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Choosing Wisely for Hospital Medicine

Page history last edited by Sheila Modi 6 years, 5 months ago

 

 

Pertinent to Hospital Medicine

 

Palliative

-Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.

In advanced dementia, studies have found feeding tubes do not result in improved survival, prevention of aspiration pneumonia, or improved healing of pressure ulcers. Feeding tube use in such patients has actually been associated with pressure ulcer development, use of physical and pharmacological restraints, and patient distress about the tube itself. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems; in the final phase of this disease, assisted feeding may focus on comfort and human interaction more than nutritional goals.


-Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations.


-Don't leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.

In about a quarter of patients with ICDs, the defibrillator fires within weeks preceding death.  For patients with advanced irreversible diseases, defibrillator shock rarely prevent death, may be painful to patients and are distressing to caregivers/family members.  Currently there are no formal practice protocols to address deactivation; fewer than 10% of hospices have official policies.  Advance care planning discussions should include the option of deactivating the ICD when it no longer supports the patient's goals.

 

 

Neuro
-Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.
Occlusive carotid artery disease does not cause fainting but rather causes focal neurologic deficits such as unilateral weakness. Thus, carotid imaging will not identify the cause of the fainting and increases cost. Fainting is a frequent complaint, affecting 40% of people during their lifetime.

 

 

ACP

-In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies.

 

-In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.

 

-Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.

 

 

Radiology
-Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

 

-Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

 

 

GI

-For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.

The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden.  It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient's quality of life rather than as a disease control measure.

 

 

Geriatrics

-Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.

People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors.  In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death.  Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose and imminent threat to themselves or others.  Identifying and addressing causes of behavior change can make drug treatment unnecessary.

 

-Avoid using medications to achieve hemoglobin A1c<7.5% in most adults age 65 and older; moderate control is generally better.

There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial.  Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates.  Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults.  Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy.  Reasonable glycemic targets would be 7.0-7.5% in healthy older adults with long life expectancy, 7.5-8.0% in those with moderate comorbidity and a life expectancy <10 years, and 8.0-9.0% in those with multiple morbidities and shorter life expectancy.

 

-Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.

Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium.  Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.

 

-Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria.  Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects.  Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection.  Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.

 

 

Echocardiography

-Avoid transesophageal echocardiography (TEE) to detect cardiac sources of embolization if a source has been identified and patient management will not change.

Tests whose results will not alter management should not be ordered.  Protocol-driven testing can be useful if it serves as a reminder not to omit a test or procedure, but should always be individualized to the particular patient.  While TEE is safe, even the small degree of risk associated with a procedure is not justified if there is no expected clinical benefit.

 

 

Nephrology

-Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

The use of NSAIDs, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function in these individuals.  Other agents such as acetaminophen, tramadol or short-term use of narcotic analgesics may be safer than and as effective as NSAIDs.

 

 

Nuclear Cardiology

-Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.

Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery or with no cardiac symptoms or clinical risk factors undergoing intermediate-risk non-cardiac surgery.  These types of testing do not change the patient's clinical management or outcomes and will result in increased costs.  Therefore, it is not appropriate to perform cardiac imaging procedures for non-cardiac surgery risk assessment in patients with no cardiac symptoms, clinical risk factors or who have moderate to good functional capacity.

 

 

SHM

-Don't place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis).

Catheter Associated Urinary Tract Infections (CAUTIs) are the most frequently occurring health care acquired infection (HAI). Use of urinary catheters for incontinence or convenience without proper indication or specified optimal duration of use increases the likelihood of infection and is commonly associated with greater morbidity, mortality and health care costs.  Published guidelines suggest that hospitals and long-term care facilities should develop, maintain and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies and replacement indications.

 

-Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.

According to published guidelines, medications for stress ulcer prophylaxis are not recommended for adult patients in non-ICU settings. Histamine-2 receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs), commonly used to treat stress ulcers, are associated with adverse drug events and increased medication costs, and commonly enhance susceptibility to community-acquired nosocomial pneumonia and Clostridium difficile. Adherence to therapeutic guidelines will aid health care providers in reducing treatment of patients without clinically important risk factors for gastrointestinal bleeding.

 

-Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.

The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients. The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration. According to a National Institutes of Health Consensus Conference, no single criterion should be used as an indication for red cell component therapy. Instead, multiple factors related to the patient’s clinical status and oxygen delivery should be considered.

 

-Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.

Telemetric monitoring is of limited utility or measurable benefit in low risk cardiac chest pain patients with normal electrocardiogram. Published guidelines provide clear indications for the use of telemetric monitoring in patients which are contingent upon frequency, severity, duration and conditions under which the symptoms occur. Inappropriate use of telemetric monitoring is likely to increase cost of care and produce false positives potentially resulting in errors in patient management.

 

-Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

Hospitalized patients frequently have considerable volumes of blood drawn (phlebotomy) for diagnostic testing during short periods of time. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have significant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals.

 

 

Nuclear Medicine and Molecular Imaging

-Avoid using a computed tomography angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead.

When the clinical question is whether or not pulmonary emboli are present, a V/Q study can provide the answer with lower overall radiation dose to the breast than can CTA, even when performed with a breast shield.

 

 

Vascular Medicine

-Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause.

Lab tests to look for a clotting disorder will not alter treatment of a venous blood clot, even if an abnormality is found. DVT is a very common disorder, and recent discoveries of clotting abnormalities have led to increased testing without proven benefit. 

 

-Don’t reimage DVT in the absence of a clinical change.

Repeat ultrasound images to evaluate “response” of venous clot to therapy does not alter treatment.

 

-Avoid cardiovascular testing for patients undergoing low-risk surgery.

Pre-operative stress testing does not alter therapy or decision-making in patients facing low-risk surgery

 

 

 

 

 

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