AMDA – The Society for Post-Acute and Long-Term Care Medicine

View all recommendations from this society

Released September 4, 2013; updated August 10, 2017 and July 1, 2019

Don’t obtain urine tests until clinical criteria are met.

Asymptomatic bacteriuria (ASB) and/or pyuria is common in residents in PALTC and is the major driver for overuse of antibiotics for Urinary Tract Infections (UTI), leading to an increased risk of adverse drug events, resistant organisms, and infection due to Clostridioides difficile. Due to the high rate of bacterial colonization of urine in older adults, it is important to avoid obtaining a urinalysis or urine culture unless the resident has signs or symptoms suggestive of UTI such as dysuria, and one or more of the following: frequency, urgency, suprapubic pain or gross hematuria. An additional concern is that the finding of bacteriuria/pyuria without urinary symptoms (ASB) may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the timely detection of an alternative source of infection.

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.

How The List Was Created

1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.

6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.

The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).

Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.

Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).

Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.

Phase 4 – CPSC members reviewed survey results and chose the five items.

The AMDA Choosing Wisely project utilized procedures similar to previous workgroups.
In Phase 1 – The Clinical Practice Steering Committee (CPSC) solicited recommendations from members of the Society’s five subcommittees.

In Phase 2 – Each member of the CPSC reviewed the submitted recommendations (with the goal to selecting the best five recommendations) considering the
perceived contribution to cost, benefit of the item and scientific evidence to support use of the item in the literature or in guidelines. Based on the feedback of the CPSC, the recommendations were narrowed to five, revised, and supporting evidence was added.

Phase 3 – The revised five recommendations and sources were reviewed by the CPSC for final approval, and then approved by the Board of Directors.

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Nace D, Perera S, Hanlon J, Saracco S, Anderson G, Schweon S, Klein-Fedyshin M, Wessel C, Mulligan M, Drinka P, Crnich C. The Improving Outcomes of UTI Management in Long-Term Care Project (IOU) Consensus Guidelines for the Diagnosis of Uncomplicated Cystitis in Nursing Home Residents. J Am Med Dir Association. 2018(19) 765-769.