Don’t routinely obtain neuro-imaging studies (CT, MRI, or carotid dopplers) in the evaluation of simple syncope in patients with a normal neurological examination.
Although an uncommon cause for syncope, providers must consider a neurological cause in every patient presenting with transient loss of consciousness. In the absence of signs or symptoms concerning for neurological causes of syncope (such as but not limited to focal neurological deficits), the utility of neuro-imaging studies are of limited benefit. Despite a lack of evidence for the diagnostic utility of neuroimaging in patients presenting with true syncope, providers continue to perform brain computed tomographic (CT) scans. Thus, inappropriate use of this diagnostic imaging modality carries high costs and subject patients to the risks of radiation exposure.
Don’t place, or leave in place, urinary catheters without an acceptable indication (such as critical illness, obstruction, palliative care).
Use of urinary catheters without an acceptable indication of use increases the likelihood of infection leading to greater morbidity and health care costs. Catheter-associated bacteriuria often leads to inappropriate antimicrobial use and secondary complications including emergence of antimicrobial-resistant organisms and infection with clostridium difficile. A previous study showed that physicians are often unaware of urinary catheterization among their patients. Use of urinary catheters has found to be inappropriate in up to 50% of cases, with urinary incontinence listed as the most common reason for inappropriate and continued placement of urinary catheters. Clinical practice guidelines support the removal or avoidance of unnecessary urinary catheters in order to reduce the risk of catheter-associated urinary tract infections (CAUTIs).
Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.
Indications for blood transfusion depend on clinical assessment and are also guided by the etiology of the anemia. No single laboratory measurement or physiologic parameter can predict the need for blood transfusion. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Adverse events range from mild to severe, including allergic reactions, acute hemolytic reactions, anaphylaxis, transfusion related acute lung injury, transfusion associated circulatory overload, and sepsis. Studies of transfusion strategies among multiple patient populations suggest that a restrictive approach is associated with improved outcomes.
In the inpatient setting, don’t order repeated CBC and chemistry testing in the face of clinical and lab stability.
Repetitive inpatient blood testing occurs frequently and is associated with adverse consequences for the hospitalized patient such as iatrogenic anemia, and pain. A Canadian study showed significant hemoglobin reductions as a result of phlebotomy. Given that anemia in hospital patients is associated with increased length of stay, readmission rates and transfusion requirements, reducing unnecessary testing may improve outcomes. Studies support the safe reduction of repetitive laboratory testing without negative effects on adverse events, readmission rates, critical care utilization or mortality. Laboratory reduction interventions have also reported significant cost savings.
Don’t routinely perform preoperative testing (such as chest X-rays, echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries.
Routine preoperative tests for low risk surgeries results in unnecessary delays, potential distress for patients and significant cost for the health care system. Numerous studies and guidelines outline lack of evidence for benefit in routine preoperative testing (e.g., chest X-ray, echocardiogram) in low risk surgical patients. Economic analyses suggest significant potential cost savings from implementation of guidelines.
How the list was created
The Canadian Society of Internal Medicine (CSIM) established its Choosing Wisely Canada Top 5 recommendations by convening a Committee of 20 members that represent a diverse group of general internists from across Canada, reflecting a broad range of geographical regions, practice settings, institution types and experience. The Committee chose to adopt pre-existing recommendations that have already undergone rigorous evidence review from the Five Things Physicians and Patients Should Question (© 2013 American College of Physicians; © 2012 Society of Hospital Medicine; © 2013 Society of General Internal Medicine), the American College of Physicians High Value Cost Conscious Care recommendations, and the “do not do” recommendations from the National Institute for Health and Care Excellence (NICE) in the United Kingdom. In addition, members brought forward recommendations based on experience and relevance to practice. Each Committee member was invited to anonymously rank all recommendations online. The Committee discussed the highest ranked recommendations and reached a consensus on a list of Top 5 items. The list of recommendations was presented at an open forum CSIM meeting and to the Executive Council at the 2013 CSIM Annual Meeting in Toronto, Canada. CSIM members who attended the Council meeting and the Choosing Wisely Update session were also given an opportunity to provide feedback. Minor refinements to the list were made and subsequently approved by the Committee. The CSIM Executive Council provides full endorsement and support for the final list of CSIM Choosing Wisely Canada recommendations.
Alboni P, Brignole M, Menozzi C, Raviele A, Del Rosso A, Dinelli M, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol. 2001 Jun 1;37(7):1921-8.
Grossman SA, Fischer C, Bar JL, Lipsitz LA, Mottley L, Sands K, et al. The yield of head CT in syncope: A pilot study. Intern Emerg Med. 2007 Mar;2(1):46-9.
Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009 Jul 27;169(14):1299-305.
Strickberger SA, Benson DW, Biaggioni I, Callans DJ, Cohen MI, Ellenbogen KA, et al. AHA/ACCF scientific statement on the evaluation of syncope: From the American Heart Association councils on clinical cardiology, cardiovascular nursing, cardiovascular disease in the young, and stroke, and the quality of care and outcomes research interdisciplinary working group; and the American College of Cardiology Foundation: In collaboration with the Heart Rhythm Society: Endorsed by the American Autonomic Society. Circulation. 2006 Jan 17;113(2):316-27.
Sheldon RS, Morillo CA, Krahn AD, O’Neill B, Thiruganasambandamoorthy V, Parkash R, et al. Standardized approaches to the investigation of syncope: Canadian Cardiovascular Society position paper. Can J Cardiol. 2011 Mar-Apr;27(2):246-53.
Schnipper JL, Ackerman RH, Krier JB, Honour M. Diagnostic yield and utility of neurovascular ultrasonography in the evaluation of patients with syncope. Mayo Clin Proc. 2005 Apr;80(4):480-8.
Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Moya A, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009 Nov;30(21):2631-71.
Bartlett JG. A call to arms: The imperative for antimicrobial stewardship. Clin Infect Dis. 2011 Aug;53 Suppl 1:S4-7.
Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care. 1998 Jul-Sep;6(3):99-102.
Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1;50(5):625-63.
Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul 10;155(13):1425-9.
Peleg AY, Hooper DC. Hospital-acquired infections due to gram-negative bacteria. N Engl J Med. 2010 May 13;362(19):1804-13.
Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000 Oct 15;109(6):476-80.
Bracey AW, Radovancevic R, Riggs SA, Houston S, Cozart H, Vaughn WK, et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: Effect on patient outcome. Transfusion. 1999 Oct;39(10):1070-7.
Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012 Apr 18;4:CD002042.
Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in critical care investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409-17.
Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: A systematic review of the literature. Crit Care Med. 2008 Sep;36(9):2667-74.
Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.
Attali M, Barel Y, Somin M, Beilinson N, Shankman M, Ackerman A, et al. A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital. Mt Sinai J Med. 2006 Sep;73(5):787-94.
Lin RJ, Evans AT, Chused AE, Unterbrink ME. Anemia in general medical inpatients prolongs length of stay and increases 30-day unplanned readmission rate. South Med J. 2013 May;106(5):316-20.
Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med. 1986 May 8;314(19):1233-5.
Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005 Jun;20(6):520-4.
Benarroch-Gampel J, Sheffield KM, Duncan CB, Brown KM, Han Y, Townsend CM,Jr, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012 Sep;256(3):518-28.
Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504.
Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of preoperative testing in ambulatory surgery. Anesth Analg. 2009 Feb;108(2):467-75.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241.
Fritsch G, Flamm M, Hepner DL, Panisch S, Seer J, Soennichsen A. Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012 Mar;56(3):339-50.
Institute of Health Economics. Routine preoperative tests – are they necessary? [Internet]. 2007 May [cited 2014 Feb 10]. Available from: URL.
May TA, Clancy M, Critchfield J, Ebeling F, Enriquez A, Gallagher C, et al. Reducing unnecessary inpatient laboratory testing in a teaching hospital. Am J Clin Pathol. 2006 Aug;126(2):200-6.
National Institute for Clinical Excellence. Preoperative tests: The use of routine preoperative tests for elective surgery [Internet]. 2003 June [cited 2014 Feb 10]. Available from: URL.