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October 21, 2013

ED doctors, endocrinologists join 'Choosing Wisely' campaign

Daily Briefing

The American College of Emergency Physicians (ACEP) and the American College of Endocrinology (ACE) have joined the American Board of Internal Medicine's "Choosing Wisely" campaign, releasing lists of unnecessary procedures for their specialties.

Choosing Wisely was launched in April 2012 with 45 recommendations from nine leading medical groups. Since then, the effort has expanded to include more than 50 groups, each with its own list of five tests or procedures that often are unnecessarily performed. The guidelines include not performing CT scans for routine evaluations of abdominal pain in children and avoiding ordering annual electrocardiograms for low-risk patients with no symptoms.

ACEP: Avoid CT scans for minor head injuries

At its annual conference last week, ACEP released a Choosing Wisely list of five tests and procedures which may not be cost effective in certain clinical situations in the ED. According to Forbes, ACEP had previously decided not to participate in the campaign because its recommendations were more applicable to office-based medical care than ED medicine.

ACEP's five recommendations were developed by the group's board of directors with help from an expert panel of ED physicians. They urge ED physicians to:

    1. Avoid CT scans in patients with minor head injuries who are already at low risk based on validated decision rules.
    2. Avoid placing catheters in patients who can urinate on their own.
    3. Avoid delays associated with palliative care services in ED patients who may benefit from early referrals.
    4. Avoid prescribing antibiotics to ED patients who suffer from straightforward skin and soft tissue abscesses that were successfully treated with an incision and drainage procedure.
    5. Avoid using IV fluids before oral rehydration in children with mild-to-moderate dehydration.

"These recommendations are evidence-based and developed with significant input from experts," ACEP's president Alex Rosenau says, adding that "overuse of medical tests is a serious problem, and health care reform is incomplete without medical liability reform."

ACE: Avoid testosterone therapy—unless there's a clear deficiency

ACE also released a list of five tests and procedures that endocrinologists should avoid to prevent further driving up health care costs and unnecessary complications. Specifically, the group urges endocrinologists to:

    1. Avoid running multiple daily self-glucose monitoring in patients with type 2 diabetes  taking agents that do not cause hypoglycemia.
    2. Avoid routinely measuring 1.25 dihydroxyvitamin D unless the patient has decreased kidney function or hypercalcemia.
    3. Avoid routinely ordering a thyroid ultrasound in patients with abnormal thyroid-function tests if there is no abnormality of the thyroid gland.
    4. Avoid ordering a T3 level test when assessing levothyroxine dose in hypothyroid patients.
    5. Avoid prescribing testosterone therapy unless there is evidence of testosterone deficiency.

"Of course, there are circumstances where any or all of these things are appropriate to do in a given individual," says ACE President Daniel Einhorn, adding that Choosing Wisely is "not a guideline, it's a standard of care. It's an observation that sometimes people do inappropriate tests or give inappropriate medication, and that could be prevented with a little education and reflection" (Tucker, Medscape Medical News, 10/18; Barclay, Medscape Medical News, 10/15; Glatter, Forbes, 10/16).

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