CHICAGO — Dedicated to reducing health care costs and improving patient care, the American College of Emergency Physicians (ACEP) today announced a second list of five tests and procedures that should be discussed to help make wise decisions about the most appropriate care based on a patient’s individual situation. These recommendations are part of ACEP’s participation in the ABIM Foundation’s Choosing Wisely® campaign and were announced at the organization’s annual meeting in Chicago.
“As emergency physicians, we are committed to reducing health care costs while at the same time continuing to fulfill our commitments to provide the best, most efficient emergency care to millions of Americans,” said Michael J. Gerardi, MD, FACEP, president of the American College of Emergency Physicians. “These specific recommendations are evidence-based and developed with significant input from experts.”
The mission of Choosing Wisely — a multi-year effort of the ABIM Foundation — is to promote conversations among physicians and patients about using appropriate tests and treatments and avoiding care when harm may outweigh benefits. Since launching in April of 2012, more than 80 national, regional and state medical specialty societies and consumer groups have become Choosing Wisely partners. ACEP officially joined the campaign in February of 2013.
ACEP’s five latest recommendations were developed through a multi-step process that included research and input from an expert panel of emergency physicians and the ACEP Board of Directors. These are recommendations that physicians have control over and are not dictated by hospitals or trauma system protocols. Also, they do not expose patients to danger or physicians to medical liability risks.
The following is a list of the five most recent Choosing Wisely evidence based recommendations approved by ACEP’s Board of Directors Each patient situation is unique, physicians and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.
1. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. Syncope (passing out or fainting) or near syncope (lightheadedness or almost passing out) is a common reason for visiting an emergency department and most of those visits are not serious. Many tests may be ordered to identify the cause of the problem. However, these tests should not be routinely ordered, and the decision to order them should be guided by information obtained from the patient’s history or physical examination.
2. Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer. Advances in medical technology have increased the ability to diagnose even small blood clots in the lung. Now, the most commonly used test is known as a CT pulmonary angiogram (CTPA). It is readily available in most hospitals and emergency departments. However, disadvantages of the CTPA include patient exposure to radiation, the use of dye in the veins that can damage kidneys and high cost.
3. Avoid lumbar spine imaging in the emergency department for adults with atraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition, such as vertebral infection or cancer with bony metastasis. Low back pain without trauma is a common presenting complaint in the emergency department. Most of the time, such pain is caused by conditions such as a muscle strain or a bulging disc that cannot be identified on an x-ray or CT scan.
4. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Sinusitis is a common reason for patients to visit the emergency department. Most patients with acute sinusitis do not require antibiotic treatment, because 98 percent of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment.
5. Avoid ordering CT of the abdomen and pelvis in young otherwise health emergency department patients with known histories of ureterolithiasis presenting with symptoms consistent with uncomplicated kidney stones. Many patients in the emergency department who are less than 50 years old and who have symptoms of recurrent kidney stones do not need a CT scan unless these symptoms persist or worsen, of if there is a fever, or a history of severe obstruction with previous stones. CT scans of patients in the emergency department with symptoms of a recurrent kidney stone usually don’t change treatment decisions, and the cost and radiation exposure can often be avoided in these cases.
Last year, ACEP released the first five Choosing Wisely recommendations of tests and procedures to question. You can view them here.
ACEP previously declined to participate in the campaign because of potential conflicts of this approach with the unique nature of emergency medicine as compared with office-based practices, and because of concerns that advocacy for medical liability is missing from the campaign.
“While we agree that the overuse of medical testing continues to be a serious problem, we will never be able to fully address rising health care costs without first addressing the need for comprehensive medical liability reform,” said Dr. Gerardi. “We continue to encourage the ABIM Foundation and its partners in this campaign to push for liability reform because it will benefit all of us, most especially our patients.”
ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.