http://www.choosingwisely.org/doctor-patient-lists/
Choosing-wisely came out with long list of suggestions (this is the group who came out with the radiology suggestions last year). These suggestions come from many different specialty societies, each giving their top 5. Basically these are general guidelines to decrease testing overall and do not mean that these tests are not appropriate for certain individuals. I will summarize some of the most relevant suggestions below. There are some minor differences between the different societies.
— avoid doing indiscriminate battery of IgE testing for allergies. Should do targeted and specific testing only.
— no sinus CT or antibiotics for uncomplicated rhinosinusitis.
— no extensive workup for chronic urticaria (e.g. allergy testing) unless there is a clear history pointing to a specific allergy
— they suggest routine spirometry for asthma, as recommended by the various asthma/pulm societies, to make sure the diagnosis is correct.
— no DEXA scans in women less than 65 and men less than 70 as a routine screen.
— no annual EKGs and asymptomatic patients
— Pap smear as per the routine that I sent out before, including stopping at age 65 unless the patient is high risk
— no carotid artery screening if the patient is asymptomatic.
— no feeding tubes in patients with advanced dementia
— do not delay palliative care even if the patient is getting a disease-directed treatment
— no carotid artery evaluation if the patient has simple syncope and a normal neurologic exam
— avoid opiates and barbiturates for migraine except as a last resort
— preop evaluation for eye surgery should be targeted. Eg, EKG the patient has heart disease, fingerstick if patient has diabetes, potassium if the patient is on a diuretic
— not give topical antibiotics for viral conjunctivitis
— did not do a head CT in kids with minor head injuries and normal neurologic exams
— do not do routine abdominal CTs in kids with abdominal pain. Low yield and radiation exposure is significant
— do not do stress cardiac imaging/advanced noninvasive imaging if the patient is without cardiac disease (though they do suggest doing an diabetics greater than age 40, patients with PAD, and patient was greater than 2% annual risk of heart disease — though I think these are too aggressive and even the American Diabetes Association has backed off from routine imaging in diabetics greater than 40)
— no need to do routine follow-up echocardiograms in patients with mild asymptomatic native valvular heart disease
— no need for routine preop chest x-rays
— in child with suspected appendicitis, do an ultrasound as the initial evaluation
— do not check Lyme serology for patients with diffuse musculoskeletal pain unless there is a known exposure and suggestive exam (i.e. it is not appropriate in general for people with just arthralgias)
— do not routinely get DEXA scans at intervals of less than every two years (though the patient reports we get often suggest getting them in one to two years)
— for GERD treatment, titrate to the lowest effective dose of the least potent medication
— do not get routine CT scans for patient with functional abdominal pain (per the ROME III criteria) unless there is a major change in symptoms
— avoid antipsychotics as a first line therapy for patients with behavior problems or psychiatric symptoms with dementia
— avoid increasing diabetic medications in patients over 65 to achieve an A1c of less than 7.5
— in areas where there is widespread vitamin D deficiency (like here), it is prudent just to give vitamins instead of testing everyone
— is unnecessary to check creatinine for patients with benign prostatic hypertrophy
— ultrasound is not a sensitive test for boys with cryptorchidism
— did not order coronary artery calcium scoring on patients with known CAD, for preop of relation for any surgery, or for screening and low risk patients except those with a family history of premature atherosclerosis
— do not use routine bronchodilators in children with bronchiolitis
— do not use routine acid suppressive therapies in infants with GERD
— do not screen for renal artery stenosis in patients who do not have resistant hypertension and have normal renal function, even if there is a history of atherosclerotic disease.
Note: These are many of the recommendations, with some supporting documentation. Part of the rationale is a undoubtedly cost-saving, but part of it is also to minimize adverse effects of testing, including unnecessary radiation exposure. Again, you should do what you think is right for the patient in front of you, but should not feel it is necessary to do the above tests routinely.
Geoff