August 15, 2018, 02:16 pm Chris Crawford – The AAFP has added five new recommendations to its Choosing Wisely list, which highlights medical tests, treatments and procedures that may be unnecessary and should prompt discussion between patients and their physicians.
The additions cover pelvic exams, home glucose monitoring, screening for genital herpes simplex virus (HSV) infection, testicular cancer screening and blood transfusion.
AAFP Commission on Health of the Public and Science member James Stevermer, M.D., of Fulton, Mo., told AAFP News the commission vetted multiple possible recommendations, working from current AAFP clinical policies and reviewing Choosing Wisely recommendations from other organizations.
"We focused on topics that had evidence to support our recommendation, and where we knew the benefits, if any, did not justify the cost, risks and harms to patients," Stevermer said. "After narrowing our slate, we moved these through two subcommittees of the commission, as well as the entire commission. Once finalized there, we moved the recommendations to the Board of Directors for their approval."
The AAFP's five recommendations are as follows:
Don't perform pelvic exams on asymptomatic nonpregnant women unless necessary for guideline-appropriate screening for cervical cancer.
"The only exception for screening is appropriate cervical cancer screening procedures (e.g., Pap smears)," Stevermer said. "There is little evidence that the exam itself finds problems that would benefit the patient by finding early. However, studies have shown that pelvic exams can lead to more invasive testing and procedures. Some data also suggest that the prospect of a pelvic exam keeps some women from seeking routine care."
Stevermer said it was important to note that this recommendation does not apply to women who have symptoms, in which case a pelvic exam can help determine appropriate treatment for their condition.
Don't routinely recommend daily home glucose monitoring for patients who have type 2 diabetes mellitus and are not using insulin.
Stevermer said a series of studies the group examined was fairly consistent in showing that daily glucose monitoring in patients not using insulin has little effect on hemoglobin A1c testing or other measures of blood glucose control. Some of these studies noted that when patients monitor their glucose daily, they were more likely to be depressed or anxious, he added.
"Here's a case where we have testing that doesn't improve glucose control, but costs money and stresses patients out -- exactly the type of practice that the Choosing Wisely program is trying to reduce," Stevermer said.
Don't screen for genital HSV infection in asymptomatic adults, including pregnant women.
This recommendation aligns with the U.S. Preventive Services Task Force's (USPSTF's) 2016 final recommendation to not screen serologically for herpes simplex, which the AAFP supports.
"There is relatively little benefit to most people by screening, and at typical prevalence in the United States (15 percent), half of the screening tests will be falsely positive," said Stevermer.
Don't screen for testicular cancer in asymptomatic adolescent and adult males.
This recommendation aligns with the USPSTF's 2011 recommendation to not screen for testicular cancer, which the AAFP supports.
"Relatively little is known about how well screening will work, but even if highly accurate, it's not likely to add that much benefit," Stevermer explained. "Regardless of stage of presentation, testicular cancer treatment is highly effective."
Don't transfuse more than the minimum of red blood cell units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable patients).
"This recommendation is consistent with multiple randomized trials that show little benefit to transfusing above the 7-8 g/dL range (for most patients)," Stevermer said. "This recommendation also parallels those from the American Association of Blood Banks."
Stevermer said he thinks the AAFP's Choosing Wisely list will prove to be quite a valuable reference for family physicians.
"It's a reminder that more is not always better, and that by being judicious, we can reduce unnecessary interventions, with no harm coming to our patients," he said.
Stevermer recommended a 2015 FPM article titled "How to Help Your Patients Choose Wisely" as a nice overview of tactics that can help family physicians implement the Choosing Wisely list.
"Once they know what's on the Choosing Wisely list, family physicians can then use their knowledge of their patients and local community to help their patients make well-informed decisions," Stevermer concluded.
The American Board of Internal Medicine Foundation and Consumer Reports formally launched Choosing Wisely in 2012. Nine medical specialty organizations -- the AAFP among them -- joined the initiative at that time; since then, more than 80 such groups have signed on to the initiative.
More From AAFP
American Family Physician: Search recommendations from the Choosing Wisely campaign
Familydoctor.org: Choosing Wisely: Tests and Treatments to Discuss With Your Doctor