Family Medicine

Eleven Things Physicians and Patients Should Question


Released April 2, 2014 (1-5) and October 29, 2014 (6-11)

1

Don’t do imaging for lower-back pain 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.

2

Don’t use antibiotics for upper respiratory infections that are likely viral in origin, such as influenza-like illness, or self-limiting, such as sinus infections of less than seven days of duration.

Bacterial infections of the respiratory tract, when they do occur, are generally a secondary problem caused by complications from viral infections such as influenza. While it is often difficult to distinguish bacterial from viral sinusitis, nearly all cases are viral. Though cases of bacterial sinusitis can benefit from antibiotics, evidence of such cases does not typically surface until after at least seven days of illness. Not only are antibiotics rarely indicated for upper respiratory illnesses, but some patients experience adverse effects from such medications.

3

Don’t order screening chest X-rays and ECGs for asymptomatic or low risk outpatients.

There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Chest X-rays for asymptomatic patients with no specific indications for the imaging have a trivial diagnostic yield, but a significant number of false positive reports. Potential harms of such routine screening exceed the potential benefit.

4

Don’t screen women with Pap smears if under 21 years of age or over 69 years of age.

  • Don’t do screening Pap smears annually in women with previously normal results
  • Don’t do Pap smears in women who have had a hysterectomy for non-malignant disease

The potential harm from screening women younger than 21 years of age outweighs the benefits and there is little evidence to suggest the necessity of conducting this test annually when previous test results were normal. Women who have had a full hysterectomy for benign disorders no longer require this screening. Screening should stop at age 70 if three previous test results were normal.

5

Don’t do annual screening blood tests unless directly indicated by the risk profile of the patient.

There is little evidence to indicate there is value in routine blood tests in asymptomatic patients; instead, this practice is more likely to produce false positive results that may lead to additional unnecessary testing. The decision to perform screening tests, and the selection of which tests to perform, should be done with careful consideration of the patient’s age, sex and any possible risk factors.

6

Don’t routinely measure Vitamin D in low risk adults.

Because Canada is located above the 35° North latitude, the average Canadian’s exposure to sunlight is insufficient to maintain adequate Vitamin D levels, especially during the winter. Therefore, measuring serum 25-hydroxyvitamin D levels is not necessary because routine supplementation with Vitamin D is appropriate for the general population. An exception is made for measuring Vitamin D levels in patients with significant renal or metabolic disease.

7

Don’t routinely do screening mammography for average risk women aged 40 – 49. Individual assessment of each woman’s preferences and risk should guide the discussion and decision regarding mammography screening in this age group.

If, after this careful assessment and discussion, a woman’s breast cancer risk is not high, current evidence indicates that the benefit of screening mammography is small.  Furthermore, for this age group there is a greater risk of false-positive screening results and consequently of undergoing unnecessary or harmful follow-up procedures. As always, clinicians need to be aware of changes in the balance of evidence on risk and benefit and support women in understanding this evidence.  High quality materials to assist these discussions are available through the Canadian Task Force on Preventive Health Care.

8

Don’t do annual physical exams on asymptomatic adults with no significant risk factors.

A periodic physical examination has tremendous benefits; it allows physicians to check on their healthy patients while they remain healthy. However, the benefits of this check-up being done on an annual basis are questionable since many chronic illnesses that benefit from early detection take longer than a year to develop. Preventive health checks should instead be done at time intervals recommended by guidelines, such as those noted by the Canadian Task Force on the Periodic Health Examination.

9

Don’t order DEXA (Dual-Energy X-ray Absorptiometry) screening for osteoporosis on low risk patients.

While all patients aged 50 years and older should be evaluated for risk factors for osteoporosis using tools such as the osteoporosis self-assessment screening tool (OST), bone mineral density screening via DEXA is not warranted on women under 65 or men under 70 at low risk.

10

Don’t advise non-insulin requiring diabetics to routinely self-monitor blood sugars between office visits.

While self-monitoring of blood glucose (SMBG) for patients with diabetes is recommended by certain groups to help monitor glycemic control, for most adults with type II diabetes who are not using insulin, many studies have shown that routine SMBG does little to control blood sugar over time.

11

Don’t order thyroid function tests in asymptomatic patients.

The primary rationale for screening asymptomatic patients is that the resulting treatment results in improved health outcomes when compared with patients who are not screened. There is insufficient evidence available indicating that screening for thyroid diseases will have these results.


How the list was created

Items 1 – 5

The Canadian Medical Association’s (CMA) Forum on General and Family Practice Issues (GP Forum) is a collective of leaders of the General Practice sections of the provincial and territorial medical associations. To establish its Choosing Wisely Canada Top 5 recommendations, each GP Forum member consulted with their respective GP Section members to contribute candidate list items. Items from the American Academy of Family Physicians’ Choosing Wisely® list were among the candidates. All candidate list items were collated and a literature search was conducted to confirm evidence-based support for the items. GP Forum members discussed which of the thirteen items that resulted should be included. Agreement was found on eight of them. Family physician members of the CMA’s e-Panel voted to select five of the eight items. These five items were then approved by the provincial and territorial GP Sections. The College of Family Physicians of Canada is a member observer of the GP Forum and was involved in this list creation process. The first four items on this list are adapted with permission from the Five Things Physicians and Patients Should Question. © 2012 American Academy of Family Physicians

Items 6 – 11

The Canadian Medical Association’s (CMA) Forum on General and Family Practice Issues (GP Forum) is a collective of leaders of the General Practice sections of the provincial and territorial medical associations. Items 6 – 11 were selected from ten candidate items that were originally proposed for items 1 – 5. GP Forum members discussed which of these items should be included and agreement was found on eight of them. As was done for the first wave, family physician members of the CMA’s e-Panel voted to select five of the eight items; however, subsequent discussions by the GP Forum resulted in six items being chosen. Feedback on these six items was then obtained from the provincial/territorial GP Sections. The College of Family Physicians of Canada is a member observer of the GP Forum and was involved in this list creation process.

The GP Forum was dissolved as of August 2015.


Sources

1

Canadian Association of Radiologists. The 2012 CAR diagnostic imaging referral guidelines [Internet]. 2012 [cited 2014 Feb 15]. Available from: URL.

Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72.

Ontario Ministry of Health and Long-Term Care (MOHLTC). Excellent care for all – low back pain strategy [Internet]. 2013 [cited 2014 Feb 15]. Available from: URL.

Physicians of Ontario Collaborating for Knowledge Exchange and Transfer (POCKET). Red and yellow flag indicator cards [Internet]. 2005 [cited 2014 Feb 15]. Available from: URL.

Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010 Feb 8;170(3):271-7.

2

American Academy of Allergy Asthma and Immunology. Sinus infections account for more antibiotic prescriptions than any other diagnosis [Internet]. 2013 [cited 2014 Feb 15]. Available from: URL.

Desrosiers M, Evans GA, Keith PK, Wright ED, Kaplan A, Bouchard J, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2,1492-7-2.

Hirschmann JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002 Feb 11;162(3):256-64.

Low D. Reducing antibiotic use in influenza: Challenges and rewards. Clin Microbiol Infect. 2008 Apr;14(4):298-306.

Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: A synopsis of recent consensus guidelines. Mayo Clin Proc. 2011 May;86(5):427-43.

Schumann SA, Hickner J. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8.

Smith SR, Montgomery LG, Williams JW Jr. Treatment of mild to moderate sinusitis. Arch Intern Med. 2012 Mar 26;172(6):510-3.

3

Canadian Association of Radiologists. 2012 CAR diagnostic imaging referral guidelines. Section E: cardiovascular [Internet]. 2012 [cited 2014 Feb 15]. Available from: URL.

Canadian Association of Radiologists. Medical imaging primer with a focus on x-ray usage and safety [Internet]. [Cited 2014 Feb 15]. Available from: URL.

Tigges S, Roberts DL, Vydareny KH, Schulman DA. Routine chest radiography in a primary care setting. Radiology. 2004 Nov;233(2):575-8.

U.S. Preventive Services Task Force (USPSTF). Screening for coronary heart disease with electrocardiography [Internet]. 2012 Jul [cited 2014 Feb 15]. Available from: URL.

4

Canadian Partnership Against Cancer. Cervical cancer screening guidelines: Environmental scan [Internet]. 2013 Sep [2014 Feb 15]. Available from: URL.

Canadian Task Force on Preventive Health Care, Pollock S, Dunfield L, Shane A, Kerner J, Bryant H, et al. Recommendations on screening for cervical cancer. CMAJ. 2013 Jan 8;185(1):35-45.

National Institute for Health and Care Excellence. Cervical screening [Internet]. 2010 [cited 2014 Feb 15]. Available from: URL.

5

Boland BJ, Wollan PC, Silverstein MD. Yield of laboratory tests for case-finding in the ambulatory general medical examination. Am J Med. 1996 Aug;101(2):142-52.

U.S. Preventive Services Task Force. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions [Internet]. 1989 [cited 2014 Feb 15]. Available from: URL.

Wians FH. Clinical laboratory tests: Which, why, and what do the results mean?. Lab Med. 2009;40:105-13.

6

Guidelines and Protocol Advisory Committee. Vitamin D testing protocol [Internet]. 2013 Jun 1 [cited 2014 Sep 25]. Available from: URL.

Hanley DA, Cranney A, Jones G, et al. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. CMAJ. Sep 7 2010;182(12):E610-618.

Ontario Association of Medical Laboratories. Guideline for the Appropriate Ordering of Serum Tests for 25-hydroxy Vitamin D and 1,25-dihydroxy Vitamin D [Internet]. 2010 Jun [cited 2014 Sep 25]. Available from: URL.

Toward Optimized Practice (TOP) Working Group for Vitamin D. Guideline for Vitamin D Testing and Supplementation in Adults [Internet]. Edmonton (AB): Toward Optimized Practice; 2012 Oct 31 [cited 2014 Sep 25]. Available from: URL.

7

Canadian Task Force on Preventive Health Care. Screening for breast cancer: Summary of recommendations for clinicians and policymakers [Internet]. 2011 Nov 22 [cited 2014 Sep 25]. Available from: URL.

Canadian Task Force on Preventive Health Care. Screening for Breast Cancer. Risk vs. Benefits Poster: For ages 40-49 [Internet]. 2014 [cited 2014 Sep 25]. Available from: URL.

Ringash J. Preventive health care, 2001 update: screening mammography among women aged 40-49 years at average risk of breast cancer. CMAJ. Feb 20 2001;164(4):469-476.

Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann. Intern. Med. Nov 17 2009;151(10):716-726, w-236.

Tonelli M, Connor Gorber S, Joffres M, et al. Recommendations on screening for breast cancer in average-risk women aged 40-74 years. CMAJ. Nov 22 2011;183(17):1991-2001.

8

Blais J, Fournier C, Goulet F, Hanna D, Kossowski A, Laberge C, et al. L’évaluation médicale périodique 2014. Agence de la santé et des services sociaux de Montréal et Collège des médecins du Québec [Internet]. 2014 [cited 2014 Aug 25]. Available from: URL.

Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann. Intern. Med. Feb 20 2007;146(4):289-300.

Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.

Si S, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br. J. Gen. Pract. Jan 2014;64(618):e47-53.

The periodic health examination. Canadian Task Force on the Periodic Health Examination. Can. Med. Assoc. J. Nov 3 1979;121(9):1193-1254.

US Preventive Services Task Force Guides to Clinical Preventive Services. The Guide to Clinical Preventive Services 2012: Recommendations of the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012.

9

Lim LS, Hoeksema LJ, Sherin K. Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. Am. J. Prev. Med. Apr 2009;36(4):366-375.

Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. Nov 23 2010;182(17):1864-1873.

Powell H, O’Connor K, Greenberg D. Adherence to the U.S. Preventive Services Task Force 2002 osteoporosis screening guidelines in academic primary care settings. J Womens Health (Larchmt). Jan 2012;21(1):50-53.

The International Institute for Clinical Densitometry. 2013 ISCD Official Positions – Adult [Internet]. 2013 [cited 2014 Aug 26]. Available from: URL.

10

Brownlee C. For Diabetics Not on Insulin, Self-Monitoring Blood Sugar Has No Benefit. The Cochrane Library [Internet]. 2012 Jan 19 [cited 2014 Sep 25]. Available from: URL.

Cameron C, Coyle D, Ur E, Klarenbach S. Cost-effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin. CMAJ. Jan 12 2010;182(1):28-34.

Gomes T, Juurlink DN, Shah BR, Paterson JM, Mamdani MM. Blood glucose test strips: options to reduce usage. CMAJ. Jan 12 2010;182(1):35-38.

O’Kane MJ, Bunting B, Copeland M, Coates VE. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. May 24 2008;336(7654):1174-1177.

Optimal therapy recommendations for the prescribing and use of blood glucose test strips. CADTH Technol Overv. 2010;1(2):e0109.

11

The Canadian Task Force on the Periodic Health Examination. Screening for thyroid disorders and thyroid cancer in asymptomatic adults. The Canadian Guide to Clinical Preventive Health Care [Internet]. 1994;612-18 [cited 2014 Sep 25]. Available from: URL.

Screening for thyroid disease: recommendation statement. Ann. Intern. Med. Jan 20 2004;140(2):125-127.

Surks MI, Ortiz E, Daniels GH, et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA. Jan 14 2004;291(2):228-238.

Management of thyroid dysfunction in adults [Internet]. BPJ. 2010 Dec.(22):22-33. [cited 2014 Sep 25]. Available from: URL.