Choosing Wisely 2013: The Need to Know for Primary Care

Charles P. Vega, MD


December 13, 2013

In This Article

Editor's Note:
The Choosing Wisely® initiative of the American Board of Internal Medicine Foundation (ABIM) was launched in 2012 with a goal of reducing overuse of tests and procedures, and helping patients, in consultation with physicians, make smart and effective care choices. Since then, 30 professional societies, including the American Academy of Family Physicians (AAFP), have joined the effort, releasing lists of common practices that should be questioned by both healthcare professionals and patients. In March 2013, AAFP published a concise summary of all recommendations to date -- an important reference for the primary care setting. Since then, another 23 organizations, including AAFP, have released additional recommendations. Although the AAFP third-wave list is clearly important, what about the messages for primary care that can be gleaned from the specialty organization documents? Medscape worked with the AAFP to select 10 key recommendations for 2013 and then asked Charles Vega, MD, Health Sciences Clinical Professor and Residency Program Director at the University of California, Irvine (and a practicing family physician) to provide his perspective.

The Recommendations That Should Change Primary Care: Screening

Annual Exams, Anyone?

The society. Society of General Internal Medicine (SGIM)

The recommendation. Don't perform routine general health checks for asymptomatic adults.

The rationale. Despite the ubiquity of this practice, the general physical exam has been under fire for years. A 2012 Cochrane review[1] concluded that routine exams for asymptomatic adults did not reduce overall morbidity or mortality, nor improve outcomes from cardiovascular disease or cancer. They did, however, increase the number of new diagnoses, and negative or harmful outcomes were often not studied or reported.

The discussion. This was a banner year for preventive care. It has been highlighted in the media, and Medicare is now funding preventive care visits for the first time. Ironically, there has been a simultaneous understanding of the lack of value of routine physical exams, at least as they have been performed traditionally.[1] A previous Best Evidence Review on Medscape addressed this important research and how to maximize preventive care visits. Ideally, physicians should practice preventive care all of the time, but an annual visit to review preventive health practices, such as cancer screening, vaccinations, and lifestyle factors, would improve the woeful performance in these parameters of the US healthcare system. Clinic visits solely for an extensive review of systems and complete physical examination do not improve mortality outcomes.

Cancer Surveillance in Women

The society. Society of Gynecologic Oncology

The recommendation. Avoid routine imaging for cancer surveillance in women with gynecologic cancer, specifically ovarian, endometrial, cervical, vulvar and vaginal cancer.

The rationale. Imaging in the absence of symptoms or rising tumor markers has shown low yield in detecting recurrence or affecting overall survival.

The discussion. Primary care physicians should heed this recommendation with some caution. The literature regarding the optimal follow-up for women with a history of cervical cancer is quite limited, and there is some research which suggests that nuclear imaging can improve survival outcomes among women with cervical cancer.[2,3] While routine imaging in the follow-up of women with gynecologic cancer may not currently be the standard of care, comanagement of these women with a physician with expertise in gynecologic oncology is ideal.

Monitoring Blood Glucose in T2DM

The society. American Association of Clinical Endocrinologists/The Endocrine Society

The recommendation. Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.

The rationale. Once target control is achieved, there is little to be gained in most individuals from repeatedly confirming unless in the context of an acute illness, change in medication, when weight fluctuates significantly, when A1c targets drift off course, and in individuals who need monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and adjusting therapy based on the result of the monitoring.

The discussion. A systematic review of 12 trials of patients with type 2 diabetes mellitus (T2DM) who were not using insulin found that home glucose testing had a weak but significant effect on reducing A1c levels at 6 months (mean reduction, -0.3%), but no effect at 12 months.[4] Intensive glucose monitoring was associated with healthcare costs that were more than double those of patients not receiving routine testing. The weak benefit of home glucose testing does not appear to be worth the cost.

Physicians should note that these recommendations focus on patients who are not receiving insulin. The use of self-monitoring of blood glucose may be more advantageous for subgroups of patients with T2DM, particularly those with uncontrolled diabetes.


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