews
• American Academy of Child and Adolescent Psychiatry guidelines
Recommendation : Don’t initiate management of low-risk prostate cancer without discussing active surveillance. Topic Areas : • Oncologic
• Urologic
Rationale : Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients. Shared decision-making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. The American Society for Radiation Oncology has published patient-directed written decision aids concerning prostate cancer and numerous other types of cancer. These types of instruments can give patients confidence about their choices, improving compliance with therapy. Sponsoring organizations : •  American Society for Radiation Oncology
Sources : • Systematic review
Recommendation : Don’t prescribe antibiotics for otitis media in children aged two to 12 years with nonsevere symptoms where the observation option is reasonable. Topic Areas : • Otolaryngologic
• Pediatric
• Infectious disease
Rationale : The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child’s age, diagnostic certainty and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • American Academy of Pediatrics guidelines
Recommendation : Don’t perform voiding cystourethrogram routinely in first febrile urinary tract infection (UTI) in children aged two to 24 months. Topic Areas : • Pediatric
• Urologic
• Infectious disease
Rationale : The risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • National Institute for Health and Clinical Excellence guidelines
• American College of Radiology guidelines
• American Academy of Pediatrics guidelines
Recommendation : Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. Topic Areas : • Oncologic
• Urologic
• Preventive Medicine
Rationale : There is convincing evidence that PSA-based screening leads to substantial overdiagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t screen adolescents for scoliosis. Topic Areas : • Pediatric
• Orthopedic
• Preventive Medicine
Rationale : There is no good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The potential harms of screening and treating adolescents include unnecessary follow-up visits and evaluations due to false-positive test results and psychological adverse effects. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications. Topic Areas : • Gynecologic
Rationale : Hormonal contraceptives are safe, effective, and well-tolerated for most women. Data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications. Hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement. Sponsoring organizations : •  American Academy of Family Physicians
Sources : • American College of Obstetricians and Gynecologists
Recommendation : Don’t use homeopathic medications, non-vitamin dietary supplements or herbal supplements as treatments for disease or preventive health measures. Topic Areas : • Preventive Medicine
• Alternative medicine
Rationale : Alternative therapies are often assumed safe and effective just because they are “natural.” There is a lack of stringent quality control of the ingredients present in many herbal and dietary supplements. Reliable evidence that these products are effective is often lacking, but substantial evidence exists that they may produce harm. Indirect health risks also occur when these products delay or replace more effective forms of treatment or when they compromise the efficacy of conventional medicines. Sponsoring organizations : •  American Academy of Clinical Toxicology
•  American College of Medical Toxicology
Sources : • Expert consensus
Recommendation : Don’t recommend chelation except for documented metal intoxication, which has been diagnosed using validated tests in appropriate biological samples. Topic Areas : • Alternative medicine
Rationale : Chelation does not improve objective outcomes in autism, cardiovascular disease, or neurodegenerative conditions like Alzheimer’s disease. Edetate disodium is not U.S. Food and Drug Administration–approved for any condition. Even when used for appropriately diagnosed metal intoxication, chelating drugs may have significant side effects, including dehydration, hypocalcemia, kidney injury, liver enzyme elevations, hypotension, allergic reactions, and essential mineral deficiencies. Inappropriate chelation, which may cost hundreds to thousands of dollars, risks these harms, as well as neurodevelopmental toxicity, teratogenicity, and death. Sponsoring organizations : •  American Academy of Clinical Toxicology
•  American College of Medical Toxicology
Sources : • Expert consensus
Recommendation : Don’t put asymptomatic children in weak reading glasses. Topic Areas : • Pediatric
• Ophthalmologic
Rationale : Low “farsightedness” is a normal finding in children. Children can easily focus to see at near, with their large accommodative reserve. If the reading glasses prescription is low (less than +2.00 diopters), their innate ability to focus can be used to see clearly at both distance and near. If the eyes are not crossed, prescription of weak glasses is generally not necessary. Sponsoring organizations : •  American Association for Pediatric Ophthalmology and Strabismus
Sources : • Expert consensus
Recommendation : Annual comprehensive eye exams are unnecessary for children who pass routine vision screening assessments. Topic Areas : • Pediatric
• Ophthalmologic
• Preventive Medicine
Rationale : Early childhood vision screening done as part of routine well-child care accurately identifies most children with significant eye problems that are otherwise asymptomatic. Annual comprehensive eye examinations increase financial costs, a child’s absence from school and parental time away from work, with no evidence that the comprehensive exam detects asymptomatic vision problems better than timely, methodical and recurrent screening efforts. Comprehensive eye exams are appropriate for children who do not pass a vision screening. Sponsoring organizations : •  American Association for Pediatric Ophthalmology and Strabismus
Sources : • AAO/AAP/AAPOS guidelines
Recommendation : Don’t recommend vision therapy for patients with dyslexia. Topic Areas : • Pediatric
• Ophthalmologic
Rationale : Dyslexia is a language-based learning disorder in which a person has trouble understanding written words. This occurs because the brain has a problem distinguishing and separating the sounds in spoken words, called a phonological deficit. Dyslexia is not due to a vision disorder. Children with dyslexia do not have any more visual problems than children without dyslexia. Vision therapy does not work for this population because the eyes are not the problem. Sponsoring organizations : •  American Association for Pediatric Ophthalmology and Strabismus
Sources : • AAO/AAPOS/AACO guidelines
Recommendation : Don’t routinely order imaging for all patients with double vision. Topic Areas : • Ophthalmologic
Rationale : Many people with double vision, or diplopia, want a CT scan or MRI to see if it is caused by a brain tumor or other serious problem. Much of the time, following a comprehensive eye evaluation, neither test is necessary. The most common causes of double vision are refractive error, dry eyes, cataract and non-neurologic eye misalignment; all readily diagnosed by a complete exam. Only a minority of cases of diplopia result from problems within the brain. Sponsoring organizations : •  American Association for Pediatric Ophthalmology and Strabismus
Sources : • Expert consensus
Recommendation : Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with nonspecific acute low back pain in the absence of red flags. Topic Areas : • Orthopedic
Rationale : In the absence of red flags, advanced imaging within the first six weeks has not been found to improve outcomes, but does increase costs. Red flags include, but are not limited to: trauma history, unintentional weight loss, immunosuppression, history of cancer, intravenous drug use, steroid use, osteoporosis, age > 50, focal neurologic deficit, and progression of symptoms. Sponsoring organizations : •  North American Spine Society
Sources : • ACP/APS guidelines
Recommendation : Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic or cervical spine pain. Topic Areas : • Neurologic
• Orthopedic
Rationale : Electromyography and nerve conduction studies are measures of nerve and muscle function. They may be indicated when there is concern for a neurologic injury or disorder, such as the presence of leg or arm pain, numbness or weakness associated with compression of a spinal nerve. As spinal nerve injury is not a cause of neck, mid back, or low back pain, EMG/NCS have not been found to be helpful in diagnosing the underlying causes of axial lumbar, thoracic, and cervical spine pain. Sponsoring organizations : •  North American Spine Society
Sources : • Expert consensus
Recommendation : Don’t recommend bed rest for more than 48 hours when treating low back pain. Topic Areas : • Orthopedic
Rationale : In patients with low back pain, bed rest exceeding 48 hours in duration has not been shown to be of benefit. Sponsoring organizations : •  North American Spine Society
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery–specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal. Topic Areas : • Surgical
Rationale : Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease. Evidence suggests that a targeted history and physical exam should determine whether preprocedure laboratory studies should be obtained. The current recommendation from the 2003 ASA amendment that all female patients of childbearing age be offered pregnancy testing rather than required to undergo testing has provided individual physicians and hospitals the opportunity to set their own practices and policies relating to preoperative pregnancy testing. Some institutions respect the right of a patient to refuse testing after a thorough explanation of the anesthetic risks during pregnancy and the required signing of a waiver. The avoidance of the routine administration of the pregnancy test was therefore excluded from our top five preoperative recommendations. The risk specifically related to the surgical procedure could however modify the above preoperative recommendation to obtain laboratory studies and when the need arises; the decision to implement should include a joint decision between the anesthesiologists and surgeons. This should be applicable to all outpatient surgery. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • American Society of Anesthesiologists guidelines
Recommendation : Don’t obtain baseline diagnostic cardiac testing (transthoracic/esophageal echocardiography) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., coronary artery disease, valvular disease) undergoing low or moderate risk noncardiac surgery. Topic Areas : • Surgical
• Cardiovascular
Rationale : Advances in cardiovascular medical management, particularly the introduction of perioperative beta-blockade and improvements in surgical and anesthetic techniques, have significantly decreased operative morbidity and mortality rates in noncardiac surgery. Surgical outcomes continue to improve causing the mortality rate of major surgeries to be low and the need for revascularization minimal. Consequently, the role of preoperative cardiac stress testing has been reduced to the identification of extremely high-risk patients, for instance, those with significant left main disease for which preoperative revascularization would be beneficial regardless of the impending procedure. In other words, testing may be appropriate if the results would change management prior to surgery, could change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • American Society of Anesthesiologists guidelines
Recommendation : Don’t administer packed red blood cells in a young healthy patient without ongoing blood loss and hemoglobin of ≥ 6 g/dL unless symptomatic or hemodynamically unstable. Topic Areas : • Hematologic
Rationale : The hemoglobin transfusion threshold used in multiple studies has varied from 6.0 to 10.0 g/dL. The optimal hemoglobin/hematocrit criterion for transfusion remains controversial in several clinical settings. Nevertheless, compared with higher hemoglobin thresholds, a lower hemoglobin threshold is associated with fewer red blood cell units transfused without adverse associations with mortality, cardiac morbidity, functional recovery, or length of hospital stay. Hospital mortality remains lower in patients randomized to a lower hemoglobin threshold for transfusion versus those randomized to a higher hemoglobin threshold. The decision to transfuse should be based on a combination of both clinical and hemodynamic parameters. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications. Topic Areas : • Surgical
Rationale : There is no evidence from multiple randomized controlled trials and recent reviews/meta-analyses that resuscitation with colloids reduces the risk of death compared to crystalloids. Colloids offer no survival benefit and are considerably more expensive than crystalloids; their continued routine use in clinical practice should therefore be questioned. Recent perioperative data on the use of colloids in certain populations remain controversial; nevertheless, there is consensus on the avoidance of the routine use of colloids for volume resuscitation in the general surgical population given the overwhelming amount of evidence in the literature of possible harm when used in un-indicated patients. Health care providers should refer to the current evolving literature when faced with specific conditions like sepsis, traumatic brain injury, acute renal injury and burns thereby creating a forum for discussion among the care providers of the efficacy of such a treatment in that individual patient. Nevertheless, it is important to note that the endpoint in most studies is mortality and morbidity. There is insufficient data to adequately address the need of colloids over crystalloids for other endpoints of interest like hypotension, need for blood transfusion, length of hospital stay, etc. Further research may be required to delineate the existence of any particular benefits of colloids over crystalloids. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Avoid CT scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules. Topic Areas : • Emergency medicine
Rationale : Minor head injury is a common reason for visiting an emergency department. The majority of minor head injuries do not lead to injuries such as skull fractures or bleeding in the brain that need to be diagnosed by a CT scan. As CT scans expose patients to ionizing radiation, increasing patients’ lifetime risk of cancer, they should only be performed on patients at risk for significant injuries. Physicians can safely identify patients with minor head injury in whom it is safe to not perform an immediate head CT by performing a thorough history and physical examination following evidence-based guidelines. This approach has been proven safe and effective at reducing the use of CT scans in large clinical trials. In children, clinical observation in the emergency department is recommended for some patients with minor head injury prior to deciding whether to perform a CT scan. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • ACEP/CDC guidelines
Recommendation : Avoid placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience. Topic Areas : • Urologic
• Emergency medicine
• Infectious disease
Rationale : Indwelling urinary catheters are placed in patients in the emergency department to assist when patients cannot urinate, to monitor urine output, or for patient comfort. Catheter-associated urinary tract infection is the most common hospital-acquired infection in the U.S., and can be prevented by reducing the use of indwelling urinary catheters. Emergency physicians and nurses should discuss the need for a urinary catheter with a patient and/or their caregivers, as sometimes such catheters can be avoided. Emergency physicians can reduce the use of indwelling urinary catheters by following the Centers for Disease Control and Prevention’s evidence-based guidelines for the use of urinary catheters. Indications for a catheter may include: output monitoring for critically ill patients, relief of urinary obstruction, at the time of surgery and end-of-life care. When possible, alternatives to indwelling urinary catheters should be used. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Expert consensus
Recommendation : Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. Topic Areas : • Emergency medicine
Rationale : Palliative care is medical care that provides comfort and relief of symptoms for patients who have chronic and/or incurable diseases. Hospice care is palliative care for those patients in the final few months of life. Emergency physicians should engage patients who present to the emergency department with chronic or terminal illnesses, and their families, in conversations about palliative care and hospice services. Early referral from the emergency department to hospice and palliative care services can benefit select patients resulting in both improved quality and quantity of life. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Expert consensus
Recommendation : Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up. Topic Areas : • Emergency medicine
• Infectious disease
Rationale : Skin and soft tissue infections are a frequent reason for visiting an emergency department. Some infections, called abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment; antibiotics offer no benefit. Even in abscesses caused by methicillin-resistant Staphylococcus aureus, appropriately selected antibiotics offer no benefit if the abscess has been adequately drained and the patient has a well-functioning immune system. Additionally, culture of the drainage is not needed as the result will not routinely change treatment. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Randomized controlled trials
Recommendation : Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children. Topic Areas : • Pediatric
• Emergency medicine
Rationale : Many children who come to the emergency department with dehydration require fluid replacement. To avoid the pain and potential complications of an IV catheter, it is preferable to give these fluids by mouth. Giving a medication for nausea may allow patients with nausea and vomiting to accept fluid replenishment orally. This strategy can eliminate the need for an IV. It is best to give these medications early during the emergency department visit, rather than later, in order to allow time for them to work optimally. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. Topic Areas : • Endocrinologic
Rationale : Once target control is achieved and the results of self-monitoring become quite predictable, there is little gained in most individuals from repeatedly confirming. There are many exceptions, such as for acute illness, when new medications are added, when weight fluctuates significantly, when A1C targets drift off course and in individuals who need monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and adjusting therapy based on the result of the monitoring. Sponsoring organizations : •  The Endocrine Society/American Association of Clinical Endocrinologists
Sources : • Randomized controlled trials
Recommendation : Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function. Topic Areas : • Preventive Medicine
Rationale : Many practitioners become confused when ordering a vitamin D test. Because 1,25-dihydroxyvitamin D is the active form of vitamin D, many practitioners think that measuring 1,25-dihydroxyvitamin D is an accurate means to estimate vitamin D stores and test for vitamin D deficiency, which is incorrect. Current Endocrine Society guidelines recommend screening for vitamin D deficiency in individuals at risk for deficiency. Serum levels of 1,25-dihyroxyvitamin D have little or no relationship to vitamin D stores but rather are regulated primarily by parathyroid hormone levels, which in turn are regulated by calcium and/or vitamin D. In vitamin D deficiency, 1,25-dihydroxyvitamin D levels go up, not down. Unregulated production of 1,25-dihydroxyvitamin D (i.e., sarcoidosis, granulomatous diseases) is an uncommon cause of hypercalcemia; this should be suspected if blood calcium levels are high and parathyroid hormone levels are low and confirmed by measurement of 1,25-dihydroxyvitamin D. The enzyme that activates vitamin D is produced in the kidney, so blood levels of 1,25-dihydroxyvitamin D are sometimes of interest in patients on dialysis or with end-stage kidney disease. There are few other circumstances, if any, where 1,25-dihydroxyvitamin D testing would be helpful. Serum 25-hydroxyvitamin D levels may be overused, but when trying to assess vitamin D stores or diagnose vitamin D deficiency (or toxicity), 25-hydroxyvitamin D is the correct test. Sponsoring organizations : •  The Endocrine Society/American Association of Clinical Endocrinologists
Sources : • Endocrine Society guidelines
Recommendation : Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland. Topic Areas : • Endocrinologic
Rationale : Thyroid ultrasound is used to identify and characterize thyroid nodules, and is not part of the routine evaluation of abnormal thyroid function tests (over- or underactive thyroid function) unless the patient also has a large goiter or a lumpy thyroid. Incidentally discovered thyroid nodules are common. Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction. Imaging may be needed in thyrotoxic patients; when needed, a thyroid scan, not an ultrasound, is used to assess the etiology of the thyrotoxicosis and the possibility of focal autonomy in a thyroid nodule. Sponsoring organizations : •  The Endocrine Society/American Association of Clinical Endocrinologists
Sources : • American Thyroid Association guidelines
• American Association of Clinical Endocrinologists
Recommendation : Don’t order a total or free triiodothyronine (T3) level when assessing levothyroxine (T4) dose in hypothyroid patients. Topic Areas : • Endocrinologic
Rationale : T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of thyroid-stimulating hormone (TSH), as well as the effects of thyroid hormone in multiple organs; a normal TSH indicates an adequate T4 dose. Conversion of T4 to T3 at the cellular level may not be reflected in the T3 level in the blood. Compared to patients with intact thyroid glands, patients taking T4 may have higher blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be misleading (low normal or slightly low); in most patients a normal TSH indicates a correct dose of T4. Sponsoring organizations : •  The Endocrine Society/American Association of Clinical Endocrinologists
Sources : • AACE/ATA guidelines
Recommendation : Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency. Topic Areas : • Endocrinologic
• Urologic
Rationale : Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing. Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, a free or bioavailable testosterone may be of additional value. Sponsoring organizations : •  The Endocrine Society/American Association of Clinical Endocrinologists
Sources : • Endocrine Society guidelines
Recommendation : Don’t screen low-risk women with cancer antigen (CA) 125 or ultrasound for ovarian cancer. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : CA-125 and ultrasound in low-risk, asymptomatic women have not led to diagnosis of ovarian cancer in earlier stages of disease or reduced ovarian cancer mortality. False-positive results of either test can lead to unnecessary procedures, which have risks of complication. Sponsoring organizations : •  Society of Gynecologic Oncology
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t perform Pap tests for surveillance of women with a history of endometrial cancer. Topic Areas : • Gynecologic
• Oncologic
Rationale : Pap testing of the top of the vagina in women treated for endometrial cancer does not improve detection of local recurrence. False-positive Pap smears in this group can lead to unnecessary procedures such as colposcopy and biopsy. Sponsoring organizations : •  Society of Gynecologic Oncology
Sources : • Society of Gynecologic Oncology guidelines
Recommendation : Don’t perform colposcopy in patients treated for cervical cancer with Pap tests of low-grade squamous intraepithelial lesion or less. Topic Areas : • Gynecologic
• Oncologic
Rationale : Colposcopy for low-grade abnormalities in this group does not detect recurrence unless there is a visible lesion and is not cost effective. Sponsoring organizations : •  Society of Gynecologic Oncology
Sources : • Expert consensus
Recommendation : Don’t perform prostate-specific antigen (PSA) testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years. Topic Areas : • Oncologic
• Urologic
• Preventive Medicine
Rationale : Since PSA levels in the blood have been linked with prostate cancer, many doctors have used repeated PSA tests in the hope of finding “early” prostate cancer in men with no symptoms of the disease. Unfortunately, PSA is not as useful for screening as many have hoped because many men with prostate cancer do not have high PSA levels, and other conditions that are not cancer (such as benign prostate hyperplasia) can also increase PSA levels. Research has shown that men who receive PSA testing are less likely to die specifically from prostate cancer. However when accounting for deaths from all causes, no lives are saved, meaning that men who receive PSA screening have not been shown to live longer than men who do not have PSA screening. Men with medical conditions that limit their life expectancy to less than 10 years are unlikely to benefit from PSA screening as their probability of dying from the underlying medical problem is greater than the chance of dying from asymptomatic prostate cancer. Sponsoring organizations : •  American Society of Clinical Oncology
Sources : • U.S. Preventive Services Task Force
• American Urological Association guidelines
• American College of Physicians
Recommendation : Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection. Topic Areas : • Dermatologic
Rationale : About half of nails with suspected fungus do not have a fungal infection. Because other nail conditions, such as nail dystrophies, may look similar in appearance, it is important to ensure accurate diagnosis of nail disease before beginning treatment. By confirming a fungal infection, patients are not inappropriately at risk for the side effects of antifungal therapy, and nail disease is correctly treated. Sponsoring organizations : •  American Academy of Dermatology
Sources : • Expert consensus
Recommendation : Don’t use oral antibiotics for treatment of atopic dermatitis unless there is clinical evidence of infection. Topic Areas : • Allergy and immunologic
• Dermatologic
Rationale : The presence of high numbers of the Staphylococcus aureus (staph) bacteria on the skin of children and adults with atopic dermatitis is common. It is widely believed that staph bacteria may play a role in causing skin inflammation, but the routine use of oral antibiotic therapy to decrease the amount of bacteria on the skin has not been definitively shown to reduce the signs, symptoms (e.g., redness, itch), or severity of atopic dermatitis. In addition, if oral antibiotics are used when there is not an infection, it may lead to the development of antibiotic resistance. The use of oral antibiotics also can cause side effects, including hypersensitivity reactions, including exaggerated immune responses such as allergic reactions. Although it can be difficult to determine the presence of a skin infection in atopic dermatitis patients, oral antibiotics should only be used to treat patients with evidence of bacterial infection in conjunction with other standard and appropriate treatments for atopic dermatitis. Sponsoring organizations : •  American Academy of Dermatology
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t routinely use topical antibiotics on a surgical wound. Topic Areas : • Surgical
• Infectious disease
Rationale : The use of topical antibiotics on clean surgical wounds has not been shown to reduce the rate of infection compared to the use of non-antibiotic ointment or no ointment. Topical antibiotics can aggravate open wounds, hindering the normal wound-healing process. When topical antibiotics are used in this setting, there is a significant risk of developing contact dermatitis, a condition in which the skin becomes red, sore, or inflamed after direct contact with a substance, along with the potential for developing antibiotic resistance. Only wounds that show symptoms of infection should receive appropriate antibiotic treatment. Sponsoring organizations : •  American Academy of Dermatology
Sources : • Randomized controlled trials
Recommendation : Don’t order autoantibody panels unless positive antinuclear antibodies (ANA) and evidence of rheumatic disease. Topic Areas : • Rheumatologic
Rationale : Up to 50% of children develop musculoskeletal pain. There is no evidence that autoantibody panel testing in the absence of history or physical exam evidence of a rheumatologic disease enhances the diagnosis of children with isolated musculoskeletal pain. Autoantibody panels are expensive; evidence has demonstrated cost reduction by limiting autoantibody panel testing. Thus, autoantibody panels should be ordered following confirmed ANA positivity or clinical suspicion that a rheumatologic disease is present in the child. Sponsoring organizations : •  American College of Rheumatology—Pediatric Rheumatology
Sources : • Agency for Healthcare Research and Quality
Recommendation : Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. Topic Areas : • Rheumatologic
• Infectious disease
Rationale : The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in one or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false-positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias or fibromyalgia alone are not criteria for musculoskeletal Lyme disease. Sponsoring organizations : •  American College of Rheumatology—Pediatric Rheumatology
Sources : • Centers for Disease Control and Prevention
• Infectious Diseases Society of America guidelines
Recommendation : Don’t perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines. Topic Areas : • Pulmonary medicine
Rationale : Clinical practice guidelines for pulmonary nodule evaluation (such as those issued by the Fleischner Society or the American College of Chest Physicians) suggest that intensity of surveillance should be guided by the likelihood of malignancy. In patients with no prior history of cancer, solid nodules that have not grown over a two-year period have an extremely low risk of malignancy (although longer follow-up is suggested for ground-glass nodules). Similarly, intensive surveillance (e.g., repeating CT scans every three months for two years or more) has not been shown to improve outcomes such as lung cancer mortality. Meanwhile, extended or intensive surveillance exposes patients to increased radiation and prolonged uncertainty. Sponsoring organizations : •  American College of Chest Physicians/American Thoracic Society
Sources : • American College of Chest Physicians guidelines
Recommendation : For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia. Topic Areas : • Pulmonary medicine
Rationale : Hypoxemia often resolves after recovery from an acute illness, and continued prescription of supplemental oxygen therapy incurs unnecessary cost and resource use. At the time that supplemental oxygen is initially prescribed, a plan should be established to re-assess the patient no later than 90 days after discharge. Medicare and evidence-based criteria should be followed to determine whether the patient meets criteria for supplemental oxygen. Sponsoring organizations : •  American College of Chest Physicians/American Thoracic Society
Sources : • Expert consensus
Recommendation : Don’t perform chest CT (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay. Topic Areas : • Pulmonary medicine
Rationale : Clinical practice guidelines for pulmonary embolism indicate that the cost and potential harms of CT angiography (including radiation exposure and the possibility of detecting and treating clinically insignificant pulmonary emboli with anticoagulation) outweigh the benefits for patients with a low pretest probability of pulmonary embolism. In patients with a low clinical prediction score (e.g., Wells or Geneva score) followed by a negative D-dimer measured with a high sensitivity test (e.g., enzyme-linked immunosorbent assay [ELISA]), pulmonary embolism is effectively excluded and no further imaging is indicated for pulmonary embolism evaluation. Sponsoring organizations : •  American College of Chest Physicians/American Thoracic Society
Sources : • AAFP/ACP guidelines
Recommendation : Don’t perform CT screening for lung cancer among patients at low risk for lung cancer. Topic Areas : • Oncologic
• Pulmonary medicine
• Preventive Medicine
Rationale : Low dose chest CT screening for lung cancer has the potential to reduce lung cancer death in patients at high risk (i.e., individuals aged 55 to 74 with at least a 30-pack-year history of tobacco use, who are either still smoking or quit within the past 15 years). However, CT screening for lung cancer also has the potential to cause a number of adverse effects (e.g., radiation exposure, high false-positive rate, harms related to downstream evaluation of pulmonary nodules, overdiagnosis of indolent tumors). Thus, screening should be reserved for patients at high risk of lung cancer and should not be offered to individuals at low risk of lung cancer. Sponsoring organizations : •  American College of Chest Physicians/American Thoracic Society
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine. Topic Areas : • Neurologic
Rationale : Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a careful clinical history and an examination that documents the absence of any neurologic findings such as papilledema. Diagnostic criteria for migraine are contained in the International Classification of Headache Disorders. Sponsoring organizations : •  American Headache Society
Sources : • American Academy of Neurology guidelines
Recommendation : Don’t perform CT imaging for headache when MRI is available, except in emergency settings. Topic Areas : • Neurologic
Rationale : When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure, which may elevate the risk of later cancers, while there are no known biologic risks from MRI. Sponsoring organizations : •  American Headache Society
Sources : • Expert consensus
Recommendation : Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial. Topic Areas : • Neurologic
Rationale : The value of this form of “migraine surgery” is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern. Sponsoring organizations : •  American Headache Society
Sources : • Expert consensus
Recommendation : Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. Topic Areas : • Neurologic
Rationale : These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache. Sponsoring organizations : •  American Headache Society
Sources : • Expert consensus
Recommendation : Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache. Topic Areas : • Neurologic
Rationale : OTC medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, known as medication overuse headache (MOH). To avoid this, OTC medication should be limited to no more than two days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding. Sponsoring organizations : •  American Headache Society
Sources : • American Academy of Neurology guidelines
Recommendation : Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation. Topic Areas : • Gynecologic
Rationale : There is no indication to order these tests, and there is no benefit to be derived in obtaining them in someone that does not have any history of bleeding or abnormal clotting and in the absence of any family history. This testing is not a part of the infertility workup. Furthermore, the testing is costly, and there are risks associated with the proposed treatments, which would also not be indicated in this routine population. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • American College of Obstetricians and Gynecologists
Recommendation : Don’t perform immunological testing as part of the routine infertility evaluation. Topic Areas : • Gynecologic
Rationale : Diagnostic testing of infertility requires evaluation of factors involving ovulation, fallopian tube patency and spermatogenesis based upon clinical history. Although immunological factors may influence early embryo implantation, routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcome. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Expert consensus
Recommendation : Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present. Topic Areas : • Cardiovascular
Rationale : Asymptomatic, low-risk patients account for up to 45% of inappropriate stress testing. Testing should be performed only when the following findings are present: diabetes in patients older than 40 years, peripheral arterial disease, and greater than 2% yearly coronary heart disease event rate. Sponsoring organizations : •  American Society of Nuclear Cardiology
Sources : • ACC/AHA guidelines
Recommendation : Don’t perform cardiac imaging for patients who are at low risk. Topic Areas : • Cardiovascular
Rationale : Chest pain patients at low risk of cardiac death and myocardial infarction (based on history, physical exam, electrocardiograms, and cardiac biomarkers) do not merit stress radionuclide myocardial perfusion imaging or stress echocardiography as an initial testing strategy if they have a normal electrocardiogram (without baseline ST-abnormalities, left ventricular hypertrophy, pre-excitation, bundle branch block, intraventricular conduction delay, paced rhythm or on digoxin therapy) and are able to exercise. Sponsoring organizations : •  American Society of Nuclear Cardiology
Sources : • ACC/AHA guidelines
Recommendation : Don’t perform cardiac imaging as a preoperative assessment in patients scheduled to undergo low- or intermediate-risk noncardiac surgery. Topic Areas : • Surgical
• Cardiovascular
Rationale : Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery or with no cardiac symptoms or clinical risk factors undergoing intermediate-risk noncardiac surgery. These types of testing do not change the patient’s clinical management or outcomes and will result in increased costs. Therefore, it is not appropriate to perform cardiac imaging procedures for noncardiac surgery risk assessment in patients with no cardiac symptoms, clinical risk factors, or who have moderate to good functional capacity. Sponsoring organizations : •  American Society of Nuclear Cardiology
Sources : • ACC/AHA guidelines
Recommendation : Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely. Topic Areas : • Cardiovascular
Rationale : The key step to reduce or eliminate radiation exposure is appropriate selection of any test or procedure for a specific person, in keeping with medical society recommendations, such as appropriate use criteria. Health care providers should incorporate new methodologies in cardiac imaging to reduce patient exposure to radiation while maintaining high-quality test results. Sponsoring organizations : •  American Society of Nuclear Cardiology
Sources : • ACC/AHA guidelines
Recommendation : Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, noncardiac inpatients). Topic Areas : • Hematologic
Rationale : Transfusion of the smallest effective dose of RBCs is recommended because liberal transfusion strategies do not improve outcomes when compared to restrictive strategies. Unnecessary transfusion generates costs and exposes patients to potential adverse effects without any likelihood of benefit. Clinicians are urged to avoid the routine administration of two units of RBCs if one unit is sufficient and to use appropriate weight-based dosing of RBCs in children. Sponsoring organizations : •  American Society of Hematology
Sources : • AABB guidelines
Recommendation : Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma, or prolonged immobility). Topic Areas : • Hematologic
Rationale : Thrombophilia testing is costly and can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labeled as thrombophilic. Thrombophilia testing does not change the management of VTEs occurring in the setting of major transient VTE risk factors. When VTE occurs in the setting of pregnancy or hormonal therapy, or when there is a strong family history plus a major transient risk factor, the role of thrombophilia testing is complex and patients and clinicians are advised to seek guidance from an expert in VTE. Sponsoring organizations : •  American Society of Hematology
Sources : • National Institute for Health and Clinical Excellence guidelines
Recommendation : Don’t administer plasma or prothrombin complex concentrates for nonemergent reversal of vitamin K antagonists (i.e., outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery). Topic Areas : • Hematologic
Rationale : Blood products can cause serious harm to patients, are costly, and are rarely indicated in the reversal of vitamin K antagonists. In nonemergent situations, elevations in the international normalized ratio are best addressed by holding the vitamin K antagonist and/or by administering vitamin K. Sponsoring organizations : •  American Society of Hematology
Sources : • American College of Chest Physicians guidelines
Recommendation : Don’t perform stress cardiovascular magnetic resonance (CMR) in the initial evaluation of chest pain patients with low pretest probability of coronary artery disease. Topic Areas : • Cardiovascular
Rationale : There are lower cost stress tests available for the initial evaluation of low-risk chest pain patients, particularly when they have a normal electrocardiogram and can exercise. Stress CMR can be valuable in evaluating intermediate-risk patients with abnormal electrocardiograms or who cannot exercise, or when initial test results are equivocal. Sponsoring organizations : •  Society for Cardiovascular Magnetic Resonance
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t perform stress cardiovascular magnetic resonance (CMR) as a preoperative assessment in patients scheduled to undergo low-risk, noncardiac surgery. Topic Areas : • Surgical
• Cardiovascular
Rationale : Stress testing has not been shown to be useful in patients undergoing low-risk surgery. Therefore, stress CMR in these patients will not improve outcomes and will increase cost. Sponsoring organizations : •  Society for Cardiovascular Magnetic Resonance
Sources : • ACC/AHA guidelines
Recommendation : Don’t perform stress cardiovascular magnetic resonance (CMR) in patients with acute chest pain and high probability of coronary artery disease. Topic Areas : • Cardiovascular
• Emergency medicine
Rationale : Stress testing can increase risk and delay therapy in patients with acute chest pain and markers of high risk, such as ST segment elevation and/or positive cardiac enzymes. After initial evaluation and therapy, non-stress CMR may aid in diagnosing ischemic or nonischemic myocardial injury. Sponsoring organizations : •  Society for Cardiovascular Magnetic Resonance
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t perform coronary cardiovascular magnetic resonance (CMR) in the initial evaluation of asymptomatic patients. Topic Areas : • Cardiovascular
Rationale : Coronary CMR has not been well established for the evaluation of coronary atherosclerosis. Coronary CMR is primarily indicated for detecting and characterizing anomalous coronary arteries. Sponsoring organizations : •  Society for Cardiovascular Magnetic Resonance
Sources : • American College of Radiology Appropriateness Criteria
Recommendation : Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. Topic Areas : • Hematologic
Rationale : Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts and electrocardiograms) are ordered at regular intervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affect management, the routine ordering of tests increases health care costs, does not benefit patients and may in fact harm them. Potential harms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-up of incidental and nonpathological results found on routine studies. Sponsoring organizations : •  Critical Care Societies Collaborative–Critical Care
Sources : • Expert consensus
Recommendation : Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL. Topic Areas : • Hematologic
Rationale : Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For all patient populations in which it has been studied, transfusing red blood cells at a threshold of 7 mg/dL is associated with similar or improved survival, fewer complications and reduced costs compared to higher transfusion triggers. More aggressive transfusion may also limit the availability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes, although most observational studies suggest harms of aggressive transfusion even among such patients. Sponsoring organizations : •  Critical Care Societies Collaborative–Critical Care
Sources : • Randomized controlled trials
Recommendation : Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. Topic Areas : • Geriatric Medicine
Rationale : Patients and their families often value the avoidance of prolonged dependence on life support. However, many of these patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ values and goals, and to provide patient-centered recommendations. Routinely engaging high-risk patients and their surrogate decision makers in discussions about the option of foregoing life-sustaining therapies may promote patients’ and families’ values, improve the quality of dying and reduce family distress and bereavement. Even among patients pursuing life-sustaining therapy, initiating palliative care simultaneously with ongoing disease-focused therapy may be beneficial. Sponsoring organizations : •  Critical Care Societies Collaborative–Critical Care
Sources : • Expert consensus
Recommendation : Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain. Topic Areas : • Neurologic
Rationale : Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., nonsteroidal anti-inflammatory drugs, anticonvulsants) should be trialed prior to commencing opioids. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • American Society of Anesthesiologists guidelines
Recommendation : Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient. Topic Areas : • Neurologic
Rationale : Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement. Physicians should be cautious in coprescribing opioids and benzodiazepines. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • Expert consensus
Recommendation : Avoid imaging studies (MRI, CT or X-rays) for acute low back pain without specific indications. Topic Areas : • Orthopedic
Rationale : Imaging for low back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery. Sponsoring organizations : •  American Society of Anesthesiologists
Sources : • ACP/APS guidelines
Recommendation : Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. Topic Areas : • Geriatric Medicine
• Neurologic
• Psychiatric and Psychologic
Rationale : In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers, and patients should discuss cognitive, functional, and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise, and nonpharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well established. Sponsoring organizations : •  American Geriatrics Society
Sources : • Systematic review
Recommendation : Don’t prescribe a medication without conducting a drug regimen review. Topic Areas : • Geriatric Medicine
Rationale : Older patients disproportionately use more prescription and nonprescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls, and functional decline. Medication review identifies high-risk medications, drug interactions, and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly. Sponsoring organizations : •  American Geriatrics Society
Sources : • Expert consensus
Recommendation : Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance, and clarify patient goals and expectations. Topic Areas : • Geriatric Medicine
Rationale : Unintentional weight loss is a common problem for medically ill or frail elderly. Although high-calorie supplements increase weight in older people, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status, or survival. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention, and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria list megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (docosahexaenoic acid and elcosapentaenoic acid), thalidomide, and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression. Sponsoring organizations : •  American Geriatrics Society
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes, or other heavy equipment. Topic Areas : • Neurologic
Rationale : The use of both strong and weak opioids has been consistently associated with increased risk of motor vehicle crashes as opioids produce sedation and hinder or impair higher cognitive function. Evidence suggests higher risk with acute opioid use, but risk remains elevated throughout treatment with any opioid and reverses on cessation. Workers who operate motor vehicles/heavy equipment should be precluded from performing these or other safety-sensitive job functions while under treatment with opioids. Sponsoring organizations : •  American College of Occupational and Environmental Medicine
Sources : • American College of Occupational and Environmental Medicine guidelines
Recommendation : Don’t offer noninvasive prenatal testing to low-risk patients or make irreversible decisions based on the results of this screening test. Topic Areas : • Obstetrical
• Genetic
Rationale : NIPT has only been adequately evaluated in singleton pregnancies at high risk for chromosomal abnormalities (maternal age >35, positive screening, sonographic findings suggestive of aneuploidy, translocation carrier at increased risk for trisomy 13, 18, or 21, or prior pregnancy with a trisomy 13, 18, or 21). Its utility in low-risk pregnancies remains unclear. False-positive and false-negative results occur with NIPT, particularly for trisomy 13 and 18. Any positive NIPT result should be confirmed with invasive diagnostic testing prior to a termination of pregnancy. If NIPT is performed, adequate pretest counseling must be provided to explain the benefits and limitations. Sponsoring organizations : •  Society for Maternal-Fetal Medicine
Sources : • Expert consensus
Recommendation : Don’t initially obtain x-rays for injured workers with acute non-specific low back pain. Topic Areas : • Orthopedic
Rationale : X-ray is unnecessary for the initial routine management of low back pain unless red flags are present. Even when red flags are suspected, it should not be mandatory to order an x-ray in all cases. There is also no reason, either medically or legally, to obtain low back x-rays as a “baseline” for work-related injuries. Sponsoring organizations : •  American College of Occupational and Environmental Medicine
Sources : • American College of Occupational and Environmental Medicine guidelines
Recommendation : Don’t routinely order x-ray for diagnosis of plantar fasciitis/heel pain in employees who stand or walk at work. Topic Areas : • Orthopedic
Rationale : As the diagnosis of plantar fasciitis is in most cases evident from the worker’s history and physical examination, x-ray is not recommended for routine evaluations for plantar fasciitis except in cases where a serious underlying medical condition is suspected (e.g., fracture, infection) Sponsoring organizations : •  American College of Occupational and Environmental Medicine
Sources : • American College of Occupational and Environmental Medicine guidelines
Recommendation : Don’t order low back x-rays as part of a routine preplacement medical examination. Topic Areas : • Preventive Medicine
Rationale : Preplacement medical examinations are conducted to determine an individual’s ability to perform the job’s essential functions. Routine low back x-rays are costly, result in unnecessary radiation exposure, do not address the worker’s abilities and do not predict future injuries. Sponsoring organizations : •  American College of Occupational and Environmental Medicine
Sources : • American College of Occupational and Environmental Medicine guidelines
Recommendation : Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis, and overtreatment. Topic Areas : • Oncologic
• Geriatric Medicine
• Preventive Medicine
Rationale : Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For prostate cancer, 1,055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1,000 patients would need to be screened to prevent one death in 10 years. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit. Sponsoring organizations : •  American Geriatrics Society
Sources : • U.S. Preventive Services Task Force
Recommendation : Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium. Topic Areas : • Geriatric Medicine
• Psychiatric and Psychologic
Rationale : Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact and supportive interaction with staff. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time. Sponsoring organizations : •  American Geriatrics Society
Sources : • Expert consensus
Recommendation : Don’t routinely order sleep studies (polysomnogram) to screen for/diagnose sleep disorders in workers suffering from chronic fatigue/insomnia. Topic Areas : • Pulmonary medicine
• Neurologic
Rationale : Workers who suffer from fatigue, but do not have other sleep apnea symptoms (e.g., waking with a very sore or dry throat, loud snoring) or risk factors (obesity, neck diameter, fullness of soft tissues in the oropharynx), may not need a polysomnogram (sleep study). While a polysomnogram is an essential tool in diagnosing many sleep disorders, it is not usually necessary in assessing insomnia. If lack of sufficient sleep or the job schedule is affecting the patient’s sleep patterns, then behavioral modification and attempts to modify the sleep schedule and improve sleep hygiene should be attempted first. Sponsoring organizations : •  American College of Occupational and Environmental Medicine
Sources : • Expert consensus
Recommendation : Don’t rely on antihistamines as firstline treatment in severe allergic reactions. Topic Areas : • Allergy and immunologic
• Emergency medicine
Rationale : Epinephrine is the first-line treatment for anaphylaxis. Data indicate that antihistamines are overused as the first-line treatment of anaphylaxis. By definition, anaphylaxis has cardiovascular and respiratory manifestations, which require treatment with epinephrine. Overuse of antihistamines, which do not treat cardiovascular or respiratory manifestations of anaphylaxis, can delay the effective first-line treatment with epinephrine. Epinephrine should be administered as soon as the diagnosis of anaphylaxis is suspected. Antihistamines are second-line supportive therapy for cutaneous non–life-threatening symptoms (hives), but do not replace epinephrine as the first-line treatment for anaphylaxis. Fatalities during anaphylaxis have been associated with delayed administration of epinephrine. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • American Academy of Allergy, Asthma and Immunology guidelines
Recommendation : Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy. Topic Areas : • Allergy and immunologic
Rationale : False or clinically irrelevant positive allergy tests for foods are frequent. Indiscriminate screening results in inappropriate avoidance of foods and wastes healthcare resources. IgE testing for specific foods must be driven by a history of signs or symptoms consistent with an IgE-mediated reaction after eating a particular food. Ordering IgE testing in individuals who do not have a history consistent with or suggestive for food allergy based on history frequently reveals positive tests that are unlikely to be clinically relevant. Testing, when done, should be limited to suspected foods. The diagnostic utility of IgE testing for specific foods is optimal when a history compatible with or suggestive for the diagnosis of food allergy is present. In the absence of a compatible or suggestive history, the pre-test probability for a diagnosis of food allergy is low and a positive skin or in vitro IgE test does not establish a diagnosis of food allergy. Skin testing or serum testing for specific-IgE to food antigens has excellent sensitivity and high negative predictive value, but has low specificity and low positive predictive value. Considering that 50 to 90% of presumed cases of food allergy do not reflect IgE-mediated (allergic) pathogenesis and may instead reflect food intolerance or symptoms not causally associated with food consumption, ordering panels of food tests leads to many incorrectly identified food allergies and inappropriate recommendations to avoid foods that are positive on testing. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • Expert consensus
Recommendation : Don’t routinely order low- or iso-osmolar radiocontrast media or pretreat with corticosteroids and antihistamines for patients with a history of seafood allergy, who require radiocontrast media. Topic Areas : • Allergy and immunologic
Rationale : Although the exact mechanism for contrast media reactions is unknown, there is no cause and effect connection with seafood allergy. Consequently there is no reason to use more expensive agents or pre-medication before using contrast media in patients with a history of seafood allergy. A prior history of anaphylaxis to contrast media is an indication to use low- or iso-osmolar agents and pretreat with corticosteroids and antihistamines. Patients with a history of seafood allergy are not at elevated risk for anaphylaxis from iodinated contrast media. Similarly, patients who have had anaphylaxis from contrast media should not be told that they are allergic to seafood. Patients with a history of seafood allergy who are labeled as being at greater risk for adverse reaction from contrast infusions experience considerable morbidity from unnecessary precautions, including but not limited to denying them indicated roentgenographic procedures and adverse effects from pretreatment with antihistamine and/or corticosteroid medications. Regardless of whether these patients truly have IgE-mediated allergies to seafood (crustacean), there is no evidence in the medical literature that indicates they are at elevated risk for anaphylaxis from contrast infusion compared with the history-negative general population. In a random telephone survey of 5,529 households with a census of 14,948 individuals, seafood allergy was reported by 3.3% of survey respondents. According to current U.S. population estimates for 2013, this corresponds to 10,395,000 Americans. The mechanism for anaphylaxis to radio-iodinated contrast media relates to the physiochemical properties of these media and is unrelated to its iodine content. Further, although delayed-type hypersensitivity (allergic contact dermatitis) reactions to iodine have rarely been reported, IgE-mediated reactions to iodine have not, and neither type of reaction would be related to IgE-mediated shellfish allergy nor to contrast media reactions. Patients with a history of prior anaphylaxis to contrast media are at elevated risk for anaphylactic reaction with re-exposure to contrast media. Patients with asthma or cardiovascular disease, or who are taking beta blockers, are at increased risk for serious anaphylaxis from radiographic contrast media. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • Expert consensus
Recommendation : Don’t perform screening panels for food allergies without previous consideration of medical history. Topic Areas : • Allergy and immunologic
Rationale : Ordering screening panels (IgE tests) that test for a variety of food allergens without previous consideration of the medical history is not recommended. Sensitization (a positive test) without clinical allergy is common. For example, about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. When symptoms suggest a food allergy, tests should be selected based on a careful medical history. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American Academy of Pediatrics guidelines
Recommendation : Avoid using acid blockers and motility agents such as metoclopramide (generic) for physiologic gastroesophageal reflux that is effortless, painless, and not affecting growth. Do not use medication in the so-called “happy-spitter.” Topic Areas : • Pediatric
• Gastroenterologic
Rationale : There is scant evidence that gastroesophageal reflux is a causative agent in many conditions though reflux may be a common association. There is accumulating evidence that acid-blocking and motility agents such as metoclopramide (generic) are not effective in physiologic gastroesophageal reflux. Long-term sequelae of infant gastroesophageal reflux is rare, and there is little evidence that acid blockade reduces these sequelae. The routine performance of upper gastrointestinal tract radiographic imaging to diagnose gastroesophageal reflux or GERD is not justified. Parents should be counseled that gastroesophageal reflux is normal in infants and not associated with anything but stained clothes. Gastroesophageal reflux that is associated with poor growth or significant respiratory symptoms should be further evaluated. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • Expert consensus
Recommendation : Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation. Topic Areas : • Allergy and immunologic
• Infectious disease
Rationale : While about 10% of the population reports a history of penicillin allergy, studies show that 90% on more of these patients are not allergic to penicillins and are able to take these antibiotics safely. The main reason for this observation is that penicillin allergy is often misdiagnosed and when present wanes over time in most (but not all) individuals. Patients labeled penicillin-allergic are more likely to be treated with alternative antibiotics (such as vancomycin and quinolones), have higher medical costs, experience longer hospital stays, and are more likely to develop complications such as infections with vancomycin-resistant enterococcus and Clostridium difficile. Evaluation for specific IgE to penicillin can be carried out by skin testing. Ideally, penicillin skin testing should be performed with both major and minor determinants. The negative predictive value of penicillin skin testing for immediate reactions approaches 100%, whereas the positive predictive value is between 40 and 100%. The usefulness of in vitro tests for penicillin-specific IgE is limited by their uncertain predictive value. They are not suitable substitutes for penicillin skin testing. By identifying the overwhelming majority of individuals who can safely receive penicillin and penicillin-like drugs, we can improve the appropriateness of antibiotic therapy and clinical care outcomes. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • Expert consensus
Recommendation : Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteruria. Topic Areas : • Infectious disease
Rationale : There is minimal evidence that surveillance urine cultures or treatment of asymptomatic bacteruria is beneficial. Surveillance cultures are costly and produce both false-positive and false-negative results. Treatment of asymptomatic bacteruria also increases exposure to antibiotics, which is a risk factor for subsequent infections with a resistant organism. This also results in the overall use of antibiotics in the community and may lead to unnecessary imaging. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American Academy of Pediatrics guidelines
Recommendation : Don’t prescribe high-dose dexamethasone (0.5mg/kg per day) for the prevention or treatment of bronchopulmonary dysplasia in preterm infants. Topic Areas : • Neonatology
• Pulmonary medicine
Rationale : High-dose dexamethasone (0.5 mg/kg day) does not appear to confer additional therapeutic benefit over lower doses and is not recommended. High doses also have been associated with numerous short- and long-term adverse outcomes, including neurodevelopmental impairment. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • American Academy of Pediatrics guidelines
Recommendation : Infant home apnea monitors should not be routinely used to prevent sudden infant death syndrome. Topic Areas : • Pediatric
Rationale : There is no evidence that the use of infant home apnea monitors decreases the incidence of sudden infant death syndrome; however, they might be of value for selected infants at risk for apnea or cardiovascular events after discharge but should not be used routinely. Sponsoring organizations : •  American Academy of Pediatrics
Sources : • Expert consensus
Recommendation : Don’t routinely avoid influenza vaccination in egg-allergic patients. Topic Areas : • Allergy and immunologic
• Preventive Medicine
Rationale : Of the vaccines that may contain egg protein (measles, mumps, rabies, influenza and yellow fever), measles, mumps and rabies vaccines have at most negligible egg protein; consequently no special precautions need to be followed in egg-allergic patients for these vaccines. Studies in egg-allergic patients receiving egg-based inactivated influenza vaccine have not reported reactions; consequently egg-allergic patients should be given either egg-free influenza vaccine or should receive egg-based influenza vaccine with a 30-minute post-vaccine observation period. Egg-allergic patients receiving the yellow fever vaccine should be skin tested with the vaccine and receive the vaccine with a 30-minute observation period if the skin test is negative. If positive, the vaccine may be given in graded doses with appropriate medical observation. Egg protein is present in influenza and yellow fever vaccines and in theory could cause reactions in egg-allergic patients. However, in 27 published studies collectively 4,172 patients with egg allergy received 4,729 doses of egg-based inactivated influenza vaccine with no cases of anaphylaxis, including 513 with severe egg allergy who uneventfully received 597 doses. The Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommends that egg-allergic persons receive inactivated influenza vaccine as a single dose without prior vaccine skin testing and be observed for 30 minutes afterwards for any possible allergic reaction. If the reaction to the ingestion of eggs was hives only, the vaccine can be administered in a primary care setting, whereas if the reaction to the ingestion of eggs was more severe, the vaccine should be administered in an allergist/immunologist’s office. Two new inactivated influenza vaccine not grown in eggs have been approved for patients 18 years and older: Flucelvax, prepared from virus propagated in cell culture, and Flublok, recombinant hemagglutinin proteins produced in an insect cell line. For egg-allergic patients 18 years of age and older, either egg-based inactivated influenza vaccine can be used with the precautions above or egg-free inactivated influenza vaccine can be used. Measles and mumps vaccines (and Purified Chick Embryo Cell rabies vaccine) are grown in chick embryo fibroblast cultures and contain negligible or no egg protein. Thus, measles, mumps, and rubella and Purified Chick Embryo Cell rabies vaccine can be administered to egg-allergic recipients in the usual manner. Per the Yellow Fever vaccine package insert, egg-allergic recipients should be skin tested with the vaccine prior to administration. If negative, the vaccine can be given in the usual manner, but the patient should be observed for 30 minutes afterward. If the vaccine skin test is positive, the vaccine can be given in graded doses under appropriate medical observation. Sponsoring organizations : •  American Academy of Allergy, Asthma and Immunology
Sources : • Advisory Committee on Immunization Practices
Recommendation : Don’t continue treatment for hepatic encephalopathy indefinitely after an initial episode with an identifiable precipitant. Topic Areas : • Neurologic
• Gastroenterologic
Rationale : In circumstances where the precipitating factors are identified and well-controlled (e.g., recurrent infections, variceal bleeding) or liver function or nutritional status improved, prophylactic therapy may be discontinued. Sponsoring organizations : •  American Association for the Study of Liver Diseases
Sources : • American Association for the Study of Liver Diseases guideline
Recommendation : Don’t repeat hepatitis C viral load testing outside of antiviral therapy. Topic Areas : • Gastroenterologic
• Infectious disease
Rationale : Highly sensitive quantitative assays of hepatitis C RNA are appropriate at diagnosis and as part of antiviral therapy. Otherwise, the results of virologic testing do not change clinical management or outcomes. Sponsoring organizations : •  American Association for the Study of Liver Diseases
Sources : • American Association for the Study of Liver Diseases guideline
Recommendation : Don’t perform CT or MRI routinely to monitor benign focal lesions in the liver unless there is a major change in clinical findings or symptoms. Topic Areas : • Gastroenterologic
Rationale : Patients with benign focal liver lesions (other than hepatocellular adenoma) who don’t have underlying liver disease and have demonstrated clinical and radiologic stability do not need repeated imaging. Sponsoring organizations : •  American Association for the Study of Liver Diseases
Sources : • Expert consensus
Recommendation : Avoid performing plain x-rays in instances of facial trauma. Topic Areas : • Emergency medicine
Rationale : Evidence currently indicates that maxillofacial CT is available in most trauma centers and is the most sensitive method for detecting fractures in instances of facial trauma. Evidence also indicates that the use of plain x-rays does not improve quality of care, causes unnecessary radiation exposure, and leads to substantial increase in costs. Use of plain x-rays for diagnosis and treatment is helpful in instances of dental and/or isolated mandibular injury or trauma. Sponsoring organizations : •  American Society of Plastic Surgeons
Sources : • Expert consensus
Recommendation : Don’t obtain imaging (plain radiographs, MRI, CT, or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags. Topic Areas : • Orthopedic
Rationale : Imaging of the spine in patients with acute low back pain during the early phase of symptom onset is unnecessary. Red flags that may indicate that early imaging of the spine is required can include neurological deficit such as weakness or numbness, any bowel or bladder dysfunction, fever, history of cancer, history of intravenous drug use, immunosuppression, steroid use, history of osteoporosis, or worsening symptoms. Sponsoring organizations : •  American Association of Neurological Surgeons and Congress of Neurological Surgeons
Sources : • Systematic review
Recommendation : Don’t routinely obtain CT scanning of children with mild head injuries. Topic Areas : • Pediatric
• Neurologic
• Emergency medicine
Rationale : A mild traumatic brain injury is a temporary loss of neurologic function resulting from a blunt blow to the head or an acceleration/deceleration injury. There are predictors that a more severe injury has occurred and CT scanning may be appropriate. In patients younger than age two, a persistent altered mental status, non-frontal scalp hematoma, loss of consciousness for five seconds or more, severe injury mechanism, palpable skull fracture, or not acting normally according to the parent may be signs of a more serious injury. In patients older than two, prolonged abnormal mental status, any loss of consciousness, history of vomiting, severe injury mechanism, clinical signs of basilar skull fracture, or severe headache may also necessitate CT imaging. Any patient with a traumatic injury to the head that has any neurologic deficits should also be imaged if no other cause can be determined. Sponsoring organizations : •  American Association of Neurological Surgeons and Congress of Neurological Surgeons
Sources : • Prospective cohort studies
Recommendation : Don’t routinely screen for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage, or genetic disorders that may predispose to aneurysm formation. Topic Areas : • Neurologic
Rationale : Family history of aneurysmal subarachnoid hemorrhage increases an individual’s risk of harboring an aneurysm. Screening patients without a family history or without a personal history of subarachnoid hemorrhage is not indicated. Sponsoring organizations : •  American Association of Neurological Surgeons and Congress of Neurological Surgeons
Sources : • American Heart Association guidelines
Recommendation : Don’t routinely use seizure prophylaxis in patients following ischemic stroke. Topic Areas : • Neurologic
Rationale : Seizures may complicate the clinical course of patients who have suffered a stroke. However, there is no evidence that using prophylactic antiepileptic drugs prevents seizure occurrence. For patients who suffer a seizure after a stroke, seizure treatment may be required. Sponsoring organizations : •  American Association of Neurological Surgeons and Congress of Neurological Surgeons
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity, and duration of exercise to the individual’s abilities and goals. Topic Areas : • Geriatric Medicine
• Sports Medicine
• Preventive Medicine
Rationale : Improved strength in older adults is associated with improved health, quality of life, and functional capacity, and with a reduced risk of falls. Older adults are often prescribed low dose exercise and physical activity that are physiologically inadequate to increase gains in muscle strength. Failure to establish accurate baseline levels of strength limits the adequacy of the strength training dosage and progression, and thus limits the benefits of the training. A carefully developed and individualized strength training program may have significant health benefits for older adults. Sponsoring organizations : •  American Physical Therapy Association
Sources : • Systematic review
Recommendation : Don’t recommend bed rest following diagnosis of acute DVT after the initiation of anti-coagulation therapy, unless significant medical concerns are present. Topic Areas : • Hematologic
Rationale : Given the clinical benefits and lack of evidence indicating harmful effects of ambulation and activity, both are recommended following achievement of anticoagulation goals unless there are overriding medical indications. Patients can be harmed by prolonged bed rest that is not medically necessary. Sponsoring organizations : •  American Physical Therapy Association
Sources : • Systematic review
Recommendation : Don’t use whirlpools for wound management. Topic Areas : • Surgical
Rationale : Whirlpools are a non-selective form of mechanical debridement. Utilizing whirlpools to treat wounds predisposes the patient to risks of bacterial cross-contamination, damage to fragile tissue from high turbine forces, and complications in extremity edema when arms and legs are treated in a dependent position in warm water. Other more selective forms of hydrotherapy should be utilized, such as directed wound irrigation or a pulsed lavage with suction. Sponsoring organizations : •  American Physical Therapy Association
Sources : • Institute for Clinical Systems Improvement guideline
Recommendation : Don’t routinely recommend follow-up mammograms more often than annually for women who have had radiotherapy following breast conserving surgery. Topic Areas : • Oncologic
• Women's health
Rationale : Studies indicate that annual mammograms are the appropriate frequency for surveillance of breast cancer patients who have had breast conserving surgery and radiation therapy with no clear advantage to shorter interval imaging. Patients should wait 6-12 months after the completion of radiation therapy to begin their annual mammogram surveillance. Suspicious findings on physical examination or surveillance imaging might warrant a shorter interval between mammograms. Sponsoring organizations : •  American Society for Radiation Oncology
Sources : • American Society of Clinical Oncology guideline
• Cochrane Database of Systematic Reviews
Recommendation : Don’t order an electromyogram for low back pain unless there is leg pain or sciatica. Topic Areas : • Neurologic
• Orthopedic
Rationale : Utilization of electromyogram studies for diagnosis of low back pain without leg pain is not supported. Electromyogram studies have good specificity for the detection of lumbosacral radiculopathy in sciatica patients when appropriate electrodiagnostic criteria are used. Sponsoring organizations : •  American Academy of Physical Medicine and Rehabilitation
Sources : • Expert consensus
Recommendation : Don’t prescribe bed rest for acute localized back pain without completing an evaluation. Topic Areas : • Orthopedic
Rationale : Prolonged bed rest (more than 2 days) in acute localized low back pain has not been shown to improve long-term function or pain. Bed rest prescriptions should be limited to less than 48 hours in patients with non-traumatic acute localized low back pain in the absence of traditional red flag signs, including, but not limited to, tumors, neurological issues, and weakness. Sponsoring organizations : •  American Academy of Physical Medicine and Rehabilitation
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t order an imaging study for back pain without performing a thorough physical examination. Topic Areas : • Orthopedic
Rationale : A thorough history and physical examination are necessary to guide imaging decisions. Ordering spine imaging without obtaining a history and physical examination has not been shown to improve patient outcomes and increases costs. Sponsoring organizations : •  American Academy of Physical Medicine and Rehabilitation
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t prescribe opiates in acute disabling low back pain before evaluation and a trial of other alternatives is considered. Topic Areas : • Orthopedic
Rationale : Early opiate prescriptions in acute disabling low back pain are associated with longer disability, increased surgical rates, and a greater risk of later opioid use. Opiates should be prescribed only after a physician evaluation by a licensed health care provider and after other alternatives are trialed. Sponsoring organizations : •  American Academy of Physical Medicine and Rehabilitation
Sources : • Retrospective cohort study
Recommendation : Don’t automatically initiate continuous electronic fetal heart rate monitoring during labor for women without risk factors; consider intermittent auscultation first. Topic Areas : • Obstetrical
Rationale : Continuous electronic FHR monitoring during labor, a routine procedure in many hospitals, is associated with an increase in cesarean and instrumental births without improving Apgar score, neonatal intensive care unit admission or intrapartum fetal death rates. Intermittent auscultation allows women more freedom of movement during labor, enhancing their ability to cope with labor pain and utilize gravity to promote labor progress. Upright positions and walking have been associated with shorter duration of first stage labor, fewer cesareans and reduced epidural use. Sponsoring organizations : •  American Academy of Nursing
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t let older adults lie in bed or only get up to a chair during their hospital stay. Topic Areas : • Geriatric Medicine
Rationale : Up to 65% of older adults who are independent in their ability to walk will lose their ability to walk during a hospital stay. Walking during the hospital stay is critical for maintaining functional ability in older adults. Loss of walking independence increases the length of hospital stay, the need for rehabilitation services, new nursing home placement, and risk for falls both during and after discharge from the hospital; places higher demands on caregivers; and increases the risk of death for older adults. Bed rest or limited walking (only sitting up in a chair) during a hospital stay causes deconditioning and is one of the primary factors for loss of walking independence in hospitalized older adults. Older adults who walk during their hospital stay are able to walk farther by discharge, are discharged from the hospital sooner, have improvement in their ability to independently perform basic activities of daily living, and have a faster recovery rate after surgery. Sponsoring organizations : •  American Academy of Nursing
Sources : • Expert consensus
Recommendation : Don’t use physical restraints with an older hospitalized patient. Topic Areas : • Geriatric Medicine
Rationale : Restraints cause more problems than they solve, including serious complications and even death. Physical restraints are most often applied when behavioral expressions of distress and/or a change in medical status occur. These situations require immediate assessment and attention, not restraint. Safe, quality care without restraints can be achieved when multidisciplinary teams and/or geriatric nurse experts help staff anticipate, identify, and address problems; family members or other caregivers are consulted about the patient’s usual routine, behavior, and care; systematic observation and assessment measures and early discontinuation of invasive treatment devices are implemented; staff are educated about restraints and the organizational culture and structure support restraint-free care. Sponsoring organizations : •  American Academy of Nursing
Sources : • Expert consensus
Recommendation : Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so. Topic Areas : • Urologic
• Infectious disease
Rationale : Catheter-associated urinary tract infections are among the most common health care–associated infections in the United States. Most catheter-associated urinary tract infections are related to urinary catheters, so the infections can largely be prevented by reduced use of indwelling urinary catheters and catheter removal as soon as possible. Catheter-associated urinary tract infections are responsible for an increase in U.S. health care costs and can lead to more serious complications in hospitalized patients. Sponsoring organizations : •  American Academy of Nursing
Sources : • Centers for Disease Control and Prevention
Recommendation : Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma, and a normal neurological evaluation. Topic Areas : • Neurologic
• Emergency medicine
Rationale : Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department and most episodes are not serious. Many tests may be ordered to identify the cause of such episodes. However, diagnostic tests for syncope should not be routinely ordered, and the decision to order any tests should be guided by information obtained from the patient’s history or physical examination. CT scans of the brain are frequently ordered for this problem to look for bleeding or strokes, but published research has confirmed that abnormalities are rarely found. CT scans are expensive, and may unnecessarily expose patients to radiation. If a head injury is associated with a syncopal episode (fainting spell), then a CT scan of the brain may be indicated. In addition, if there were symptoms of a stroke (i.e., headache, garbled speech, weakness in one arm or leg, trouble walking, or confusion) before or after a syncopal episode, a CT scan may be indicated. However, in the absence of head injury or signs of a stroke, a CT scan of the brain should not be routinely ordered. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Cohort studies
Recommendation : Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria or a negative D-dimer. Topic Areas : • Pulmonary medicine
• Emergency medicine
Rationale : Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram. It is readily available in most hospitals and emergency rooms. However, disadvantages of the CT pulmonary angiogram include patient exposure to radiation, the use of dye in the veins that can damage kidneys, and high cost. Studies have demonstrated that certain findings in a patient’s medical history put them at very low risk for having a blood clot in the lung. In some cases, a blood test called a D-dimer may be additionally used to screen for the possibility of a clot. If patient historical factors and physical examination findings are negative, along with a negative D-dimer (if the physician chooses to order it), evidence shows that the risk of an undiagnosed blood clot is the same as if the patient had a negative CT pulmonary angiogram. Such a strategy saves the risk of radiation, kidney injury and the high cost of a CT pulmonary angiogram. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • AAFP/ACP guidelines
Recommendation : Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis). Topic Areas : • Neurologic
• Orthopedic
Rationale : Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an X-ray or CT scan. When a patient has symptoms or physical findings of a serious or progressive neurological condition, or is suspected of having a serious underlying condition such as cancer or a spinal infection, imaging may be appropriate and may include plain X-rays or advanced imaging (e.g., MRI or CT scan). Diagnostic imaging does not accurately identify the cause of most low back pain and does not improve the time to recovery. The vast majority of cases of back pain in the emergency department are related to muscle strain or inflammation. As a result, routine imaging of the low back should be avoided in order to reduce ionizing radiation exposure and unnecessary cost. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • ACP/APS guidelines
Recommendation : Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Topic Areas : • Otolaryngologic
• Infectious disease
Rationale : Sinusitis is a common reason for patients to visit the emergency department. Most patients with acute sinusitis do not require antibiotic treatment, because approximately 98% of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment. For some patients with sinusitis, antibiotics might be appropriate, such as those patients taking drugs that reduce the effectiveness of the immune system, those with prolonged, severe symptoms, or those with worsening symptoms. Antibiotics can cause many side effects and have potentially severe complications, and these risks usually outweigh the benefits of their use for sinusitis. In addition, inappropriate antibiotic use for sinusitis can contribute to the development of antibiotic-resistant infections and contributes to avoidable health care costs. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • IDSA/AAP guidelines
Recommendation : Avoid ordering CT of the abdomen and pelvis in young otherwise healthy emergency department patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic. Topic Areas : • Urologic
Rationale : Kidney stones can cause severe pain (called renal colic) and nausea, which can usually be relieved with medication. Most stones pass spontaneously in the urine in a few days, though kidney stones often do recur. CT scans may be needed to diagnose kidney stones, and rule out other problems that may mimic the pain of kidney stones. Many patients in the emergency department who are less than 50 years old and who have symptoms of recurrent kidney stones do not need a CT scan unless these symptoms persist or worsen, or if there is a fever or a history of severe obstruction with previous stones. CT scans of patients in the ED with symptoms of recurrent kidney stones usually do not change treatment decisions, and the cost and radiation exposure can often be avoided in these cases. Close follow-up by a primary care physician or specialist is necessary. Sponsoring organizations : •  American College of Emergency Physicians
Sources : • Expert consensus
Recommendation : Don’t treat with an anticoagulant for more than three months in a patient with a first VTE occurring in the setting of a major transient risk factor. Topic Areas : • Hematologic
Rationale : Anticoagulation is potentially harmful and costly. Patients with a first VTE triggered by a major, transient risk factor such as surgery, trauma, or an intravascular catheter are at low risk for recurrence once the risk factor has resolved and an adequate treatment regimen with anticoagulation has been completed. Evidence-based and consensus guidelines recommend three months of anticoagulation over shorter or longer periods of anticoagulation in patients with VTE in the setting of a reversible provoking factor. By ensuring a patient receives an appropriate regimen of anticoagulation, clinicians may avoid unnecessary harm, reduce health care expenses, and improve quality of life. This Choosing Wisely recommendation is not intended to apply to VTE associated with non-major risk factors (e.g., hormonal therapy, pregnancy, travel-associated immobility), as the risk of recurrent VTE in these groups is either intermediate or poorly defined. Sponsoring organizations : •  American Society of Hematology
Sources : • American College of Chest Physicians guidelines
Recommendation : Don’t routinely transfuse patients with sickle cell disease for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication. Topic Areas : • Hematologic
Rationale : Patients with sickle cell disease are especially vulnerable to potential harms from unnecessary red blood cell transfusion. In particular, they experience an increased risk of alloimmunization to minor blood group antigens and a high risk of iron overload from repeated transfusions. Patients with the most severe genotypes of sickle cell disease with baseline hemoglobin values in the 7 to 10 g/dL range can usually tolerate further temporary reductions in Hb without developing symptoms of anemia. Many patients with sickle cell disease receive intravenous fluids to improve hydration when hospitalized for management of pain crisis, which may contribute to a decrease in hemoglobin by 1 to 2 g/dL. Routine administration of red blood cells in this setting should be avoided. Moreover, there is no evidence that transfusion reduces pain due to vaso-occlusive crises. For a discussion of when transfusion is indicated in sickle cell disease, readers are referred to recent evidence-based guidelines from the National Heart, Lung, and Blood Institute (see references). Sponsoring organizations : •  American Society of Hematology
Sources : • National Heart, Lung and Blood Institute guidelines
Recommendation : Don’t test or treat for suspected heparin-induced thrombocytopenia in patients with a low pretest probability of heparin-induced thrombocytopenia. Topic Areas : • Hematologic
Rationale : In patients with suspected heparin-induced thrombocytopenia, use the “4T’s” score to calculate the pretest probability of heparin-induced thrombocytopenia. This scoring system uses the timing and degree of thrombocytopenia, the presence or absence of thrombosis, and the existence of other causes of thrombocytopenia to assess the pretest probability of heparin-induced thrombocytopenia. It can be excluded by a low pretest probability score (4T’s score of 0-3) without the need for laboratory investigation. Do not discontinue heparin or start a non-heparin anticoagulant in these low-risk patients because presumptive treatment often involves an increased risk of bleeding, and because alternative anticoagulants are costly. Sponsoring organizations : •  American Society of Hematology
Sources : • Systematic review
Recommendation : Don’t treat patients with immune thrombocytopenic purpura in the absence of bleeding or a very low platelet count. Topic Areas : • Hematologic
Rationale : Treatment for immune thrombocytopenic purpura should be aimed at treating and preventing bleeding episodes and improving quality of life. Unnecessary treatment exposes patients to potentially serious treatment side effects and can be costly, with little expectation of clinical benefit. The decision to treat immune thrombocytopenic purpura should be based on an individual patient’s symptoms, bleeding risk (as determined by prior bleeding episodes and risk factors for bleeding such as use of anticoagulants, advanced age, high-risk activities, etc.), social factors (distance from the hospital/travel concerns), side effects of possible treatments, upcoming procedures, and patient preferences. In the pediatric setting, treatment is usually not indicated in the absence of mucosal bleeding regardless of platelet count. In the adult setting, treatment may be indicated in the absence of bleeding if the platelet count is very low. However, immune thrombocytopenic purpura treatment is rarely indicated in adult patients with platelet counts greater than 30,000/microL unless they are preparing for surgery or an invasive procedure, or have a significant additional risk factor for bleeding. In patients preparing for surgery or other invasive procedures, short-term treatment may be indicated to increase the platelet count prior to the planned intervention and during the immediate postoperative period. Sponsoring organizations : •  American Society of Hematology
Sources : • American Society of Hematology guidelines
Recommendation : Avoid polysomnography in chronic insomnia patients unless symptoms suggest a comorbid sleep disorder. Topic Areas : • Neurologic
• Psychiatric and Psychologic
Rationale : Chronic insomnia is diagnosed by a clinical evaluation that includes a thorough sleep history along with a medical, substance, and psychiatric history. Some instruments can be helpful at the clinical encounter; these include self-administered questionnaires, sleep logs completed at home, and symptom checklists. Although polysomnography may confirm self-reported symptoms of chronic insomnia, it does not provide additional information necessary for diagnosis of chronic insomnia. However, polysomnography is indicated in some specific circumstances; for example, when sleep apnea or sleep-related movement disorders are suspected, the initial diagnosis is uncertain, behavioral or pharmacologic treatment fails, or sudden arousals occur with violent or injurious behavior. Sponsoring organizations : •  American Academy of Sleep Medicine
Sources : • Expert consensus
Recommendation : Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive behavioral therapy, and reserve medication for adjunctive treatment when necessary. Topic Areas : • Psychiatric and Psychologic
Rationale : Cognitive behavioral therapy for chronic insomnia involves a combination of behavioral modification, such as stimulus control and sleep restriction, and cognitive strategies, such as replacement of unrealistic fears about sleep with more positive expectations. In clinical trials, cognitive behavioral therapy is generally as effective as or more effective than hypnotics at improving sleep, and can be effective over an extended period of time without side effects associated with hypnotics. Some patients may benefit from a limited course of hypnotics while cognitive behavioral therapy for chronic insomnia is initiated. Patients who have successfully used hypnotics for extended periods and are reluctant to discontinue their current treatment regimen may be reasonable candidates for continued pharmacologic treatment. Sponsoring organizations : •  American Academy of Sleep Medicine
Sources : • Randomized controlled trials
Recommendation : Don’t prescribe medication to treat childhood insomnia, which usually arises from parent-child interactions and responds to behavioral intervention. Topic Areas : • Pediatric
Rationale : No medications are approved by the U.S. Food and Drug Administration for the treatment of pediatric insomnia. Because childhood insomnia usually arises due to parent-child interactions, treatment should involve efforts to improve relevant parent and child behavior, establish better sleep hygiene, and manage expectations. Basic environmental, scheduling, sleep practice, and physiological features should be optimized before hypnotic use is considered for children. When necessary, hypnotics should be used short term, with caution and close monitoring for efficacy and side effects. Some children with significant developmental delay or cognitive impairment may not respond to behavioral management and may benefit from judicious use of hypnotics. Sponsoring organizations : •  American Academy of Sleep Medicine
Sources : • Expert consensus
Recommendation : Don’t use polysomnography to diagnose restless legs syndrome, except rarely when the clinical history is ambiguous and documentation of periodic leg movements is necessary. Topic Areas : • Neurologic
Rationale : Restless legs syndrome is a neurologic disorder that can be diagnosed based on a patient’s description of symptoms and additional clinical history. Polysomnography generally does not provide additional information necessary to make the diagnosis. If a patient’s clinical history for RLS is ambiguous, PSG to assess for periodic leg movements may be useful to help confirm an RLS diagnosis. Sponsoring organizations : •  American Academy of Sleep Medicine
Sources : • Expert consensus
Recommendation : Don’t perform positive airway pressure retitration studies in asymptomatic, adherent patients with sleep apnea and stable weight. Topic Areas : • Pulmonary medicine
Rationale : Retitration of positive airway pressure is not indicated for adult obstructive sleep apnea patients with stable weight whose symptoms are well-controlled by their current positive airway pressure treatment. Follow-up polysomnography or retitration is indicated for adult patients who are again symptomatic despite the continued, proper use of positive airway pressure, especially if they have gained substantial weight (e.g., 10% of original weight) since the last titration study. A new diagnostic polysomnography or retitration may be indicated for patients who have lost substantial weight, to determine whether positive airway pressure treatment is still necessary. Sponsoring organizations : •  American Academy of Sleep Medicine
Sources : • American Academy of Sleep guidelines
Recommendation : Don’t use interventions (including surgical bypass, angiogram, angioplasty or stent) as a first line of treatment for most patients with intermittent claudication. Topic Areas : • Surgical
• Cardiovascular
Rationale : A trial of smoking cessation, risk factor modification, diet and exercise, as well as pharmacologic treatment should be attempted before any procedures. When indicated, the type of intervention (surgery or angioplasty) depends on several factors. Intermittent claudication can vary due to several factors. The lifetime incidence of amputation in a patient with claudication is less than 5% with appropriate risk factor modification. Procedures for claudication are usually not limb-saving, but, rather, lifestyle-improving. However, interventions are not without risks, including worsening the patient’s perfusion, and should be reserved until a trial of conservative management has been attempted. Many people will actually realize an increase in their walking distance and pain threshold with exercise therapy. In cases in which the claudication limits a person’s ability to carry out normal daily functions, it is appropriate to intervene. Depending on the characteristics of the occlusive process, and patient comorbidities, the best option for treatment may be either surgical or endovascular. Sponsoring organizations : •  Society for Vascular Surgery
Sources : • Expert consensus
Recommendation : Avoid use of ultrasound for routine surveillance of carotid arteries in the asymptomatic healthy population at any time. Topic Areas : • Cardiovascular
• Preventive Medicine
Rationale : The presence of a bruit alone does not warrant serial duplex ultrasounds in low-risk, asymptomatic patients, unless significant stenosis is found on the initial duplex ultrasound. The presence of asymptomatic severe carotid artery disease in the general population yields a risk of neurologic event, which is <2%. Even in patients who have a bruit, if no other risk factors exist, the incidence is only 2%. Age (over 65), coronary artery disease, need for coronary bypass, symptomatic lower extremity arterial occlusive disease, history of tobacco use, and high cholesterol would be appropriate risk factors to prompt ultrasound in patients with a bruit. Otherwise, these ultrasounds may prompt unnecessary and more expensive and invasive tests, or even unnecessary surgery. In general population-based studies, the prevalence of severe carotid stenosis is not high enough to make bruit alone an indication for carotid screening. With these facts in mind, screening should be pursued only if a bruit is associated with other risk factors for stenosis and stroke, or if the primary care physician determines a patient is at increased risk for carotid artery occlusive disease. Sponsoring organizations : •  Society for Vascular Surgery
Sources : • Society for Vascular Surgery guidelines
Recommendation : Don’t do nerve conduction studies without also doing a needle EMG for testing for radiculopathy, a pinched nerve in the neck or back. Topic Areas : • Neurologic
Rationale : For diagnosis of a pinched nerve in the neck or back, nerve conduction studies alone cannot make the diagnosis. Needle EMG is necessary to identify and characterize the disease process. Sponsoring organizations : •  American Association of Neuromuscular & Electrodiagnostic Medicine
Sources : • Expert consensus
Recommendation : Don’t do an MRI scan of the spine or brain for patients with only peripheral neuropathy (without signs or symptoms suggesting a brain or spine disorder). Topic Areas : • Neurologic
Rationale : Because the vast majority of people with peripheral neuropathy (also called polyneuropathy) have the longest nerves of the body primarily affected (mostly in the toes and feet, but sometimes also in the hands), there is essentially no justification for MRI of the brain or spine in these cases. Sponsoring organizations : •  American Association of Neuromuscular & Electrodiagnostic Medicine
Sources : • American Academy of Neurology guidelines
Recommendation : Don’t order imaging studies in patients with non-pulsatile bilateral tinnitus, symmetric hearing loss, and an otherwise normal history and physical examination. Topic Areas : • Otolaryngologic
Rationale : The utility of imaging procedures in primary tinnitus is undocumented; imaging is costly, has potential for radiation exposure, and does not change management. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • Practice guideline
Recommendation : Don’t order more than one CT scan of the paranasal sinuses within 90 days to evaluate uncomplicated chronic rhinosinusitis patients when the paranasal sinus CT obtained is of adequate quality and resolution to be interpreted by the clinician and used for clinical decision-making and/or surgical planning. Topic Areas : • Otolaryngologic
• Infectious disease
Rationale : CT scanning is expensive, exposes the patient to ionizing radiation, and offers no additional information that would improve initial management. Multiple CT scans within 90 days may be appropriate in patients with complicated sinusitis or when an alternative diagnosis is suspected. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • Practice guideline
Recommendation : Don’t routinely perform sinonasal imaging in patients with symptoms limited to a primary diagnosis of allergic rhinitis alone. Topic Areas : • Otolaryngologic
• Allergy and immunologic
Rationale : History, physical examination, and allergy testing are the cornerstones of diagnosis of allergic rhinitis. The utility of imaging for allergic rhinitis is unproven. Sponsoring organizations : •  American Academy of Otolaryngology–Head and Neck Surgery Foundation
Sources : • Practice guideline
Recommendation : Don’t order an erythrocyte sedimentation rate to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein to detect acute phase inflammation. Topic Areas : • Rheumatologic
• Hematologic
Rationale : C-reactive protein is a more sensitive and specific reflection of the acute phase of inflammation than is the erythrocyte sedimentation rate. In the first 24 hours of a disease process, the C-reactive protein will be elevated, whereas the erythrocyte sedimentation rate may be normal. If the source of inflammation is removed, the C-reactive protein will return to normal within a day or so, whereas the erythrocyte sedimentation rate will remain elevated for several days until excess fibrinogen is removed from the serum. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Expert consensus
Recommendation : Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio and does not respond to vitamin K therapy. Topic Areas : • Hematologic
Rationale : Measurements of the level of vitamin K in the blood are rarely used to determine if a deficiency exists. Vitamin K deficiency is very rare, but when it does occur, a prolonged prothrombin time and elevated international normalized ratio will result. A diagnosis is typically made by observing the prothrombin time correction following administration of vitamin K, plus the presence of clinical risk factors for vitamin K deficiency. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Expert consensus
Recommendation : Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency. Topic Areas : • Urologic
Rationale : With the increased incidence of obesity and diabetes, there may be increasing numbers of older men with lower testosterone levels that do not fully meet diagnostic or symptomatic criteria for hypogonadism. Current clinical guidelines recommend making a diagnosis of androgen deficiency only in men with consistent symptoms and signs coupled with unequivocally low serum testosterone levels. Serum testosterone should only be ordered in patients exhibiting signs and symptoms of androgen deficiency. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Endocrine Society guidelines
Recommendation : Don’t test for myoglobin or creatine kinase MB in the diagnosis of acute myocardial infarction. Instead, use troponin I or T. Topic Areas : • Cardiovascular
Rationale : Unlike creatine kinase MB and myoglobin, the release of troponin I or T is specific to cardiac injury. Troponin is released before creatine kinase MB and appears in the blood as early as, if not earlier than, myoglobin after acute myocardial infarction. Approximately 30% of patients experiencing chest discomfort at rest with a normal creatine kinase MB will be diagnosed with acute myocardial infarction when evaluated using troponins. Single-point troponin measurements equate to infarct size for the determination of the acute myocardial infarction severity. Accordingly, there is much support for relying solely on troponin and discontinuing the use of creatine kinase MB and other markers. Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • Expert consensus
Recommendation : Don’t order multiple tests in the initial evaluation of a patient with suspected thyroid disease. Order TSH, and if abnormal, follow up with additional evaluation or treatment depending on the findings. Topic Areas : • Endocrinologic
Rationale : The TSH test can detect subclinical thyroid disease in patients without symptoms of thyroid dysfunction. A TSH value within the reference interval excludes the majority of cases of primary overt thyroid disease. If the TSH is abnormal, confirm the diagnosis with free thyroxine (T4). Sponsoring organizations : •  American Society for Clinical Pathology
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t take a multi-vitamin, vitamin E, or beta-carotene to prevent cardiovascular disease or cancer. Topic Areas : • Oncologic
• Cardiovascular
• Preventive Medicine
Rationale : Vitamin supplementation is a multi-billion dollar industry ($28.1 billion in 2010) in the United States, much of which is taken with the intention to prevent cardiovascular disease or cancer. However, there is insufficient evidence to demonstrate benefit from multivitamin supplementation to prevent cardiovascular disease or cancer. Adequate evidence demonstrates that supplementation with vitamin E and beta-carotene in healthy populations specifically has no benefit on cardiovascular disease or cancer. Beta-carotene is also associated with increased risks of lung cancer in smokers and people who have been exposed to asbestos. Sponsoring organizations : •  American College of Preventive Medicine
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t routinely perform PSA-based screening for prostate cancer. Topic Areas : • Oncologic
• Urologic
• Preventive Medicine
Rationale : More than 1,000 symptom-free men need to be screened for prostate cancer to save one additional life. As a result, increased harms and medical costs due to widespread screening of asymptomatic men are believed to outweigh the benefits of routine screening. There is a high likelihood of having a false-positive result, leading to worry, decreased quality of life, and unnecessary biopsies when many of these elevated PSAs are caused by enlarged prostates and infection instead of cancer. This recommendation pertains to the routine screening of most men. In rare circumstances, such as a strong family history of prostate and related cancers, screening may be appropriate. Sponsoring organizations : •  American College of Preventive Medicine
Sources : • USPSTF/ACPM/ACP guidelines
Recommendation : Don’t use whole-body scans for early tumor detection in asymptomatic patients. Topic Areas : • Oncologic
• Preventive Medicine
Rationale : Whole-body scanning with a variety of techniques (magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, CT) is marketed by some to screen for a wide range of undiagnosed cancers. However, there are no data suggesting that these imaging studies will improve survival or improve the likelihood of finding a tumor (estimated tumor detection is less than 2% in asymptomatic patients screened). Whole-body scanning has a risk of false-positive findings that can result in unnecessary testing and procedures with additional risks, including considerable exposure to radiation with positron emission tomography and CT, a very small increase in the possibility of developing cancer later in life, and accruing additional medical costs as a result of these procedures. Whole-body scanning is not recommended by medical professional societies for individuals without symptoms, nor is it a routinely practiced screening procedure in healthy populations. Sponsoring organizations : •  American College of Preventive Medicine
Sources : • Expert consensus
Recommendation : Don’t use expensive medications when an equally effective and lower-cost medication is available. Topic Areas : • Preventive Medicine
Rationale : On average, the cost of a generic drug is 80–85% lower than the brand-name product, although generic drugs are required to have the same active ingredients and strength, and similar effectiveness as brand-name drugs. Studies estimate that for every 10% increase in the use of generic cholesterol drugs, Medicare costs could be reduced by $1 billion annually. Sponsoring organizations : •  American College of Preventive Medicine
Sources : • Expert consensus
Recommendation : Don’t perform screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease. Topic Areas : • Gynecologic
• Oncologic
• Preventive Medicine
Rationale : Health care professionals should not perform cervical cancer screening in women who have had a hysterectomy that removed their cervix and do not have a history of high-grade precancerous lesions or cervical cancer. Screening provides no benefits to these patients and may subject them to potential risks from false-positive results, including physical (e.g., vaginal bleeding from biopsies) or psychological (e.g., anxiety). In addition, cervical cancer screening should not be performed in women over the age of 65 that are at low risk for cervical cancer and have had negative results from prior screenings. Health care professionals should make this decision on a case-by-case basis, but once a patient stops receiving screenings, in general, they should not restart screenings. Screening for women in this population provides little to no benefit because the incidence and prevalence of cervical disease declines for women starting at age 40–50 years. Sponsoring organizations : •  American College of Preventive Medicine
Sources : • U.S. Preventive Services Task Force
Recommendation : Don’t treat asymptomatic bacteruria with antibiotics. Topic Areas : • Urologic
• Infectious disease
Rationale : Inappropriate use of antibiotics to treat asymptomatic bacteruria, or a significant number of bacteria in the urine that occurs without symptoms such as burning or frequent urination, is a major contributor to antibiotic overuse in patients. With the exception of pregnant patients, patients undergoing prostate surgery or other invasive urological surgery, and kidney or kidney pancreas organ transplant patients within the first year of receiving the transplant, use of antibiotics to treat asymptomatic bacteruria is not clinically beneficial and does not improve morbidity or mortality. The presence of a urinary catheter increases the risk of bacteruria; however, antibiotic use does not decrease the incidence of symptomatic catheter-associated urinary tract infection, and unless there are symptoms referable to the urinary tract or symptoms with no identifiable cause, catheter-associated asymptomatic bacteruria does not require screening and antibiotic therapy. The overtreatment of asymptomatic bacteruria with antibiotics is not only costly, but can lead to Clostridum difficile infection and the emergence of resistant pathogens, raising issues of patient safety and quality. Sponsoring organizations : •  Infectious Diseases Society of America
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Avoid prescribing antibiotics for upper respiratory infections. Topic Areas : • Infectious disease
Rationale : The majority of acute upper respiratory infections are viral in etiology, and the use of antibiotic treatment is ineffective, inappropriate, and potentially harmful. However, proven infection by Group A Streptococcal disease (Strep throat) and pertussis (whooping cough) should be treated with antibiotic therapy. Symptomatic treatment for upper respiratory infections should be directed to maximize relief of the most prominent symptom(s). It is important that health care providers have a dialogue with their patients and provide education about the consequences of misusing antibiotics in viral infections, which may lead to increased costs, antimicrobial resistance, and adverse effects. Sponsoring organizations : •  Infectious Diseases Society of America
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Don’t use antibiotic therapy for stasis dermatitis of lower extremities. Topic Areas : • Dermatologic
• Infectious disease
Rationale : Stasis dermatitis is commonly treated with antibiotic therapy, which may be a result of misdiagnosis or lack of awareness of the pathophysiology of the disease. The standard of care for the treatment of stasis dermatitis affecting lower extremities is a combination of leg elevation and compression. Elevation of the affected area accelerates improvements by promoting gravity drainage of edema and inflammatory substances. The routine use of oral antibiotics does not improve healing rates and may result in unnecessary hospitalization, increased health care costs, and potential for patient harm. Sponsoring organizations : •  Infectious Diseases Society of America
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Avoid testing for a Clostridium difficile infection in the absence of diarrhea. Topic Areas : • Gastroenterologic
• Infectious disease
Rationale : Testing for Clostridium difficile or its toxins should be performed only on diarrheal (unformed) stool, unless ileus due to Clostridium difficile is suspected. Because Clostridium difficile carriage is increased in patients on antimicrobial therapy and in patients in the hospital, only diarrheal stools warrant testing. In the absence of diarrhea, the presence of Clostridium difficile indicates carriage and should not be treated and, therefore, not tested. Sponsoring organizations : •  Infectious Diseases Society of America
Sources : • SHEA/IDSA guidelines
Recommendation : Avoid prophylactic antibiotics for the treatment of mitral valve prolapse. Topic Areas : • Cardiovascular
• Infectious disease
Rationale : Antibiotic prophylaxis is no longer indicated in patients with mitral valve prolapse for prevention of infective endocarditis. The risk of antibiotic-associated adverse effects exceeds the benefit (if any) from prophylactic antibiotic therapy. Limited use of prophylaxis will likely reduce the unwanted selection of antibiotic-resistant strains and their unintended consequences such as Clostridium difficile–associated colitis. Sponsoring organizations : •  Infectious Diseases Society of America
Sources : • ACC/AHA guidelines
Recommendation : Don’t obtain a karyotype as part of the initial evaluation for amenorrhea. Topic Areas : • Gynecologic
Rationale : Amenorrhea is the absence of menstruation and can be attributed to many causes. A karyotype (chromosomal analysis) is not indicated as an initial test for amenorrhea as it is not a screening test. However, it is indicated to further evaluate the etiology of an elevated follicle-stimulating hormone in a woman under 40 years of age or in the presence of physical findings suggestive of disorders of sexual development. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Expert consensus
Recommendation : Don’t prescribe testosterone or testosterone products to men contemplating/ attempting to initiate pregnancy. Topic Areas : • Endocrinologic
• Urologic
Rationale : Testosterone therapy is widely used as treatment for hypoandrogenemia and associated symptoms such as sexual dysfunction. However, it is well established that exogenous testosterone and other androgens can lead to decreased or absent sperm production, low sperm count, and infertility. Furthermore, this is not always reversible, even after removing the exogenous androgens. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Randomized controlled trials
Recommendation : Don’t obtain follicle-stimulating hormone levels in women in their 40s to identify the menopausal transition as a cause of irregular or abnormal menstrual bleeding. Topic Areas : • Gynecologic
Rationale : Menstrual bleeding patterns for women after age 40 are less predictable than in the younger years due to the normal menopausal transition. Menopause is defined as the absence of menstrual periods for one year when no other cause can be identified (it is often accompanied by symptoms such as hot flashes and night sweats). During this time, blood levels of follicle-stimulating hormone vary both from woman to woman and from day to day in the same woman. A follicle-stimulating hormone level does not predict when the transition to menopause will occur, diagnose that it has begun, or provide reassurance that contraception is no longer necessary. If there are no other causes of irregular or abnormal bleeding, the treatment for these women will not change based on the follicle-stimulating hormone level. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Prospective cohort studies
Recommendation : Don’t perform endometrial biopsy in the routine evaluation of infertility. Topic Areas : • Gynecologic
Rationale : Endometrial biopsy performed for histologic dating does not distinguish fertile from infertile women. Chronic endometritis on endometrial biopsy does not predict the likelihood of pregnancy in general nor is it associated with live birth rates in assisted reproductive technology cycles. Endometrial biopsy should not be utilized in the routine evaluation of infertility. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Expert consensus
Recommendation : Don’t perform prolactin testing as part of the routine infertility evaluation in women with regular menses. Topic Areas : • Gynecologic
Rationale : It has become common practice to obtain prolactin levels in the routine infertility evaluation. However, there is no reason to expect that a woman would exhibit clinically significant, elevated prolactin levels in the presence of normal menstrual cycles and without galactorrhea (milk discharge from breast). Therefore, serum testing of prolactin levels in a normally menstruating woman without galactorrhea provides no benefit and would not impact clinical management. Sponsoring organizations : •  American Society for Reproductive Medicine
Sources : • Expert consensus
Recommendation : Don’t place an indwelling urinary catheter to manage urinary incontinence. Topic Areas : • Geriatric Medicine
• Urologic
Rationale : The most common source of bacteremia in the post-acute and long-term care setting is the bladder when an indwelling urinary catheter is in use. The federal Healthcare Infection Control Practices Advisory Committee recommends minimizing urinary catheter use and duration of use in all patients. Specifically, the Healthcare Infection Control Practices Advisory Committee recommends not using a catheter to manage urinary incontinence in the post-acute and long-term care setting. Appropriate indications for indwelling urinary catheter placement include acute retention or outlet obstruction, to assist in healing of deep sacral or perineal wounds in patients with urinary incontinence, and to provide comfort at the end of life if needed. Sponsoring organizations : •  Society for Post-Acute and Long-Term Care Medicine
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years. Topic Areas : • Oncologic
• Geriatric Medicine
• Preventive Medicine
Rationale : Many patients residing in the long-term care setting are elderly and frail, with multimorbidity and limited life expectancy. Although research evaluating the impact of screening for breast, colorectal, and prostate cancer in older adults in general and long-term care residents in particular is scant, available studies suggest that multimorbidity and advancing age significantly alter the risk-benefit ratio. Preventive cancer screenings have both immediate and longer term risks (e.g., procedural and psychological risks, false positives, identification of cancer that may be clinically insignificant, treatment-related morbidity and mortality). Benefits of cancer screening occur only after a lag time of 10 years (colorectal or breast cancer) or more (prostate cancer). Patients with a life expectancy shorter than this lag time are less likely to benefit from screening. Discussing the lag time (“When will it help?”) with patients is at least as important as discussing the magnitude of any benefit (“How much will it help?”). Prostate cancer screening by PSA testing is not recommended for asymptomatic patients because of a lack of life-expectancy benefit. One-time screening for colorectal cancer in older adults who have never been screened may be cost-effective; however, it should not be considered after age 85 and for most long-term care patients older than 75 the burdens of screening likely outweigh any benefits. Sponsoring organizations : •  Society for Post-Acute and Long-Term Care Medicine
Sources : • Expert consensus
Recommendation : Don’t obtain a Clostridium difficile toxin test to confirm “cure” if symptoms have resolved. Topic Areas : • Gastroenterologic
• Infectious disease
Rationale : Rates of C. difficile infection have been increasing, especially among older adults who have recently been hospitalized or who reside in the post-acute and long-term care setting. Patients residing in post-acute and long-term care facilities are particularly at risk for C. difficile infection because of advanced age, frequent hospitalizations and frequent antibiotic exposure. Studies show that up to 57% of patients in the post-acute and long-term care setting are asymptomatic carriers of C. difficile. Furthermore, studies have also shown that C. difficile tests may remain positive for as long as 30 days after symptoms have resolved. False positive “test-of-cure” specimens may complicate clinical care and result in additional courses of inappropriate anti-C. difficile therapy. To limit the spread of C. difficile, care providers in the post-acute and long-term care setting should concentrate on early detection of symptomatic patients and consistently use proper infection control practices, including hand washing with soap and water. Sponsoring organizations : •  Society for Post-Acute and Long-Term Care Medicine
Sources : • Expert consensus
Recommendation : Don’t recommend aggressive or hospital-level care for a frail elder without a clear understanding of the individual’s goals of care and the possible benefits and burdens. Topic Areas : • Geriatric Medicine
Rationale : Hospital-level care has known risks, including delirium, infections, side effects of medications and treatments, disturbance of sleep, and loss of mobility and function. These risks are often more significant for patients in the post-acute and long-term care setting, who are more likely to be frail and to have multimorbidity, functional limitations, and dementia. Therefore, for some frail elders, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization, in the context of prognosis, preferences, indications, and the balance of risks and benefits. Advance directives such as the Physician Orders for Life Sustaining Treatment paradigm form and Do Not Hospitalize orders communicate a patient’s preferences about end-of-life care. Patients with Do Not Hospitalize orders are less likely to be hospitalized than those who do not have these directives. Patients who opt for less-aggressive treatment options are less likely to be subjected to unnecessary, unpleasant, and invasive interventions and the risks of hospitalization. Sponsoring organizations : •  Society for Post-Acute and Long-Term Care Medicine
Sources : • Expert consensus
Recommendation : Don’t initiate antihypertensive treatment in individuals ≥ 60 years of age for systolic blood pressure < 150 mm Hg or diastolic blood pressure < 90 mm Hg. Topic Areas : • Cardiovascular
Rationale : There is strong evidence for the treatment of hypertension in older adults. Achieving a goal systolic blood pressure of 150 mm Hg reduces stroke incidence, all-cause mortality, and heart failure. Target systolic and diastolic blood pressure levels should be set cautiously, however, as data do not suggest benefit in treating more aggressively to a goal systolic blood pressure of < 140 mm Hg in the general population ≥ 60 years of age. Furthermore, moderate- or high-intensity treatment of hypertension has been associated with an increased risk of serious fall injury in older adults. Sponsoring organizations : •  Society for Post-Acute and Long-Term Care Medicine
Sources : • Eighth Joint National Committee guideline
Recommendation : Don’t use phenytoin or fosphenytoin to treat seizures caused by drug toxicity or drug withdrawal. Topic Areas : • Neurologic
• Emergency medicine
Rationale : With rare exceptions, phenytoin is ineffective for convulsions caused by drug or medication toxicity. Phenytoin has been demonstrated to be ineffective for the treatment of isoniazid-induced seizures and withdrawal seizures and may potentially be harmful when used to treat seizures induced by theophylline or cyclic antidepressants. First-line treatment of toxin-induced seizures and withdrawal seizures is benzodiazepines, followed by additional medications that act through agonism at the γ-aminobutyric acid A receptor, such as barbiturates. Sponsoring organizations : •  American Academy of Clinical Toxicology
•  American College of Medical Toxicology
Sources : • Expert consensus
Recommendation : Avoid using a fluoroquinolone antibiotic for the first-line treatment of uncomplicated UTIs in women. Topic Areas : • Urologic
• Infectious disease
Rationale : For women with uncomplicated UTIs (defined as premenopausal, non-pregnant women with no known urologic abnormalities or comorbidities), fluoroquinolone antibiotics should not be considered first-line treatment. Although fluoroquinolones are efficacious in three-day regimens, they have a higher risk of ecological adverse events, such as increasing multidrug resistant organisms. Thus, fluoroquinolones should only be used for the treatment of acute UTIs for women who should not be prescribed nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. Sponsoring organizations : •  American Urogynecologic Society
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Don’t perform cystoscopy, urodynamics or diagnostic renal and bladder ultrasound in the initial work-up of an uncomplicated overactive bladder patient. Topic Areas : • Urologic
Rationale : The initial evaluation of an uncomplicated patient presenting with symptoms should include history, physical examination and urinalysis. In some cases, urine culture, post-void residual urine assessment and bladder diaries may be helpful. More invasive testing should be reserved for complex patients, patients who have failed initial therapies (i.e., behavioral therapies and medications), or patients who have abnormal findings on their initial evaluation. Sponsoring organizations : •  American Urogynecologic Society
Sources : • American Urological Association guidelines
Recommendation : Don’t exclude pessaries as a treatment option for pelvic organ prolapse. Topic Areas : • Gynecologic
Rationale : Nonsurgical treatment options for pelvic organ prolapse include pessaries, which are removable devices that are placed into the vagina to support the prolapsed organs (i.e., uterus, vagina, bladder and/or rectum). A pessary trial can be offered to almost all women with pelvic organ prolapse. Exceptions include women with an active vaginal infection and those who would be noncompliant with follow-up. Sponsoring organizations : •  American Urogynecologic Society
Sources : • Cochrane Database of Systematic Reviews
Recommendation : Don’t prescribe antimicrobials to patients using indwelling or intermittent catheterization of the bladder unless there are signs and symptoms of urinary tract infection. Topic Areas : • Urologic
• Infectious disease
Rationale : Antibiotics in the absence of signs and symptoms (which may include fever; altered mental status or malaise with no other cause; flank or pelvic pain; flank or suprapubic tenderness; hematuria; dysuria, urinary urgency or frequency; and, in spinal cord injury patients, increased spasticity, autonomic dysreflexia, or sense of unease) is not efficacious and risks inducing resistance to antimicrobials. This applies to both indwelling and intermittent catheterization of the bladder. The major exception is patients needing periprocedural antimicrobials. Additionally, initial placement of a suprapubic tube requires a skin puncture or incision and therefore antibiotics should be considered. Sponsoring organizations : •  American Urological Association
Sources : • Infectious Diseases Society of America guidelines
Recommendation : Don’t obtain computed tomography scan of the pelvis for asymptomatic men with low-risk clinically localized prostate cancer. Topic Areas : • Oncologic
• Urologic
Rationale : Computed tomography scan of the pelvis is very unlikely to provide actionable information in men with low-risk prostate cancer (one commonly accepted definition of low-risk prostate cancer is Gleason score less than 7, PSA less than 20.0 ng/mL, and tumor stage of T2 or less). Magnetic resonance imaging of the pelvis may be useful in some men considering active surveillance. Sponsoring organizations : •  American Urological Association
Sources : • American Urological Association guidelines
Recommendation : Offer PSA screening for detecting prostate cancer only after engaging in shared decision making. Topic Areas : • Oncologic
• Urologic
• Preventive Medicine
Rationale : Shared decision making (between health care provider and patient and, in some cases, family members) is an excellent strategy for making health care decisions when there is more than one medically reasonable option. Since both screening and not screening may be reasonable options, depending on the particular situation, shared decision making is recommended. Sponsoring organizations : •  American Urological Association
Sources : • Expert consensus
Recommendation : Don’t diagnose microhematuria solely on the results of a urine dipstick (macroscopic urinalysis). Topic Areas : • Urologic
Rationale : Microhematuria is defined only on urine microscopy: three or more red blood cells per high-powered field on microscopy of a properly collected urinary specimen. Urine dipsticks positive for hemoglobin should be confirmed with urine microscopy, as false positive dipsticks are common. Performing radiographic and cystoscopic evaluation is unnecessary in the absence of microscopically confirmed microhematuria. Sponsoring organizations : •  American Urological Association
Sources : • American Urological Association guidelines