WA ACEP
November 2014
• Disclaimers
• Introduction – Choosing Wisely Campaign II
• 2014 ACEP Recommendations – Avoid:
• CT scan of the head for asymptomatic adults with
syncope, minor trauma, & normal neurological exam
• CT pulmonary angiography if low-pretest probability of
PE and either a negative PERC score or D-dimer
• Lumbar spine imaging for atraumatic back pain
• Antibiotics for uncomplicated sinusitis
• CT KUB for young otherwise healthy patients with
known histories of kidney stones
• Conclusion
• The following tests and procedures were
recommended for inclusion in the “Choosing Wisely”
campaign in 2014 by an expert panel of emergency
physicians and the ACEP Board of Directors because
they may not be cost effective in some situations.
• However, these recommendations should not be
construed or used to supersede the decision of the
responsible provider, who possesses the knowledge,
clinical judgment, and the situational awareness of the
context and availability of appropriate resources.
• The following summaries are intended to serve as a
guide and facilitate increased awareness, but only
represent a portion of the available information and
references. Providers are encouraged to incorporate
any and all references available prior to
implementation in clinical practice.
• The authors of this presentation have no relevant
conflicts of interest to disclose.
• Originally conceived and piloted by the National
Physicians Alliance along with Consumer Reports
• Endorsed by the ABIM Foundation and over 20
medical specialty organizations
• Identify tests and procedures commonly used in their
field whose necessity should be questioned OR
discussed with patients
• First set of recommendations released in Nov 2013
http://www.choosingwisely.org/
http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx
• ACEP declined initial participation in 2012 because:
• the impact on the unique nature of emergency
medicine, liability concerns, and potential harm to
physician reimbursement had not yet been
appropriately examined, and
• any tests and procedures identified should be
evidenced-based and have meaningful contribution to
cost-effective care.
• In February 2013, after review by an expert panel of
emergency physicians, the ACEP Board of Directors
elected to participate in the campaign and
recommended the first five tests and procedures.
http://thecentralline.org/?p=2723
http://www.acep.org/Clinical---Practice-Management/ACEP-Announces-List-ofTests-As-Part-of-Choosing-Wisely-Campaign/
Avoid computed tomography (CT) of the head in
asymptomatic adult patients in the emergency
department (ED) with syncope, insignificant trauma, and
a normal neurological evaluation.
• Syncope or near syncope is a common reason for
visiting an ED and most of these visits are not serious.
Many tests may be ordered to identify the cause of
the problem.
• However, these tests should not routinely ordered,
and the decision to order them should be guided by
information obtained from the patient’s history or
physical examination.
• Clinical Study – 2005
•
http://link.springer.com/article/10.1007/s10140-005-0434z#page-1
• Clinical Study - 2007
•
http://link.springer.com/article/10.1007/s11739-007-00105#page-1
• ACEP Clinical Policy – 2007
•
http://www.annemergmed.com/article/S01960644(07)00130-8/abstract
Avoid CT pulmonary angiography in ED patients with a
low-pretest probability of pulmonary embolism and either
a negative Pulmonary Embolism Rule-Out Criteria (PERC)
or a negative D-dimer.
• Advances in medical technology have increased the
ability to diagnose even small blood clots in the lung.
Now, the most commonly used test is known as a CT
pulmonary angiography (CTPA). It is readily available
in most hospitals and EDs.
• However, disadvantages of the CTPA include patient
exposure to radiation, the use of dye in the veins that
can damage kidneys, and high cost.
• Clinical Study – 2010
•
http://www.annemergmed.com/article/S01960644(10)00276-3/fulltext
• ACEP Clinical Policy – 2011
•
http://www.annemergmed.com/article/S01960644(11)00097-7/abstract
• Meta-Analysis – 2012
•
http://www.annemergmed.com/article/S01960644(11)01761-6/fulltext
• Journal Club – 2012
•
http://www.annemergmed.com/article/S01960644(12)01370-4/fulltext
Avoid lumbar spine imaging in the ED for adults with
atraumatic back pain unless the patient has severe or
progressive neurological deficits or is suspected of
having a serious underlying condition, such as vertebral
infection or cancer with bony metastasis.
• Low back pain without trauma is a common
presenting complaint in the ED.
• Most of the time, such pain is caused by conditions
such as a muscle strain or bulging disc that cannot be
identified on an x-ray or CT scan.
• Epidemiological Study - 2010
•
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2982879/
• Review Article – 2010
•
http://www.mdconsult.com/das/article/body/4718697853/jorg=journal&source=MI&sp=23728018&sid=1554383254/N/770100/s
0733862710000465.pdf?SEQNO=1&issn=0733-8627
• ACR Appropriateness Criteria Low Back Pain – 2011
•
http://www.guideline.gov/content.aspx?id=35145
Avoid prescribing antibiotics in the ED for uncomplicated
sinusitis. Most patients with acute sinusitis do not require
antibiotic treatment, because 98% of acute sinusitis
cases are caused by a viral infection and resolve in 10-14
days without treatment.
• Special Report - CDC Principles of Judicious Antibiotic
Use - 2001
•
http://www.annemergmed.com/article/S01960644(01)70089-3/fulltext
• Clinical Study – 2011
•
http://archinte.jamanetwork.com/article.aspx?articleid=110
8815
Avoid ordering CT of the abdomen and pelvis in young
otherwise health ED patients with known histories of
ureterolithiasis presenting with symptoms consistent with
uncomplicated kidney stones.
• Many patients < 50 years old who have symptoms of
recurrent kidney stones do not need a CT scan unless
symptoms persist/worsen, there is a fever, or a history
of solitary kidney or severe obstruction.
• CT scans of patients with symptoms suggestive of
recurrent kidney stones usually do not change
treatment, and the cost and radiation exposure can
often be avoided in these cases.
• Clinical Study – 2010
•
http://www.mdconsult.com/das/article/body/4718697858/jorg=journal&source=MI&sp=23007066&sid=155438772
7/N/739797/s073567570800819x.pdf?issn=0735-6757
• Epidemiological Study - 2013
•
http://www.nature.com/ki/journal/v83/n3/full/ki2012419a.ht
ml