The US Choosing Wisely
What interventions do you think GPs should do less of? Do you think we sometimes prescribe inappropriately or order too many tests? I’m not talking about individual anecdotes, but widespread trends accepted as ‘normal’ in some parts of Australian general practice.
I am chairing the RACGP working group for the NPS MedicineWise Choosing Wisely initiative, tasked with developing a list of five tests or treatments which GPs should be doing less of, or not doing at all.
Published for the first time ever, below are 28 suggestions and our shortlist of ten. We will hone these down to the five best ones and formally launch them on 29 April 2015.
Choosing Wisely originated in the US, where all specialties and subspecialty colleges were invited to highlight tests and treatments which are used widely despite evidence to the contrary. Canada soon followed, and now it is spreading to 12 countries, including Australia…which is where I come in!
To make the list:
- the intervention must be done often – indeed, too often!
- it must result in significant cost or harm, and
- the recommendation against the intervention must be backed by evidence.
If you are an Australian GP, you can vote on which of the top ten you think should make the cut, at the RACGP Choosing Wisely poll. You may not ever get to see the other 18, which is a pity, and why I’m publishing them here. They are not ‘official’ recommendations endorsed by anyone at this stage – we will work up the top five with full evidence and references, ready for official publication.
The 28 below are in rough order of what I think is important. As with all such lists, opinions will vary. I’d like to hear yours, so please do comment.
Because we have deliberately avoided the easy decisions and have concentrated on things which many GPs actually do, GP opinion is almost by definition divided for many of the recommendations. We don’t pretend to be adamant, but we do feel that the list is based on evidence.
This list is not trivial. Even if you disagree with a few here or there, I believe that if most GPs followed these recommendations in most cases, it would substantially improve patient safety, reduce harms caused by overtesting, overdiagnosis and overtreatment and, as a bonus, free up tens of millions of dollars annually within our health system.
List of recommendations
Top ten:
- Don’t commence medications for hypertension or hyperlipidaemia without first assessing CV risk, to guide the need for therapy.
- Don’t order screening lipid tests more often than 5-yearly in a person who is low-risk (i.e. absolute 5-yr CV risk < 10%).
- Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- Don’t use cardiovascular imaging (CT coronary calcium score, stress test, carotid u/s) to screen low-risk patients (i.e. absolute 5-yr CV risk < 10%, and asymptomatic).
- Don’t routinely use prostate specific antigen (PSA) as a screening tool. If ordering PSA, first inform the patient of the benefits and harms.
- Don’t order imaging for back pain (XR, CT, MRI) except to investigate fracture, tumour, infection or cauda equina syndrome.
- Individualise the HbA1c target in type 2 diabetes, and don’t aim too low in the elderly and those with a long duration of diabetes.
- Avoid, wherever possible, addictive medications (benzodiazepines, opioids) for chronic conditions, especially in those with a history of mental health conditions or substance abuse.
- Don’t use long-term anti-acid therapy without at least annual attempts to down-titrate or cease, unless Barrett’s oesophagus.
- Don’t use antipsychotics first-line in older patients for insomnia or dementia.
Eighteen more:
[n.b These are hitherto unpublished, so I may not have worded them quite as accurately, or included all caveats.)
- Don’t use shoulder imaging for straightforward shoulder pain.
- Don’t use antibiotics in asymptomatic bacteruria, except in pregnancy.
- Don’t order tumour markers as a general screening tool (e.g.CEA, PSA).
- Don’t order knee ultrasounds.
- Don’t order FBC, B12 or iron studies as a ‘routine annual screen’: order them if you have a reason to do so.
- Don’t use ultrasound guidance for shoulder joint injections.
- Don’t order upper abdominal ultrasound to investigate mildly abnormal LFTs.
- Don’t use antibiotics for otitis media (for age 2-12 years, non-Indigenous) where reassessment is a reasonable option.
- Don’t make ‘pre-disease’ diagnoses (e.g. pre-hypertension, pre-diabetes, osteopaenia) if doing so will tempt you to instigate medications.
- Don’t prescribe antibiotics for acute sinusitis (unless >7 days or worsening). Nor for pharyngitis or bronchitis.
- Avoid unnecessary ‘routine screening’ tests in pregnancy unless targeted reason. E.g. UEC, LFT, thalassaemia screen, full iron studies [ferritin alone is more useful], toxoplasma and listeria.
- Avoid early routine dating scans in pregnancy unless there is doubt about a woman’s dates.
- Don’t advocate screening mammography in women less than 50 years of age unless high risk, nor for women over 70 years of age.
- Don’t order ankle imaging unless the Ottawa ankle rules indicate it (ditto cervical spine imaging without applying Ottawa C-spine rules).
- Don’t treat osteoporosis without explaining risk-benefit to the patient in absolute terms, including a fracture risk calculation. Low BMD is not enough.
- Don’t order serological testing for herpes simplex.
- Don’t use anti-acid medication in unsettled infants.
- Don’t routinely do pelvic or breast examination before prescribing oral contraceptives.
The above list was developed along with RACGP members Drs Evan Ackermann, Jenny Doust, Simon Morgan and Rob Hosking. Thanks to Joanna Ong for logistics support, and to NPS MedicineWise for bringing this excellent initiative to Australia.
#FOAM4GP and #FOAMed are twitter hashtags referring to the brilliant concept of Free Open Access Medical Education, which is what this is all about. Making medicine a safer place for patients.
drjustincoleman 
A good list Justin — a really good read. I note that a theme threading through several of these is the importance of considering absolute chance of bnefit from interventions (whether this is cardiovascular risk, fracture risk, etc).
Re: osteoporosis decision-making and absolute risk of fracture, I really like this: http://osteoporosisdecisionaid.mayoclinic.org
To your list I have a couple of other suggested additions:
1. Don’t blindly advocate any sort of cancer screening, but instead reach a shared decision with patients about whether to proceed after considering issues including numbers needed to screen to save a life, risk of harm from false positive results and risk of harm from overdiagnosis.
2. Don’t routinely do pelvic examinations as a screening test in low-risk asymptomatic women. A Pap smear needn’t imply a pelvic exam. (See http://annals.org/article.aspx?articleid=1884537 )
I’m not so sure about the shoulder one, though. We looked into this at my EBM journal club recently. It seems there is a bit of evidence suggesting better effect of ultrasound-guided versus clinically-guided injections. This was admittedly not of the very highest quality (no trials used blinding, for example), and the effect size was not huge. My feeling was that the evidence was neither strong enough to mandate ultrasound guidance, nor to prohibit it. See http://rheumatology.oxfordjournals.org/content/52/4/743.full.pdf
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A comprehensive reply, thanks Brett, and I like your additional suggestions.
I hadn’t seen that shoulder systematic review, which I agree does show some small difference where I had previously read there was none.
I’d still be very happy to use that review to teach registrars etc that they should be doing the injections themselves, as it saves considerable time and expense with almost the same outcomes. However, I agree that your article would make us more cautious about publishing a general recommendation. Luckily it ranked outside our top ten!
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I like the suggestions. I was surprised though that there was no mention of “Don’t routinely order Vitamin D tests on elderly patients”. Apparently the epidemic of Vitamin D testing alone is sending the budget into deficit! A nice discussion here: http://theconversation.com/six-things-you-need-to-know-about-your-vitamin-d-levels-15814
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Good point Peter: Vitamin D is undoubtedly over-ordered in Australia, and you are quite right that it is a glaring omission. Our hesitation was that it is quite hard to phrase the recommendation, to define the population group who should not be screened. Your phrasing re “routine…on elderly patients” might be reasonable. Do others agree?
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Agree Vit D testing should definitely be on the list but can see how population group is hard to define. Perhaps leaving it general “Don’t routinely order Vit D tests on low risk populations” or “Don’t routinely order Vit D tests unless high risk factors are present” ??
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Imaging the spine in the case of radiculopathy is indicated, so I would add it to your list. The natural history is of regression (90% in 6/52) but there may be reasons to investigate earlier than that. Certainly agree re no imaging for nonspecific conditions; red flag list useful here.
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Thanks Chris. Actually, we were vacillating as to whether to use the phrase ‘red flags’ or naming the conditions. We had some concerns that the traditional red flags, particularly where radiculopathy is concerned, may be evolving with newer evidence. But I agree that we need to look carefully at our wording around radiculopathy, where the current recommendation is to consider imaging only if surgery is being actively contemplated. http://www.nps.org.au/medical-tests/medical-imaging/for-health-professionals/low-back-pain
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Also – and it’s over 12 years since I left general practice now, so I’m not sure if this is still widespread – don’t do epidural injections (caudal or lumbar) for chronic undifferentiated back pain. More relevant for the rural GPs with admission rights than for urban GPs, clearly. I’ve published on this topic.
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Geez, you rural Victorian GPs were a cowboy bunch 12 years ago, Chris!
The thought of poking something sharp near the spinal cord for chronic pain never occurred to me. Handy if they happened to be 41 weeks pregnant at the time, I guess!
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Great list. I am going to add “Dont check vitamin D levels in fit and well patients…. ever!”
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Another reason for not including Vitamin D testing in our list are the changes to the MBS item so that the test can only be paid by Medicare for the following:
a patient who:
(a) has signs or symptoms of osteoporosis or osteomalacia; or
(b) has increased alkaline phosphatase and otherwise normal liver function tests; or
(c) has hyperparathyroidism, hypo- or hypercalcaemia, or hypophosphataemia; or
(d) is suffering from malabsorption (for example, because the patient has cystic fibrosis, short bowel syndrome, inflammatory bowel disease or untreated coeliac disease, or has had bariatric surgery); or
(e) has deeply pigmented skin, or chronic and severe lack of sun exposure for cultural, medical, occupational or residential reasons; or
(f) is taking medication known to decrease 25OH-D levels (for example, anticonvulsants); or
(g) has chronic renal failure or is a renal transplant recipient; or
(h) is less than 16 years of age and has signs or symptoms of rickets; or
(i) is an infant whose mother has established vitamin D deficiency; or
(j) is a exclusively breastfed baby and has at least one other risk factor mentioned in a paragraph in this item; or
(k) has a sibling who is less than 16 years of age and has vitamin D deficiency
But maybe that message needs to get out still
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NPS also talks about MRI in radiculopathy if considering epidural steroid injections in persistent radiculopathy. The use of imaging and treatments in persistent radiculopathy is an emerging science. I think the over imaging issues may be more with lower back pain WITHOUT persistent radiculopathy or other red flag symptoms?
Great list
Great initiative
Can we add a cost benefit analysis….the most potential to save money….
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Reblogged this on Iris Pasternack and commented:
Australian yleislääkärit listaavat vaikuttamattomia hoitoja, joista voisi luopua tai ainakin reippaasti vähentää.
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I have finally made it onto a Finnish website. Needed Google Translate to check it wasn’t spam, and it turns out Iris’s website is all about overdiagnosis in Finland. Well done!
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Justin – this campaign I do totally agree with
I would add never order a CRP in General Practice unless known rheumatological condition
Never order a d-dimer or Cardiac enzymes in city general practice – call an ambulance instead
and outside of our specialty- slap lesions should they really be operated on.
Gee the kids look young
John Carter
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Great to have you on board, John, and some good suggestions.
Photo is Pompeii, 2010. Even I look young(er)! Slightly.
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I don’t agree: CRP is very useful in GP practice to assess the risk of bacterial infection,eg pneumonia. Also D dimer is used in GP guidelines to assess risk of DVT.
Cardiac enzymes could be useful if you see patient who had chest pain a few days earlier on to see if there is cardiac muscle damage ( not an emergency anymore)
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you still look as youthful as ever
JC
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Reblogged this on FOAM4GP.
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You mean we talk to our Patients Justin about risks and benefits of investigation…Now thats radical…I feel relieved that my practice most certainly aligns with the Top 10 but its always a longer discussion…
In the next 18 up for discussion: mostly agree however I could be guilty of
#5 as in womens health FE deficiency is so so common. and in elderly practice B12 deficiency is surprisingly common perhaps due to Increased antacid use, and decreased nutrition
#13 not as a routine but I have a low threshold for IVF mums, and for dense lumpy breasts and have picked up quite a few this way. I am not sure the studies have clearly demonstrated this as I thought one of the major studies was performed on women over 65 yoa….And with respect to those patients >70yoa. I feel if they still have a parent alive and there is some indication that they too have another 20-30 years of good quality life left as many are increasingly doing I make a judicious call here with respect to the amount and quality of the breast tissue.
#17 Unsettled infants are my nightmare…….despite constant reassurance this is a very difficult group does anyone want to see this cohort of mine? 🙂
This list is great and well thought through thanks to all of you…as long as we retain professional contextual decision making rather than dogma……Good Practice Points not Policy.
KP
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Fantastic idea Justin! Even though primary care is the most efficient form of healthcare, there is always room to improve.
I’m particularly interested in the over reliance on shoulder imaging and injection under guidance. Moving towards clinical diagnosis and treatment will save even more for country patients like ours who would otherwise need to drive 2 hours to have the imaging. As an pain specialist taught me once “its not a blind procedure if you know your anatomy!”
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I would personally say the rise in U/s guided shoulder injections occurred when:
1. The government removed the item number
2. the courts ruled that similar injections must be done under sterile technique
I agree there seems little clinical advantage of scanning and recent papers suggest little advantage of sterile procedures over clean procedures. If the college and NPS medicine-wise was to come out and say categorically that doing it as an office procedure under the non touch technique was the gold standard and lobby the government to reinstall the item number, this would have great savings to Medicare.
Also teaching physios that shoulder scans are highly inaccurate would also take some pressure off us GPS.
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Thanks for your article Justin, I found it very helpful, and just today I didn’t do one of the things on the list…… but I can’t remember which one. Which indicates that I am an old GP…..
I was thinking about this list from the point of view of registrars or less experienced doctors.
Perhaps it could be re-written as a list of “do’s” rather than a list of “don’ts”. It is so easy to say what not to do, but for less experienced doctors, they may need some guidance towards a positive action eg for the first on the list, it could read “Assess cardiac risk before making a decision to start antihypertensive treatment, and base the decision to start on the cardiac risk rather than the BP alone.”
Just a thought from a forgetful old bloke…….
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Great to hear from the writing master, Hilton, even a forgetful one.
Yes, you’re not the first to mention that, including those commenting at Australian Doctor (this blog became a news piece the day after I published – http://www.australiandoctor.com.au/news/latest-news/10-things-gps-should-stop-doing )
The format of DON’T is really just the standard used by the Choosing Wisely recommendations. In the US they now have 60 colleges providing lists, so I suppose they wanted to settle on a preferred phrasing. It is a bit negative, but I guess it helps focus the recommendations and discourage broad motherhood statements. I’d otherwise be happy either way.
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another suggested test NOT to do: NEVER order FHH testing in people who are symptomatic of bowel disease or those under 50 (it is a screening test) and DON”T order FHH tests in people who have had a colonoscopy in last 3 years or in people too old or unfit to benefit from screening. Doing them in this way overloads colonoscopy services and delays appropriately screened people receiving colonoscopy
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Thanks. Very useful advice.
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