Research among primary care physicians has outlined “Top 5” practices to avoid in order to deliver better quality, more cost-effective medical care.
For internists and family physicians, the top item on the not-to-do list: Don't do imaging for low-back pain within the first 6 weeks unless red flags are present. For pediatricians, the top quality-promoting, cost-reducing activity is: Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus.
Working groups convened by the nonprofit National Physicians Alliance sought to find evidence-based activities that were common in primary care. To be included on the top 5 lists, the activities had to lead to significant health benefits, as well as reduce harms to patients and cut health care costs.
The top 5 practices that should be adopted by internists include:
▸ Don't do imaging for low-back pain within the first 6 weeks unless red flags are present.
▸ Don't obtain blood chemistry panels or urinalyses for screening in asymptomatic, healthy adults.
▸ Don't order annual electrocardiograms (ECG) or any other cardiac screening tests for asymptomatic, low-risk adults.
▸ Use only generic statins when initiating lipid-lowering drug therapy.
▸ Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.
The top 5 not-to-do list for family physicians is similar, but not identical, and includes:
▸ Don't do imaging for low-back pain within the first 6 weeks unless red flags are present.
▸ Don't routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for 7 days or more or symptoms worsen after initial clinical improvement
▸ Don't order annual ECG or any other cardiac screening for asymptomatic, low-risk adults.
▸ Don't perform Pap tests on patients younger than 21 years or in women status post hysterectomy for benign disease.
▸ Don't use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.
For pediatricians, the top 5 quality-improving activities include:
▸ Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus.
▸ Don't obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.
▸ Don't refer otitis media with effusion early in its course.
▸ Advise patients not to use cough and cold medications.
▸ Use inhaled corticosteroids to control asthma appropriately.
Consensus lists were drawn up by working group members and tested initially with 83 NPA physicians who rated the activity based on how often they engaged in the activity in their practice, its impact on quality of care and cost, the strength of the evidence supporting the activity, and how easy or hard it was to eliminate from their practice.
Field testing then was expanded through an invitation to all NPA members. There were 172 testers in the second round, all of whom completed the same surveys as the initial testers.
Field testing showed support for the evidence that backed the recommendations, and the ease with which they could be implemented, according to the study's authors in the Good Stewardship Working Group. However, they pointed out, field testing physicians might not be representative of all internists, family physicians, and pediatricians.
The authors pointed out that although the groups worked independently, several activities to avoid appeared on more than one list. “This commonality across specialties reinforced the importance and relevance of addressing overuse of these activities,” the authors said (Arch. Intern. Med. 2011[doi: 10.1001/archinternmed.2011.231]).
The NPA plans to distribute the top 5 lists to all its members who are internists, family physicians, and pediatricians. The organization also plans to create a virtual practice community to help members implement the recommendations. And it says it will create a training video that will teach physicians how to enlist their patients' support for the recommendations; another video will be created specifically to explain to patients the rationale behind the lists.
The NPA plans to seek endorsements from patient advocacy and patient safety groups to “help dispel the misconception that these clinical recommendations represent rationing and support the idea that often less is truly more.”
The project was funded by a grant from the American Board of Internal Medicine Foundation.