Society of General Internal Medicine

Five Things Physicians and Patients Should Question

Released September 12, 2013

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1

Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.

Self-monitoring of blood glucose (SMBG) is an integral part of patient self-management in maintaining safe and target-driven glucose control in type 1 diabetes. However, there is no benefit to daily finger glucose testing in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia, and there is negative economic impact and potential negative clinical impact of daily glucose testing. SMBG should be reserved for patients during the titration of their medication doses or during periods of changes in patients’ diet and exercise routines.

2

Don’t perform routine general health checks for asymptomatic adults.

Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the “health maintenance” annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.

3

Don’t perform routine pre-operative testing before low-risk surgical procedures.

Pre-operative assessment is expected before all surgical procedures. This assessment includes an appropriately directed and sufficiently comprehensive history and physical examination, and, in some cases, properly includes laboratory and other testing to help direct management and assess surgical risk. However, pre-operative testing for low-risk surgical procedures (such as cataract extraction) results in unnecessary delays and adds to significant avoidable costs and should be eliminated.

4

Don’t recommend cancer screening in adults with life expectancy of less than 10 years.

Screening for cancer can be lifesaving in otherwise healthy at-risk patients. While screening tests lead to a mortality benefit, which emerges years after the test is performed, they expose patients to immediate potential harms. Patients with life expectancies of less than 10 years are unlikely to live long enough to derive the distant benefit from screening. However, these patients are in fact more likely to experience the harms since patients with limited life expectancy are more likely to be frail and more susceptible to complications of testing and treatments. Therefore the balance of potential benefits and harms does not favor recommending cancer screening in patients with life expectancies of less than 10 years.

5

Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience.

Peripherally inserted central catheters (or “PICCs”) are commonly used devices in contemporary medical practice that are associated with two costly and potentially lethal health care-acquired complications: central-line associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). Given the clinical and economic consequences of these complications, placement of PICCs should be limited to acceptable indications (long-term intravenous antibiotics, total parenteral nutrition, chemotherapy and frequent blood draws). PICCs should be promptly removed when acceptable indications for their use ends.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The membership of Society of General Internal Medicine (SGIM) consists of academic general internal medicine faculty practicing, teaching and conducting research in outpatient settings as well as in our nation’s teaching hospitals. As leading teachers of the next generation of physicians, we are committed to moving the practice of medicine to a more evidence-based approach. We are deeply committed to using science to improve our knowledge-base so that our patients can receive the best treatments, the optimal prevention care and the highest quality of life. We believe that the Choosing Wisely® campaign mirrors these same commitments to the evidence-based practice of medicine for the benefit of our patients. 

To learn more about the SGIM, visit www.sgim.org.

How this List was Created: An ad hoc committee of the Society of General Internal Medicine (SGIM) was impaneled, taking advantage of the clinical expertise of members from the existing Clinical Practice and the Evidence-Based Medicine Committees within the Society. Members of the ad hoc committee were then solicited to determine possible topics for consideration. The topics chosen were selected to meet the goals of the Choosing Wisely campaign, utilizing the unique clinical perspective of members of the Society in ambulatory General Medicine as well as hospital-based practice. The final topics were selected by a vote of committee members based on the strength of the existing evidence, the unique standing members of the Society have in addressing the clinical topics selected, as well as contributions the recommendations would make in terms of patient safety, quality and economic impact. The final recommendations were approved by the governing Council of SGIM.

For SGIM’s disclosure and conflict of interest policies, please visit www.sgim.org.

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