Choosing Wisely: Understanding options in healthcare decision making

Sound Family Medicine understands that your time, resources and health are all extremely important which is why we’re joining the American Board of Internal Medicine Foundation’s Choosing Wisely initiative to promote conversations between providers and patients by helping patients choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

The goal with the Choosing Wisely campaign is to reduce waste in the healthcare system and avoid risks associated with unnecessary treatment. It pushes organizations to identify tests or procedures commonly used whose necessity should be questioned and discussed with patients.

With support from the Robert Wood Johnson Foundation, this effort brings together healthcare organizations from across the country to focus on implementation of at least 3 Choosing Wisely recommendations, including reducing the use of antibiotics for viral infections by at least 20% over nearly three years at participating medical groups.

Our provider team here at Sound Family Medicine met in 2015 to adopt Choosing Wisely guidelines into our practice in our ongoing mission to provide excellent, comprehensive and compassionate care delivered with respect and honesty. Read below to see how these options will help us provide the best care to you and your family in the future. You’ll also see this information posted in our exam rooms so please feel free to ask us any questions you have during your next visit.

EKGs and exercise stress tests

Obtain screening exercise electrocardiogram (EKG) testing in individuals who are symptomatic and at risk for coronary heart disease.

When you do not need it:

• No active symptoms
• Low risk-factors for heart disease

When you might it:

• Symptoms of heart disease (chest pain, shortness of breath, irregular heart beat)
• You have diabetes or other known heart disease before starting exercise.

X-rays, CT scans or MRIs for assessing lower back pain

Imaging for low back pain should not be done within the first six weeks of onset unless exam demonstrates nerve damage or serious conditions like cancer or other infection appear likely.

When you likely don’t need imaging:

• Pain without signs of nerve pressure or damage
• Duration of pain is less than 6 weeks. Most people feel better in about a month, whether or not they have an imaging test.

In the meantime:

• Stay as active as possible. Walking is a good way to easy lower back pain.
• A heating pad for short periods or a warm bath or shower is often very helpful.
• Take over-the-counter pain relievers/anti-inflammatories to reduce pain and swelling.
• Let your provider know what you’ve already tried and what’s worked.
• Discuss other options, such as physical therapy.

Brain imaging

For patients who experience a temporary loss of consciousness with spontaneous recovery (fainting, syncope) and have a normal neurological examination, brain imaging studies (CT or MRI) are not necessary.

Antibiotic use

1 in 8 people given antibiotics have complications from treatment such as diarrhea, yeast infections, rash or allergy. When you take an antibiotic you don’t need, that antibiotic still attacks bacteria that are either beneficial to your body or at least not causing disease. Any bacterium that survives an antibiotic treatment is said to be “resistant”.

For skin: Uncomplicated skin and soft tissue infections (abscesses) should be treated with incision and drainage and with adequate medical follow-up. Avoid antibiotics and wound cultures.

• Skin and soft tissue infections are a frequent reason for visiting the Same Day Clinic. Some infections, called abscesses, become walled off and form pus under the skin. Opening and draining an abscess is the appropriate treatment.
• Obtaining a culture of the drainage is not needed as the result will not routinely change treatment.

When you might need antibiotics:

• A weakened immune system.
• A poorly healing wound, with evidence of redness, pain, drainage, swelling and unusual warmth possibly associated with fever, sweats or chills.

For Sinuses: New onset mild-to-moderate sinusitis does not routinely require antibiotics, unless symptoms last for seven or more days, or symptoms worsen after initial improvement.

• Most sinusitis is due to a viral infection that will resolve on its own.

For ears: For ear infections in children aged 2–12 years, observation for 2-3 days is reasonable before prescribing antibiotics when fever is under 102.2, pain is manageable and close follow up is possible. Antibiotics should be used when the ear drum is bulging and fluid is present, if there is uncontrollable pain, or fever over 102.

• It may not be an ear infection when there is congestion or pressure without other signs.

For respiratory illnesses: Antibiotics should not be used for apparent viral respiratory illnesses (these can mimic sinusitis, pharyngitis, bronchitis).

Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.

• Research shows that they offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product.

Vitamin E or beta carotene to prevent cardiovascular disease or cancer

Multi-vitamin, vitamin E or beta carotene should not be used to prevent heart disease or cancer.

PSA testing for prostate cancer

There is convincing evidence that PSA screening diagnoses more tumors, but doesn’t save lives. Many tumors will not harm patients while the risks of treatment are significant, therefore routine screening for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam is not ordered routinely.

When you don’t need it:

• It is rarely needed for men under the age of 50 or over the age of 75, with no risk factors.

When you might need it: (discuss with your provider)

• A family history of prostate cancer, especially if diagnoses before the age of 60 or died before the age of 75.
• The PSA test is most useful to monitor patients who already have prostate cancer.

Allergy Testing

Positive tests, without allergic symptoms, are common. For example, about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. Allergy testing can be expensive and not all are covered by insurance.

When you don’t need it:

• When you don’t have symptoms and haven’t had a medical exam that points towards a specific allergy.

Obstetrics

Good Samaritan does not schedule elective, non-medically 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.
• Medically indicated for delivery prior to 39 weeks 0 days when there are certain problems with mom or baby.

Good Samaritan does not schedule elective, non-medically 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 whenever possible.
• Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable (not ready or “ripe”).
• Your Provider will discuss the risks and benefits with you before considering inductions of labor without medical indications.