Choose Your Tests Wisely: Advice From the AASLD

Lauri R. Graham; Raphael B. Merriman, MD, FRCPI

Disclosures

November 10, 2014

Editor's Note: Choosing Wisely®, an initiative of the American Board of Internal Medicine (ABIM) Foundation, comprises evidence-based recommendations from specialty organizations on commonly used tests and procedures. The goal of the campaign is to use these recommendations as the starting point for discussions between clinicians and patients about avoiding unnecessary care. Choosing Wisely launched in 2012 with five recommendations each from nine specialties; more than 60 specialty societies have now joined the campaign, with new lists continuing to be published through 2014 and more planned beyond that. Medscape interviewed Raphael B. Merriman, MD, of the American Association for the Study of Liver Diseases (AASLD), who helped craft its Choosing Wisely recommendations.

Medscape: Would you give a brief history of AASLD's involvement in the Choosing Wisely campaign, and why you believed this would be important?

Dr Merriman: We welcomed the opportunity to embrace this leadership challenge to help physicians be better stewards of finite healthcare resources.

The AASLD established the Choosing Wisely task force in December 2013 to develop its list of recommendations. Members were selected from the AASLD practice guidelines committee to broadly represent varying practice settings and subspecialty expertise within the field of hepatology. Hepatologists with methodological experience in evidence-based medicine were also included. The working group solicited recommendations from the entire AASLD membership that would be considered for inclusion in the list of five tests or treatments that physicians and patients should question. These recommendations were then rated on the basis of judgments related to harm, benefit, and excess resource utilization.

On the basis of voting by the working group, as well as a literature review of supporting data, a total of 10 suggestions were identified. Subsequently, voting by the working group generated the final top five recommendations. These top five recommendations were submitted and approved by the AASLD Governing Board.

Medscape: I'd like to go through the recommendations and ask you how they were selected. Could you also speak briefly about the evidence behind the recommendations? The first recommendation is: Don't perform surveillance esophagogastroduodenoscopy (EGD) in patients with compensated cirrhosis and small varices without red signs treated with nonselective beta-blockers for preventing a first variceal bleed.

Dr Merriman: This first recommendation is based on a recommendation in the AASLD practice guidelines related to portal hypertension and variceal bleeding. It relates to patients with cirrhosis and small varices that have not bled and do not have criteria for an increased risk for bleeding (that is, Child-Pugh class A and the absence of red signs on endoscopic variceal evaluation); for these patients, beta-blockers can be used. In patients with cirrhosis and medium or large varices that have not bled and, again, are not at the highest risk for bleeding (that is, Child-Pugh class A and no red signs), beta-blockers are preferred. The doses of the beta-blockers should be adjusted to the maximum tolerated dose.

In both of these clinical scenarios, follow-up EGD is not necessary. This practice would reduce the need for non-indicated upper gastrointestinal endoscopy.

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