February 10, 2014

Leaders in medicine and health policy are focusing on a new component of care:  appropriateness.  Only those medical services and interventions that are likely to help and not harm the patient and that represent value (cost/quality) are appropriate.  The real issue is, of course, knowing which services are appropriate.

The Choosing Wisely^® campaign, an initiative of the American Board of Internal Medicine Foundation, aims to promote conversations between physicians 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

In response to this challenge, more than 40 national organizations including the American Society of Anesthesiologists have stepped up to the ABIM Foundation’s invitation and identified one or more sets of five tests or procedures commonly used in their field the appropriateness of which should be questioned and discussed with patients.  The resulting lists of “Five Things Physicians and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently-ordered tests or treatments.

ASA released its first set of “Five Things Physicians and Patients Should Question” on October 12, 2013:

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery—specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
• Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/esophageal echocardiography—TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.
• Don’t use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE)).
• Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ? 6 g/dL unless symptomatic or hemodynamically unstable.
• Don’t routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications.

On January 21, 2014, ASA released its second set of five targeted, evidence-based recommendations, this time for pain medicine:

• Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain.
• Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention.  If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids.
• Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient.
• Patients should be informed of the risks of such treatment, including the potential for addiction.  Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (e.g., urine drug testing) and the consequences of non-compliance with the agreement.  Physicians should be cautious in co-prescribing opioids and benzodiazepines.  Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen.
• Avoid imaging studies (MRI, CT or X-rays) for acute low-back pain without specific indications.
• Imaging for low-back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurologic deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.
• Don’t use intravenous sedation for diagnostic and therapeutic nerve blocks, or joint injections as a default practice. *
• Intravenous sedation, such as with propofol, midazolam, or ultrashort-acting opioid infusions for diagnostic and therapeutic nerve blocks, or joint injections, should not be used as the default practice.  Ideally, diagnostic procedures should be performed with local anesthetic alone.  Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain-relieving effects of the procedure and the potential for false positive responses ASA Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated.
• Avoid irreversible interventions for non-cancer pain that carry significant costs and/or risks.
• Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain.

*This recommendation does not apply to pediatric patients.

ASA’s process of developing its two lists began with a review of relevant ASA literature and practice guidelines (among them, the Practice Advisory for Preanesthesia Evaluation, last updated in 2012, the Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies, last updated in 2006,  and the Practice Guidelines for Chronic Pain Management, last updated in 2010).  ASA conducted a multi-step survey of academic and private practice physician anesthesiologists and analyzed the results in order to generate “Top 5 List” activities to be questioned. The lists were reviewed and finalized by ASA committees and leadership.

The Choosing Wisely campaign, although it has now produced some 250 tests and procedures considered overused and frequently inappropriate, is not without its critics.  A Perspective in the New England Journal (Morden NE, Colla CH, Sequist TD, Rosenthal MD. Choosing Wisely—The Politics and Economics of Labeling Low-Value Services.  January 22, 2014 DOI: 10.1056/NEJMp1314965) suggests that the lists are not sufficiently “courageous” in terms of targeting high-revenue services:

The American Academy of Orthopedic Surgeons, for example, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures—the source of orthopedic surgeons' revenue—appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion. [Footnote omitted] Other societies' lists similarly include low-impact items.

Some specialties, however, have put some of their own high-revenue services on the lists, notably the Society of General Internal Medicine, whose list includes the annual physical, a common visit type for primary care physicians.

More important at this early stage than the specific services placed on the lists of “Things Physicians and Patients Should Question” is the willingness to examine and re-examine established practices and beliefs, while engaging patients in their own care and seeking to provide high-value care.  We congratulate the ABIM Foundation and the ASA on their respective initiatives and invite readers to use our Alerts to help continue the discussion.

With best wishes,

Tony Mira
President and CEO