The AAFP released its third list of Choosing Wisely recommendations today during the 2013 Scientific Assembly, with the latest list focusing on issues such as routine prostate-specific antigen (PSA)-based screening and physical examinations tied to prescribing oral contraceptive medications.
An original member of the ongoing American Board of Internal Medicine Foundation effort(www.choosingwisely.org) to help physicians curtail the practice of ordering unnecessary tests and procedures, the AAFP now has issued a total of 15 recommendations on procedures or tests that physicians and patients should question(www.choosingwisely.org).
The Academy is the only organization to have released a list in all three phases of the Choosing Wisely project, underscoring family physicians' long-term commitment to ensuring high-quality, cost-effective care for patients, according to AAFP President-elect Reid Blackwelder, M.D., of Kingsport, Tenn.
- The AAFP and 34 other medical specialty organizations are continuing efforts to cut unnecessary health care spending and reduce patient harms.
- Each of the 35 organizations has created a list of tests and procedures that physicians and patients should question.
- The organizations will roll out their lists on a staggered schedule that runs through 2014.
"As primary care specialists, family physicians are the frontline providers for millions of Americans -- so we have a duty to make sure our members are doing everything they can to provide the right care, for the right patient, at the right time," said Blackwelder. "In today's health care environment, it is increasingly important to ensure that physicians are delivering the most effective, beneficial care possible. These Choosing Wisely lists can help our members identify treatments and procedures that may be unnecessary or duplicative."
The Academy created its latest Choosing Wisely list of clinical recommendations via the AAFP Commission on Health of the Public and Science, which evaluated and approved each item using sources such as reviews from the Cochrane Collaboration and evidence reports from the Agency for Healthcare Research and Quality.
The most recent list adds the following five recommendations:
- Don't routinely screen for prostate cancer using a PSA test or digital rectal exam. 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.
- Don't require a pelvic exam or other physical exam to prescribe oral contraceptive medications. 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.
- Don't prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable. 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.
- Don't perform voiding cystourethrogram routinely in first febrile urinary tract infection (UTI) in children aged 2-24 months. 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.
- Don't screen adolescents for scoliosis. 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.
"These recommendations demonstrate the ability of our Academy and others to look at evidence that may go against some of the established perceptions out there," Blackwelder said. "And while they are obviously not absolutes, owing to the fact that we treat individual patients, they are good evidence-based guidelines."
"For PSA screening in men without symptoms, the data is extremely clear that the test provides very little benefit for patients, along with a significant risk of harm from the diagnostic procedures and the treatments that are performed," he said. "Similarly, in terms of oral contraceptives to women, the data is very clear that unwanted pregnancy carries a much higher risk than the use of these various medications, as well as the fact that pelvic exams and other evaluations are really not necessary before prescribing."
To date, more than 50 medical specialty organizations have joined the effort, identifying a list of more than 160 tests and procedures physicians and their patients should question. Other lists will be released throughout 2013 and 2014(www.abimfoundation.org).
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