Family physicians who follow the AAFP's clinical policies are well on their way to improving quality and lowering costs as indicated in an article(archinte.ama-assn.org) (abstract) recently published in the Archives of Internal Medicine. The article focuses on the "top five" evidence-based practices physicians in three primary care specialties -- family medicine, internal medicine and pediatrics -- can follow to improve quality and lower costs. Many of the suggestions reflect existing AAFP policy.
"These are very good recommendations, and we support them through our policies already in place," said Carrie Nelson, M.D., M.S., of Wheaton, Ill., chair of the Academy's Commission on Health of the Public and Science. "These are good reminders."
Rather than offering guidance on things that physicians should do, the top five article targets unnecessary screenings, tests and treatments that should not be done, such as annual cardiac screening of asymptomatic, low-risk patients.
The AAFP already has policies, or has endorsed the policies of others, that are consistent with the list developed for family medicine, according to Nelson.
"We family physicians can benefit our patients by adhering to all 12 unique recommendations cited in the article," said Nelson, who is medical director of the Illinois Medicaid program, Your Healthcare Plus. "I think this article is a great contribution to the pursuit of evidence-based practice by identifying a few simple rules that we physicians should be following. In so doing, we can have a significant impact on both quality and cost. I especially agree with the author's assertion that these concepts in no way represent rationing and that 'Often, less is truly more.'"
The list was compiled by the National Physicians Alliance through a grant provided by the American Board of Internal Medicine Foundation. The alliance convened working groups in family medicine, internal medicine and pediatrics to develop a preliminary list for each specialty. Lists then were finalized in two rounds of field testing.
Although the specialty groups worked independently, three of the five recommendations for family medicine also are included in the list developed by the internal medicine working group. Those items are
- Don't do imaging for low back pain within the first six weeks after a patient presents with symptoms unless red flags are present.
- Don't order annual electrocardiograms or other cardiac screening for asymptomatic, low-risk patients.
- Don't use dual-emission X-ray absorptiometry screening for osteoporosis in women younger than age 65 or men younger than 70 with no risk factors.
The other two recommendations made for family medicine were to not perform Pap tests on patients younger than 21 years or on patients who have had a hysterectomy for a benign disease. "Most dysplasia in adolescents regresses spontaneously," the authors note. Additionally, "Pap tests have low yield in women after hysterectomy (for benign disease), and there is poor evidence for improved outcomes."
The authors also advise against routinely prescribing antibiotics for acute mild to moderate sinusitis unless symptoms, including purulent nasal secretions, maxillary pain, or facial or dental tenderness, last for seven days or more or symptoms worsen after initial improvement. "Most maxillary sinusitis in the ambulatory setting is due to viral infection that will resolve on its own," the authors say. They also point to the number of antibiotics prescribed for acute sinusitis despite recommendations to the contrary.
Although none of the top five items on the family medicine list are specifically related to the care of children, two of the five items listed for pediatrics are based on recommendations developed by the AAFP in collaboration with the American Academy of Pediatrics. These include not referring otitis media with effusion(64 page PDF), or OME, early in the course of the problem. "Many cases of OME resolve spontaneously within three months with no adverse consequences," the authors say. However, they advise early referral for patients with craniofacial or neurological abnormalities, language delay or learning problems, and when structural abnormalities of the eardrum or middle ear are suspected.
The list for pediatricians also includes the advice to not obtain diagnostic images of minor head injuries, unless the patient lost consciousness or there are other risk factors, such as dizziness, external signs of injury, changes in neurologic function or dangerous mechanism of injury. "Imaging low-risk patients rarely detects traumatic abnormalities, and of the abnormalities detected, few, if any, require surgery," the authors say. In addition, "early exposure to radiation poses a significant risk of cancer."