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

View all recommendations from this society

November 20, 2020

Don’t order routine follow up chest imaging for post-acute and long-term care residents with community acquired pneumonia whose symptoms have resolved within 5–7 days.

Radiographic findings tend to lag behind clinical response. Obtaining routine follow up chest radiograph in patients with CAP who have responded to prescribed therapy is therefore not indicated and does not improve care outcomes. This approach is similar to that outlined by the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA), both of whom recommend not obtaining a follow-up chest radiograph in patients whose symptoms have resolved within five to seven days.


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.

(11–15)
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.
Sources

For more information, visit www.paltc.org.

Sources

Diagnosis and Treatment of adults with Community-acquired Pneumonia. Official guideline of the American Thoracic Society and Infectious Disease Society of America. August 2019; https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1581ST

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

Bruns AH, Oosterheert JJ, Prokop M, et al. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis 2007; 45:983.

Mittl RL Jr, Schwab RJ, Duchin JS, et al. Radiographic resolution of community-acquired pneumonia. Am J Respir Crit Care Med 1994; 149:630.