AAFP Releases Third Choosing Wisely List

Larry Hand

September 25, 2013

The American Academy of Family Physicians (AAFP) has released its third list of commonly prescribed tests and procedures that may not be necessary. The evidence-based recommendations, part of the American Board of Internal Medicine Foundation Choosing Wisely campaign, were released on September 24 and are:

  1. "Do not prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable." The "observation option" is the ability to defer antibacterial treatment of selected children for 48 to 72 hours, limiting management to symptomatic relief.

  2. "Do not perform voiding cystourethrogram...routinely in first febrile urinary tract infection...in children aged 2-24 months." Risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delay.

  3. "Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam." Evidence suggests that PSA-based screening leads to substantial overdiagnosis of prostate tumors.

  4. "Do not screen adolescents for scoliosis." Potential harms include unnecessary follow-up visits and evaluations resulting from false-positive test results and psychological adverse effects.

  5. "Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications. Hormonal contraceptives are safe, effective, and well tolerated for most women."

"Has to Change"

"Evidence shows that much of the care delivered in America could be duplicative or unnecessary. In fact, according to a report from the Institute of Medicine, up to 30% of healthcare may be duplicative or unnecessary," Reid Blackwelder, MD, a family physician in Kingsport, Tennessee, and AAFP president as of September 25, said in a news conference.

He continued, "Unfortunately, the way that healthcare is often delivered in America often includes tests and procedures that may provide little, if any, benefit to the patient. Our health outcomes are not as good, and more money is spent per capita in the US than in any other developed country, and that has to change. When healthcare resources are wasted, it threatens our nation's ability to deliver the highest quality of healthcare possible for all of our patients."

The goal of Choosing Wisely is "to start a national conversation about the right [care], at the right time, for the right patient, and avoiding unnecessary care," Dr. Blackwelder said.

Choosing Wisely, launched in April 2012, is a national campaign involving more than 50 medical specialty societies identifying common medical tests and procedures that may not necessarily benefit patients. The AAFP is so far the only Choosing Wisely participating medical society to release 3 lists of recommendations.

"All of these lists provide targeted and very evidence-based interventions to help family physicians and patients choose the best treatment options. The goal is for physicians and patients to have conversations about making wise choices about the care in order to avoid inappropriate tests and procedures.... Family physicians treat people, not diseases," Dr. Blackwelder said in the news conference.

Previous Recommendations

The AAFP's previously released Choosing Wisely recommendations are:

  • "Don't schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

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

  • Don't screen for carotid artery stenosis...in asymptomatic adult patients.

  • 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.

  • Don't screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.

  • Don't do imaging for low back pain within the first six weeks, unless red flags are present.

  • Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days OR symptoms worsen after initial clinical improvement.

  • Don't use dual-energy X-ray absorptiometry...screening for osteoporosis in women under age 65 or men under 70 with no risk factors.

  • Don't order annual electrocardiograms...or any other cardiac screening for low-risk patients without symptoms.

  • Don't perform Pap smears on women under the age of 21 or women who have had a hysterectomy for non-cancer disease."

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