IN THIS ISSUE
MAKING DECISIONS IN PRIMARY CARE--TESTS
These tests may not be necessary and could even be harmful; do not recommend them without considering the risk and likely benefit (5).
Allergy and immunology (7)
Unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
Diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient's clinical history.
Routine diagnostic testing in patients with chronic urticaria.
In the vast majority of patients, the etiology of chronic urticaria cannot be determined. Limited laboratory testing may be warranted to exclude underlying causes, and targeted laboratory testing based on clinical suspicion is appropriate. Skin or serum-specific IgE testing for inhalants or foods is not indicated unless there is a clear history implicating an allergen.
Annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms (8).
There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes.
Stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of asymptomatic patients without high-risk markers (9-11).
Asymptomatic patients at low risk for coronary heart disease (10-year risk <10%) account for up to 45% of unnecessary screening for the disease. Among asymptomatic patients, testing should be performed in those aged ≥40 years who have diabetes, in those with peripheral arterial disease, and when there is a greater than 2% yearly risk for coronary heart disease events (Resources--Cardiac imaging).
Echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms (9).
Patients with native valve disease usually have years without symptoms before the onset of deterioration. An annual echocardiogram is not recommended unless there is a change in clinical status.
Cardiac imaging that results in unnecessary radiation exposure, including higher-dose tests, tests in patients at low risk for coronary heart disease, and routine repeat testing in asymptomatic individuals when benefits are likely to be limited (11).
Reduce or eliminate radiation exposure with appropriate selection of tests and procedures, in keeping with national recommendations to reduce patient exposure to radiation while maintaining high-quality test results (Resources--Cardiac imaging).
Computed tomography (CT) to evaluate suspected appendicitis in children unless ultrasound results are equivocal (12).
In experienced hands, ultrasound is nearly as good as CT for initial evaluation of appendicitis in children, and it reduces radiation exposure. If the results of the ultrasound exam are equivocal, a CT may be done. This approach is cost-effective, reduces potential radiation risks, and has sensitivity and specificity of 94%.
Follow-up colorectal cancer screening (by any method) in average-risk individuals less than 10 years after a high-quality colonoscopy is negative (13).
In average-risk individuals, the risk of cancer is low for 10 years after a high-quality colonoscopy shows no evidence of neoplasia. Screening should begin at age 50 years in these patients.
Follow-up colonoscopy sooner than 5 years following complete removal of 1 or 2 small (<1 cm) adenomatous polyps without high-grade dysplasia (13).
The timing of follow-up colonoscopy should be based on the results of a previous high-quality colonoscopy. Patients with 1 or 2 small tubular adenomas with low-grade dysplasia should have surveillance colonoscopy 5 to 10 years after initial polypectomy. The timing should be based on other clinical factors such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician.
Follow-up CT scans for a patient with functional abdominal pain syndrome (per ROME III criteria; see www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf) unless there is a change in clinical findings or symptoms (13).
There is a small but measurable increase in cancer risk from x-ray exposure. An abdominal CT scan is associated with exposure to higher levels of radiation--equivalent to 3 years of natural background radiation. To minimize this risk and to reduce costs, perform CT scans only when they are likely to provide information that changes patient management.
Imaging studies instead of a high-sensitive D-dimer measurement as the initial diagnostic test in patients with low pretest probability of venous thromboembolism (VTE) or pulmonary embolism (PE) (10,12).
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. Pulmonary embolism is relatively common clinically, but rare in the absence of elevated blood D-dimer levels and certain specific risk factors. Imaging is helpful to confirm or exclude PE only when these characteristics are present (Resources--Embolism).
Imaging for low back pain within the first 6 weeks, unless red flags are present (8,10).
Imaging of the lower spine with plain radiography, MRI, or CT before 6 weeks does not improve outcomes, but does increase costs. Earlier imaging may be indicated in certain situations, including severe or progressive neurological deficits or when serious underlying conditions such as cancer, osteomyelitis, or cauda equina syndrome are suspected.
Dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors (8).
DEXA is not cost-effective in younger, low-risk patients, but is cost-effective in older patients. Younger patients should not be screened unless they have a 9.3% 10-year risk for any fracture, based on factors such as tobacco and alcohol use, low body mass index, and parental history of fractures (14) (Resources--Osteoporosis).
Imaging for uncomplicated headache (12).
Imaging headache patients without specific risk factors for structural disease is not likely to change management or improve outcome. Use validated clinical screens to identify patients with a significant likelihood of structural disease requiring immediate attention (Resources--Headache).
Brain imaging studies (CT or MRI) in the evaluation of simple syncope in a patient with a normal neurologic examination (10).
Imaging for patients with witnessed syncope but no suggestion of seizure and no report of other neurologic symptoms or signs does not improve outcomes. In these cases, the likelihood that the central nervous system caused the syncope is extremely low.
Preoperative (10-12) or admission (12) chest radiography, preoperative stress cardiac imaging (9,11), or advanced noninvasive imaging in patients scheduled to undergo low-risk or intermediate-risk noncardiac surgery (9,11).
In the absence of cardiopulmonary symptoms, preoperative chest radiography for low- or intermediate-risk noncardiac surgery (eg, cataract removal) rarely provides any meaningful changes in management or improved patient outcomes. Obtain a chest radiograph if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 years who has not had chest radiography within 6 months.
Routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms (15).
Routine cancer screening--including mammography, colonoscopy, prostate-specific antigen (PSA), and Pap smears--does not improve survival in dialysis patients with limited life expectancy, such as those who are not transplant candidates. Screening should be individualized based on patients' cancer risk factors, expected survival, and transplant status.
Respiratory system (7)
Diagnosing or managing asthma without spirometry.
Symptoms can be misleading and may be due to other causes. Spirometry is essential to confirm the diagnosis in those patients who can perform this procedure and to assess control.
Any sinus imaging in cases of acute, mild, uncomplicated sinusitis.
In the absence of complicating circumstances, imaging studies rarely add to the diagnostic accuracy or change management strategies.
Follow-up imaging for clinically inconsequential adnexal cysts (12).
Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small, simple cysts in postmenopausal women are common, clinically inconsequential, and do not lead to ovarian cancer. After a high-quality ultrasound, do not recommend follow-up for a classic corpus luteum or simple cyst <5 cm in women of reproductive age or <1 cm in postmenopausal women.
Surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent (16).
Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (eg, colorectal), but for asymptomatic patients who have been treated for breast cancer with curative intent, there is no benefit from routine imaging or serial measurement of serum tumor markers.
Pap smears for women younger than 21 years or those who have had a hysterectomy for noncancer disease (8).
Most observed cervical cytology abnormalities in adolescents regress spontaneously; therefore, Pap smears for this age group are unnecessary. There is little evidence for improved outcomes using Pap smears in women after hysterectomy for noncancer disease.