Notable Choosing Wisely Recommendations for Johns Hopkins Bayview Internal Medicine

The following list is a selection of our most frequently noted Choosing Wisely recommendations, adapted from the Choosing Wisely Master List.. 
 

BayviewPro Top Recommendations from Choosing Wisely

 

INPATIENT TOP RECOMMENDATIONS

Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.

Telemetric monitoring is of limited utility or measurable benefit in low risk cardiac chest pain patients with normal electrocar diogram. Published guidelines provide clear indications for the use of telemetric monitoring in patients which are contingent upon frequency, severity, duration and conditions under which the symptoms occur. Inappropriate use of telemetric monitoring is likely to increase cost of care and produce false positives potentially resulting in errors in patient management.  (SGIM)

 

Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability/ Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

 

Hospitalized patients frequently have considerable volumes of blood drawn (phlebotomy) for diagnostic testing during short periods of time. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals. (SGIM)

Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts and electrocardiograms) are ordered at regular intervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affect management, the routine ordering of tests increases health care costs, does not benefit patients and may in fact harm them. Potential harms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-up of incidental and non-pathological results found on outine studies. (Critical Care)

 

 

In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).

In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies. (ACP)

 

Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.

The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients. The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration. According to a National Institutes of Health Consensus Conference, no single criterion should be used as an indication for red cell component therapy. Instead, multiple factors  related to the patient’s clinical status and oxygen delivery should be considered. (SGIM)

 

Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms th at, when associated with bacteriuria, define urinary tract infec tion. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.  (AGS)

 

OUTPATIENT TOP RECOMMENDATIONS

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

Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth mostcommon reason for all physician visits. (AAFP, ACP)

 

Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes. (ACP)

 

Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.

Self-monitoring of blood glucose (SMBG) is an integral part of patient self-management in maintaining safe and target-driven glucose control in type 1 diabetes. However, there is no benefit to daily finger glucose testing in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia, and there is negative economic impact and potential negative clinical impact of daily glucose testing.  SMBG should be reserved for patients during the titration of their medication doses or during periods of changes in patients’ diet and exercise routines. (SGIM)

Don’t perform routine pre-operative testing before low-risk surgical procedures.

Pre-operative assessment is expected before all surgical procedures. This assessment includes an appropriately directed and sufficiently comprehensive history and physical examination, and, in some cases, properly includes laboratory and other testing to help direct management and assess surgical risk. However, pre-operative testing for low-risk surgical procedures (such as cataract extraction) results in unnecessary delays and adds to significant avoidable costs and should be eliminated. (SGIM)

 

Don’t recommend cancer screening in adults with life expectancy of less than 10 years.

Screening for cancer can be lifesaving in otherwise healthy at-risk patients. While screening tests lead to a mortality benefit, which emerges years after the test is performed, they expose patients to immediate potential harms. Patients with life expectancies of less than 10 years are unlikely to livelong enough to derive the distant benefit from screening. However, these patients are in fact more likely to experience the harms since patients with limited life expectancy are more likely to be frail and more susceptible to complications of testing and treatments. Therefore the balance of potential enefits and harms does not favor recommending cancer screening in patients with life expectancies of less than 10 years. (SGIM)

 

Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.

There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy. (AGS)