Five Commonly Performed Tests and Treatments in Pulmonary Medicine May Not Always Be Necessary

A list released today identified five commonly performed tests and procedures in pulmonary medicine that may not always be necessary. The list, part of the ABIM Foundation’s Choosing Wisely® campaign, was produced by a collaborative task force assembled by the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP).

The Choosing Wisely campaign brings together national physician groups to identify specific tests, procedures and medications that are commonly used but may be duplicative or unnecessary. The pulmonary medicine list developed by ATS and ACCP is designed to help promote conversations between physicians and patients about which tests and treatments are most appropriate and about avoiding care whose potential harm may outweigh its benefits.

“The Choosing Wisely campaign can help physicians take the moral high ground in reining in the costs of their practices, rather than leaving such decisions to external policymakers. There are a lot of diagnostic tests and therapies for which available evidence suggests a lack of effectiveness, and physicians are in the best position to determine exactly which practices in their own specialties fit that bill,” said Scott Halpern, MD, PhD, MBE, an assistant professor of medicine, epidemiology, and medical ethics and health policy at the University of Pennsylvania and co-chair of the task force that produced the list.

Dr. Halpern, who is vice chair of the ATS Ethics and Conflict of Interest Committee, noted that the pulmonary medicine guidelines and the critical care guidelines which will be released in January are being produced collaboratively by more than one medical organization. Dr. Halpern also chairs the task force developing the critical care guidelines, which are being developed by the American Association of Critical-Care Nurses and the Society of Critical Care Medicine, as well as by the ATS and the ACCP.

“The collaboration between ATS and ACCP has been very important,” he said. “It should lend considerable strength to the agreed-upon recommendations of these diverse stakeholders.”

The five recommendations in pulmonary medicine are:

1. Don’t perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.

2. Don’t routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left-sided heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension).

3. For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia.

4. Don’t perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.

5. Don’t perform CT screening for lung cancer among patients at low risk for lung cancer.

“These recommendations reflect a consensus on the available evidence, not only on medical necessity but on patient safety and quality of life as well as economic considerations,” said Renda Wiener, MD, MPH, assistant professor of medicine at the Boston University School of Medicine and a physician-researcher at the Center for Health Quality, Outcomes and Economic Research at the U.S. Department of Veterans Affairs, who also co-chaired the task force. “We hope these recommendations will help improve patient care and outcomes while also reducing health care costs.”

To date, over 80 national and state medical specialty societies, regional health collaboratives and consumer partners have participated in the Choosing Wisely campaign, which has covered more than 250 tests and procedures that the specialty society partners say are over or inappropriately used, and that physicians and patients should discuss. More information about the Choosing Wisely campaign is available at