WASHINGTON – More than a dozen medical groups have issued new lists of tests and procedures that they say are often unnecessary and overused and should be questioned by both physicians and patients.
The lists – issued by 17 physician organizations on Feb. 21 – comprise the second iteration of the Choosing Wisely campaign, launched by the American Board of Internal Medicine Foundation in April 2012. The lists, compiled by each group as "Five Things Physicians and Patients Should Question," are evidence-based recommendations to help physicians and patients make decisions together.
"Patient empowerment and appropriate care is what Choosing Wisely is all about," ABIM Foundation president and CEO Christine Cassel said at the press conference. The groups aim to change the perception that, "more is always better," she said.
Groups such as AARP, the National Business Group on Health, labor unions, and even Wikipedia have been brought into the campaign. Patient outreach is spearheaded by Consumer Reports, which is producing patient-friendly brochures based on the lists.
The first lists were issued in April 2012 and covered procedures and tests deemed overused by the American Academy of Family Physicians (AAFP), the American College of Physicians, the American Gastroenterological Association, and six other physician organizations.
"As part of our longstanding efforts to address the issues associated with health care utilization, the AGA is pleased to be a part of the Choosing Wisely campaign, which aims to build a more sustainable health care system that delivers high-quality, effective care," said Lawrence R. Kosinski, M.D., MBA, AGAF, chair of the AGA Institute Practice Management and Economics Committee. "AGA’s participation in Choosing Wisely is a natural extension of our years of work defining quality gastroenterological care and giving gastroenterologists tools for working with patients."
Each "Five Things" list is the result of a long process within the organization, which is explained at the end of the list. And each recommendation is accompanied by the reasoning and evidence for its selection.
The AGA’s list of Five Things makes the following recommendations:
• For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. The decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient’s quality of life rather than as a disease control measure.
• Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
A screening colonoscopy every 10 years is the recommended interval for adults without increased risk for colorectal cancer, beginning at age 50 years. Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population.
• Do not repeat colonoscopy for at least 5 years for patients who have one or two small (less than 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.
The timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Evidence-based (published) guidelines provide recommendations that patients with one or two small tubular adenomas with low-grade dysplasia have surveillance colonoscopy 5-10 years after initial polypectomy. "The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician)."
• For a patient who is diagnosed with Barrett’s esophagus who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than 3 years as per published guidelines.
In patients with Barrett’s esophagus without dysplasia (cellular changes) the risk of cancer is very low. In these patients, it is appropriate and safe to examine the esophagus and check for dysplasia no more often than every 3 years because if these cellular changes occur, they do so very slowly.
• For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
There is a small but measurable increase in one’s cancer risk from x-ray exposure. An abdominal CT scan is one of the higher-radiation exposure x-rays – equivalent to 3 years of natural background radiation. Because of this risk and the high costs of this procedure, CT scans should be performed only when they are likely to provide useful information that changes patient management.
