In an effort to change entrenched medical practices, 17 major medical specialty groups recommended on Thursday that doctors greatly reduce their use of 90 widely used but largely unnecessary tests and treatments.
This list of "don'ts" builds on 45 recommendations made last April, under a broad initiative by the American Board of Internal Medicine Foundation, in partnership with the magazine Consumer Reports.
"As you look through the lists, a lot of these were mea culpas," said Dr. Eric Topol, chief academic officer of Scripps Health, a health care provider in San Diego. Dr. Topol was not involved in creating the new recommendations. "The literature had supported these recommendations, but until now they were not sanctioned as no-no's by the professional groups," he said.
Some of the recommendations reinforce existing guidelines, but others aggressively go after procedures that have little evidence of benefit and may cause harm, yet are still practiced on a daily basis.
For example, the American Society of Echocardiography recommended against using echocardiograms before or during surgery for patients with no history or symptoms of heart disease; doctors routinely perform this test. The Society of Nuclear Medicine and Molecular Imaging urged physicians not to perform routine annual stress testing using a nuclear heart scan after coronary artery surgery. This is also a routine test, and it exposes the patient to radiation equivalent to 2,000 chest X-rays.
"Many of these tests are wasteful, and they could put patients in danger of harm without any benefits," said Daniel Wolfson, executive vice president of the American Board of Internal Medicine Foundation. "The goal is to begin to change attitudes both from the public side and the physician side that sometimes less is better."
Each medical specialty society participating in the foundation's initiative has offered up five procedures that patients should question. "That's a key point. I don't think they'll have any impact unless patients get activated," Dr. Topol said.
The new list includes recommendations against inducing labor or performing a Caesarean section before a woman's 39th week of pregnancy, unless it is medically necessary. Scheduled Caesareans and inductions are commonly performed for convenience, but delivery before 39 weeks is associated with increased risk of learning disabilities, respiratory problems and other risks to the baby.
The American Academy of Pediatrics urged doctors not to automatically use computed tomography, or CT scans to evaluate children's minor head injuries. According to the report, approximately 50 percent of children who visit hospital emergency departments with head injuries undergo a CT scan, exposing them to radiation. Other groups also called for reductions in the use of CT, PET and M.R.I. scans for a variety of ailments.
Several physician groups recommended against prescribing antibiotics for common respiratory illnesses, including sinusitis, sore throat and bronchitis. The vast majority of these illnesses are caused by viruses, not bacteria, making antibiotics pointless. The pediatrics group also said not to treat children under 4 years of age with cough and cold medicines. Studies have shown that these products have little benefit and may cause serious side effects in children.
The American Geriatrics Society recommended against using feeding tubes in patients with advanced dementia. These patients should be fed orally. Tube feeding is associated with agitation, increased use of physical and chemical restraints and pressure ulcers.
Other notable recommendations include:
· Don't use opioid or butalbital treatment for migraine except as a last resort. Frequent use of these drugs can worsen headaches.
· Don't routinely treat acid reflux in infants with anti-reflux therapy. There is emerging evidence that it may be harmful to infants in certain situations.
· Avoid routine preoperative testing for low-risk surgeries without a clinical indication. Most pre-op tests turn up nothing unusual and don't lead to better outcomes.
· Avoid using medications to achieve tight control of glucose levels in most adults aged 65 and older with Type 2 diabetes. Moderate control is generally better.
· Don't use benzodiazepines or other sedative hypnotics in older adults as a first choice for insomnia, agitation or delirium. Studies consistently show a doubling of risk of car accidents, falls and hip fractures in older adults taking these medications.
· Don't perform annual Pap tests in women 30 to 65 years of age who are not at high risk for cervical cancer. The Pap test should be performed every three years in women aged 21 to 30, and every three to five years for women aged 30 to 65.
