Clinical question	Bottom-line answer	Clinical actions to consider for Choosing Wisely
Does early imaging of older adults with back pain improve outcomes?A1	Among adults 65 years or older who present to primary care clinicians for a new episode of back pain, imaging before six weeks resulted in no improved outcomes at one year, but increased overall health care costs by almost 30%.	In older patients with new onset back pain, do not routinely order early imaging.
Is acetaminophen effective for the treatment of low back pain or osteoarthritis?A2	Although acetaminophen was hoped to be a safer alternative to nonsteroidal anti-inflammatory drugs and opioids for the treatment of common musculoskeletal problems, on average it provides only minimal pain relief and improvement in function for patients with low back pain or osteoarthritis. Some persons may benefit with full dosages, but most will not.	In patients with low back, hip, or knee osteoarthritis pain, do not routinely tell patients to expect a clinically important effect on pain and disability from acetaminophen.
What is the optimal medication regimen for treating adults with acute low back pain?A3	Naproxen alone is as effective as naproxen plus oxycodone/acetaminophen or naproxen plus cyclobenzaprine (Flexeril) in reducing pain and improving function in adults with acute musculoskeletal low back pain without radicular symptoms. Adverse events were significantly more common in patients additionally treated with muscle relaxants or opioids. Exclusion criteria included radicular pain below the gluteal folds, direct trauma to the back within the previous month, pain duration longer than two weeks, and recent history of more than one episode of low back pain per month.	In patients with acute low back pain and no history of trauma, do not routinely prescribe naproxen plus oxycodone/acetaminophen or naproxen plus cyclobenzaprine over naproxen alone as first-line treatment.
Is early physical therapy more effective than usual care in treating adults with acute low back pain?A4	Early referral to physical therapy (within 72 hours of study enrollment) compared with usual care for adults with recent-onset low back pain is minimally, if at all, effective for reducing measures of disability and pain or for improving quality of life. Compared with usual care, patients randomized to physical therapy had a three-point greater improvement on a 100-point scale, which was judged to be clinically unimportant.	In patients with low back pain for less than 16 days (and in those who were not treated for low back pain in the past six months), do not routinely provide early referral to physical therapy.
For adults with chronic low back pain, is a prescribed walking program as effective as physical therapy?A5	Giving patients a pedometer, a walking diary, and instructions to walk at least four days per week, then gradually increase the walk's duration and intensity, leads to improvement in pain and disability similar to usual physical therapy or to a group exercise program. Patient satisfaction and days lost from work are similar, and patients are more likely to continue treatment for at least one year. One option is to give an inexpensive pedometer to patients who have low back pain and other problems that would benefit from some get-up-and-go.	In adults with chronic low back pain, do not routinely refer patients for standard physical therapy in place of a program of gradually increased walking.
Do negative rapid strep test results need to be confirmed by culture?A6	Although rheumatic heart disease caused by a group A streptococcal infection has all but disappeared in wealthy countries, some countries, like the United States, still go to great lengths to test for streptococcal throat infections. As a result, we spend more than $8 million per each additional case of rheumatic heart disease prevented.A7 This meta-analysis found that the rapid antigen tests widely in use are highly effective in identifying and excluding strep. The sensitivity of these tests is 86% and the specificity is 96%, both overall and in children. The authors of this analysis argue convincingly that the sensitivity is high enough, and the likelihood of rheumatic heart disease low enough, to abandon the practice of confirming negative antigen test results with culture.	In patients with acute pharyngitis who have a negative rapid strep test, do not routinely perform a throat culture.
Are there subgroups of adults with acute lower respiratory tract infection who may benefit from antibiotics?A8	This British study excluded patients with clinically suspected pneumonia and included patients who would commonly be diagnosed with acute bronchitis in the United States. Patients with green sputum or cardiopulmonary comorbidities experience a slightly shorter duration and intensity of symptoms with amoxicillin use. That must be balanced against the harms of antibiotics on the individual and population levels, and the fact that none of the subgroups saw a benefit in terms of preventing a worsening of illness.	In patients with acute bronchitis and green sputum or cardiopulmonary comorbidities, do not routinely prescribe antibiotics.
Does exercise training, vitamin D, or the combination of both decrease the number of falls in older women?A9	Group exercise sessions twice a week for the first year and once a week for the second year did not decrease the number of falls among older women, but they halved the likelihood of a fall resulting in an injury. Vitamin D was ineffective.	In typical community-dwelling women younger than 75 years, do not routinely prescribe vitamin D to prevent falls.
Are men who are invited to receive systematic prostate cancer screening better off than men who receive routine care?A10	One would have to screen approximately 800 men to prevent one from dying of prostate cancer. However, screening has no effect on all-cause mortality. The authors note that their study does not support population-based screening.	In men, do not routinely offer screening for prostate cancer.
Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?A11	After approximately 10 years of follow-up, this study found one fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control (mean A1C = 6.9%), but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms (such as hypoglycemia) with long-term follow-up.	In persons with type 2 diabetes, do not routinely offer intensive glycemic control to prevent cardiovascular events.
Does intensive glycemic control in high-risk patients with type 2 diabetes decrease the frequency of ischemic heart disease events?A12	Intensive glycemic control compared with usual care does not reduce the rate of cardiovascular or all-cause mortality, and produced only small changes in the number of cardiovascular events. This change in cardiovascular events went away after adjusting for the lowest achieved A1C level during the five-year study period. In fact, the original trial showed an increase in mortality among persons randomized to intensive control.	In persons with type 2 diabetes, do not routinely offer intensive glycemic control to prevent cardiovascular events.
Is low-dose aspirin beneficial for the primary prevention of cardiovascular disease in high-risk older adults with atherosclerotic risk factors?A13	This study of high-risk older adults in Japan found no net benefit to low-dose aspirin. This was also true for subgroups with hypertension, hyperlipidemia, diabetes mellitus, obesity, male sex, smoking, and family history of cardiovascular disease. Although there was a small reduction in nonfatal myocardial infarction and transient ischemic attack, the risks of major gastrointestinal bleeding and brain hemorrhage were increased with aspirin use.	In high-risk older adults, do not routinely prescribe aspirin for primary prevention of cardiovascular events.