Things Physicians Should Question
Maine Orthopaedic Center supports ABIM Foundation’s Choosing Wisely® campaign as it aims to promote conversations between providers and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
In response to this challenge, national organizations representing medical specialists have asked its providers to “choose wisely” through the identification of tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of “Things Providers and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments.
These lists represent specific, evidence-based recommendations providers and patients should discuss together in order to make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.
Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.
In collaboration with the partner organizations, Consumer Reports has created resources for consumers and providers to engage in these important conversations about the overuse of medical tests and procedures that provide little benefit and in some cases harm.
AVOID PERFORMING ROUTINE POST-OPERATIVE DEEP VEIN THROMBOSIS ULTRASONOGRAPHY SCREENING IN PATIENTS WHO UNDERGO ELECTIVE HIP OR KNEE ARTHROPLASTY.
Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.
DON’T USE NEEDLE LAVAGE TO TREAT PATIENTS WITH SYMPTOMATIC OSTEOARTHRITIS OF THE KNEE FOR LONG-TERM RELIEF.
The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.
DON’T USE GLUCOSAMINE AND CHONDROITIN TO TREAT PATIENTS WITH SYMPTOMATIC OSTEOARTHRITIS OF THE KNEE.
Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.
DON’T USE LATERAL WEDGE INSOLES TO TREAT PATIENTS WITH SYMPTOMATIC MEDIAL COMPARTMENT OSTEOARTHRITIS OF THE KNEE.
In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.
DON’T USE POST-OPERATIVE SPLINTING OF THE WRIST AFTER CARPAL TUNNEL RELEASE FOR LONG-TERM RELIEF.
Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental affects including adhesion formation, stiffness and prevention of nerve and tendon movement.
DON’T PRESCRIBE OPIATES IN ACUTE DISABLING LOW BACK PAIN BEFORE EVALUATION AND A TRIAL OF OTHER ALTERNATIVES IS CONSIDERED.
Early opiate prescriptions in acute disabling low back pain are associated with longer disability, increased surgical rates, and a greater risk of later opioid use. Opiates should be prescribed only after a physician evaluation by a licensed health care provider and after other alternatives are trialed.
DON’T ORDER REPEAT EPIDURAL STEROID INJECTIONS WITHOUT EVALUATING THE INDIVIDUAL’S RESPONSE TO PREVIOUS INJECTIONS.
Utilization of repeat epidural steroid injections has not been shown to improve patient outcomes. Physicians should consider patient re-evaluation prior to repeat epidural steroid injections.
DON’T OBTAIN IMAGING (PLAIN RADIOGRAPHS, MAGNETIC RESONANCE IMAGING, COMPUTED TOMOGRAPHY [CT], OR OTHER ADVANCED IMAGING) OF THE SPINE IN PATIENTS WITH NON-SPECIFIC ACUTE LOW BACK PAIN AND WITHOUT RED FLAGS.
Imaging of the spine in patients with acute low back pain during the early phase of symptom onset is unnecessary. Red flags that may indicate that early imaging of the spine is required can include neurological deficit such as weakness or numbness, any bowel or bladder dysfunction, fever, history of cancer, history of intravenous drug use, immunosuppression, steroid use, history of osteoporosis or worsening symptoms.
DON’T ROUTINELY REPEAT DXA SCANS MORE OFTEN THAN ONCE EVERY TWO YEARS.
Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation recommendations. The optimal interval for repeating Dual-energy X-ray Absorptiometry (DXA) scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, frequent testing (e.g., <2 years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DXA changes do not always correlate with probability of fracture. Therefore, DXAs should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women age 67 and older with normal bone mass may not need additional DXA testing for up to ten years provided osteoporosis risk factors do not significantly change.
AVOID ORDERING A BRAIN CT OR BRAIN MRI TO EVALUATE AN ACUTE CONCUSSION UNLESS THERE ARE PROGRESSIVE NEUROLOGICAL SYMPTOMS, FOCAL NEUROLOGICAL FINDINGS ON EXAM OR THERE IS CONCERN FOR A SKULL FRACTURE.
Concussion is a clinical diagnosis. Concussion is not associated with clinically relevant abnormalities on standard neuroimaging with CT or MRI. These studies should be ordered if more severe brain injury is suspected. CT is best utilized for skull fracture and intracranial bleeding, whereas MRI may be ordered for prolonged symptoms, worsening symptoms or other suspected structural pathology.
AVOID ORDERING A KNEE MRI FOR A PATIENT WITH ANTERIOR KNEE PAIN WITHOUT MECHANICAL SYMPTOMS OR EFFUSION UNLESS THE PATIENT HAS NOT IMPROVED FOLLOWING COMPLETION OF AN APPROPRIATE FUNCTIONAL REHABILITATION PROGRAM.
The most common cause of anterior knee pain is patellofemoral pain syndrome. Magnetic resonance imaging (MRI) is rarely helpful in managing this syndrome. Treatment should focus on a guided exercise program to correct lumbopelvic and lower limb strength and flexibility imbalances. If pain persists, if there is recurrent swelling or if mechanical symptoms such as locking and painful clicking are present, and radiographs are non-diagnostic, an MRI may be useful.
AVOID RECOMMENDING KNEE ARTHROSCOPY AS INITIAL MANAGEMENT FOR PATIENTS WITH DEGENERATIVE MENISCAL TEARS AND NO MECHANICAL SYMPTOMS.
Degenerative meniscal tears may respond to non-operative treatments such as exercise to improve muscle strength, endurance and flexibility. Other treatment options include mild analgesics, anti-inflammatory medication, activity modification or corticosteroid injection. If mechanical symptoms such as locking, painful clicking or recurrent swelling are present, or if pain relief is not obtained after a trial of non-operative treatment, arthroscopy may be warranted. If significant osteoarthritis is also present, other surgical options should be considered.
DON’T PERFORM SURGERY FOR A BUNION OR HAMMERTOES WITHOUT SYMPTOMS.
Foot surgery for cosmetic reasons is not supported by medical research. Symptoms such as pain and limitations of activity are the most common reasons to pursue bunion or hammertoe surgery. Patients having surgery for bunions and hammertoes are at risk for a wide range of complications such as nerve damage, infection, bone healing problems and toe stiffness.
DON’T USE SHOE INSERTS FOR SYMMETRIC FLAT FEET OR HIGH ARCHES IN PATIENTS WITHOUT SYMPTOMS.
Symmetric flat feet or high arches are common conditions, and generally they are asymptomatic. The development of the arch is not related to external supports, and no evidence exists that any support is needed in asymptomatic patients.