AAFP RELEASES 2ND CHOOSING WISELY LIST OF QUESTIONABLE TESTS, PROCEDURES

As part of an ongoing effort to help physicians curtail the practice of ordering unnecessary tests and procedures, the American Academy of Family Physicians (AAFP) today released its second Choosing Wisely list of recommendations.

For this extension of the original American Board of Internal Medicine Foundation initiative, which launched in April 2012, the Academy joined 16 other medical specialty organizations in Washington, DC, to unveil the second wave of lists detailing various tests and treatments physicians should think twice about before performing, ordering, or prescribing. AAFP Board Chair Glen Stream, MD, MBI, of Spokane, Washington, represented the Academy at the February 21 press event.

The campaign underscores family physicians’ long-term commitment to ensuring high-quality, cost-effective care for patients, Stream said in a prepared statement.

“The American Academy of Family Physicians is committed to the Choosing Wisely campaign and its mission of sharing evidence-based clinical information about tests and procedures to help family physicians and their patients make informed decisions. So much so that the AAFP has extended its involvement, developing a second list of 5 screenings and treatments that are frequently overused or misused,” Stream said.

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 AAFP collaborated with the American College of Obstetricians and Gynecologists in developing the final language of the first 2 items on the Academy’s latest list, both of which concern elective, nonmedically indicated inductions of labor or Cesarean deliveries.

The AAFP’s most recent list adds the following five recommendations to its initial 5 statements:

• Don’t schedule elective, nonmedically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age

  Delivery prior to 39 weeks, 0 days, has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

• Avoid elective, nonmedically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable

  Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care clinicians should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

• Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients

  There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and heart attack.

• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer

  There is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit.

• Don’t screen women younger than 30 years of age for cervical cancer with HPV (human papillomavirus) testing, alone or in combination with cytology

  There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate. The harms include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety and distress.

“It has been estimated that nearly one-third of health care delivered in the United States is unnecessary,” said Stream. “Tests and procedures that lack evidence of their effectiveness put our patients at risk and drive up the cost of care.”

To date, more than 130 questionable tests and procedures have been released as part of the Choosing Wisely campaign. The organizations that joined the AAFP in releasing this latest round of recommendations are the American Academy of Hospice and Palliative Medicine; American Academy of Neurology; American Academy of Ophthalmology; American Academy of Otolaryngology-Head and Neck Surgery; American Academy of Pediatrics; American College of Obstetricians and Gynecologists; American College of Rheumatology; American Geriatrics Society; American Society for Clinical Pathology; American Society of Echocardiography; American Urological Association; Society for Vascular Medicine; Society of Cardiovascular Computed Tomography; Society of Hospital Medicine; Society of Nuclear Medicine and Molecular Imaging; and the Society of Thoracic Surgeons.

A third wave of lists will be unveiled later in 2013, including another 5 recommendations by the AAFP. For that round, the Academy is expected to be joined by the AMDA—Dedicated to Long Term Care Medicine; American Academy of Dermatology; American Academy of Orthopaedic Surgeons; American College of Chest Physicians; American College of Rheumatology; American College of Surgeons; American Headache Society; American Society for Radiation Oncology; American Society of Clinical Oncology; American Society of Hematology; American Thoracic Society; Heart Rhythm Society; North American Spine Society; and the Society of General Internal Medicine.

• © 2013 Annals of Family Medicine, Inc.