Choosing Wisely Campaign - Part I

I am on outpatient this month. The questions I find myself asking on most of the patients are focused on the type of health maintenance that the patient needs. I understand that medical care is ever evolving and changing but I find that preventative medicine, in my very limited experience, seems to change faster, more often. I came across the AAFP's recent release of the Choosing Wisely Campaign. It was released just last week and I thought it would be good to summarize a few (the table is 89 pages long) recommendations on topics I know I will deal with frequently in the clinical setting. 

Allergy/Immunology 

• Don’t perform screening panels, IgE panels, for food allergies without previous consideration of medical history -It is important to use clinical correlation when considering allergen testing. For example, only consider testing a patient specifically for peanut allergy if the patient endorses symptoms after ingestion of peanuts. Studies have shown that about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. When symptoms suggest a food allergy, tests should be selected based on a careful medical history. 

Cardiovascular

• Don't order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients - Who is considered low risk? Risk factors can be combined in many ways to allow classification of a person's risk for a CHD event as low, intermediate, or high. Several calculators and models are available to quantify a person's 10-year risk for CHD events. The Framingham Adult Treatment Panel III calculator (http://hp2010.nhlbihin.net/atpiii/calculator.asp) performs well for the U.S. population. Persons with a 10-year risk greater than 20% are generally considered high-risk, those with a 10-year risk less than 10% are considered low-risk, and those in the 10% to 20% range are considered intermediate-risk.
• Don’t perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high risk markers are present - Asymptomatic, low-risk patients account for up to 45% of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40 years; peripheral arterial disease; or greater than 2% yearly risk of coronary heart disease events.
• Avoid using stress echocardiograms on asymptomatic patients who meet "low-risk" scoring criteria for coronary disease -Stress echocardiography is mostly used in symptomatic patients to assist in the diagnosis of obstructive CAD. There is very little information on using stress echocardiography in asymptomatic individuals for the purposes of cardiovascular risk assessment, as a stand-alone test or in addition to conventional risk factors. 
• Don't repeat echocardiograms in stable, asymptomatic patients with a murmur or click when no pathology has been previously found and there has been no clinical change in the patient’s condition - Trace mitral, tricuspid, and pulmonic regurgitation can be detected in 70% to 90% of normal individuals and has no adverse clinical implications. Aortic stenosis is an exception. The 2014 American Heart Association/American College of Cardiology valvular guideline recommends serial echocardiography in patients with aortic stenosis. In patients with Stage B mild AS (transvalvular velocity 2 to 2.9 m/s), echocardiography is recommended every three to five years. In patients with Stage B moderate AS (transvalvular velocity 3 to 3.9 m/s), echocardiography is recommended every one to two years. In patients with asymptomatic Stage C1 severe AS (transvalvular velocity 4 m/s or higher), echocardiography is recommended every 6 to 12 months. Echocardiography is indicated earlier if there is a change in symptoms or signs suggestive of worsening cardiac status. 
• Don't perform routine annual stress testing after coronary artery revascularization - Routine annual stress testing in patients without symptoms does not usually change management. This practice may lead to unnecessary testing without any proven impact on patient management