American Academy of Family Physicians Releases ‘Top 5’ List Of Possibly Overused Tests and Procedures

A partner in the new Choosing Wisely® Campaign, the AAFP encourages doctors, patients to carefully consider these items before proceeding with a treatment plan

Wednesday, April 04, 2012

Megan Moriarty
Public Relations Strategist
American Academy of Family Physicians
(800) 274-2237 Ext. 6052

WASHINGTON — Today the American Academy of Family Physicians released a list of “Five Things Physicians and Patients Should Question” ( the specialty of family medicine. The announcement comes as part of the new, national Choosing Wisely®( campaign, an initiative of the ABIM Foundation( that encourages doctors and patients to carefully consider and openly discuss certain tests, treatments and procedures before they take any action.

The AAFP’s “Five Things Physicians and Patients Should Question” list* includes the following:

1. Imaging for low back pain — Do not do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.) Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs and involves unnecessary radiation exposure. Low back pain is the fifth most common reason for all physician visits.

2. Routine antibiotic prescriptions— Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial clinical improvement. (Symptoms must include discolored nasal secretions and facial or dental tenderness when pressure is applied.) Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis, resulting in risk of side effects without benefit. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

3. Dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis — Do not use DEXA in women younger than age 65 or men younger than 70 with no risk factors. DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.

4. Annual electrocardiograms (EKGs) or any other cardiac screening — Do not order EKGs or other cardiac screening for low-risk patients without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

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

“Our involvement in the Choosing Wisely® campaign underscores family physicians’ long-term commitment to ensuring high-quality, cost-effective care to our patients,” said Glen R. Stream, MD, MBI, FAAFP, president of the AAFP. “Family medicine’s ‘top 5’ list encourages more in-depth conversations between patients and their doctors so they discuss all options and then ‘choose wisely’ when it comes to a treatment plan.”

Each “top 5” list provides specific, evidence-based recommendations that physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.

"As physicians, we need to recognize the importance of these conversations with our patients, and make sure the right patient gets the right care at the right time. Sometimes this means not ordering a particular test or treatment if it is not supported by evidence or guidelines," said Christine K. Cassel, MD, president and CEO of the ABIM Foundation. "As trusted voices in our health care system, it is our responsibility to our patients to make sure they get only the tests and treatments they need and will benefit from."

Currently, the campaign comprises nine leading physician specialty societies that have each identified specific tests or procedures within their specialty that are commonly used, but are not always necessary. Patient advocates, such as partnering organization Consumer Reports(, say the campaign helps take a significant step toward improving the quality and safety of health care.

"We’re looking forward to being a part of this innovative effort working with the ABIM Foundation and the specialty societies and welcome AAFP's participation in the Choosing Wisely campaign,” said James A. Guest, J.D., president and CEO of Consumer Reports. "By identifying tests and procedures that might warrant additional conversations between doctors and patients, we are able to help patients receive better care through easy-to-use and accessible information. Consumer Reports is excited to be able to reach millions of consumers with important health care information in its role as 'consumer communicator' in the Choosing Wisely campaign."

How the List Was Developed
The AAFP’s “top 5” list is an endorsement of the five recommendations for family medicine previously proposed by the National Physicians Alliance and published in 2011 in the Archives of Internal Medicine, as part of its Less is MoreTM series. The goal was to identify items common in primary care practice, strongly supported by the evidence and literature, that would lead to significant health benefits, reduce risks and harm, and reduce costs. More detail on the study and methodology can be found in the Archives of Internal Medicine article, “The ‘Top 5’ Lists in Primary Care.”

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

Founded in 1947, the AAFP represents 120,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Approximately one in four of all office visits are made to family physicians. That is 214 million office visits each year — nearly 74 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.

To learn more about the specialty of family medicine, the AAFP's positions on issues and clinical care, and for downloadable multi-media highlighting family medicine, visit For information about health care, health conditions and wellness, please visit the AAFP’s award-winning consumer Web site,