H e a l t h C a r e Po l i c y a n d Q u a l i t y • R ev i ew Rao and Levin The Choosing Wisely Initiative
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Health Care Policy and Quality Review
The Choosing Wisely Initiative of the American Board of Internal Medicine Foundation: What Will Its Impact Be on Radiology Practice? Vijay M. Rao1 David C. Levin1,2 Rao VM, Levin DC
OBJECTIVE. The Choosing Wisely initiative is a large-scale effort to reduce the use of unnecessary tests and procedures, many of which involve imaging. CONCLUSION. By identifying specific tests and procedures that are often overused, unnecessary, inappropriate, or ineffective, Choosing Wisely places the onus on physicians to reduce their use.
I
Keywords: Choosing Wisely initiative, medical economics, overutilization of imaging, radiologists, radiology, socioeconomic issues, threats to radiology DOI:10.2214/AJR.13.11123 Received April 23, 2013; accepted after revision June 17, 2013. 1
Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, 132 S 10th St, Ste 1087, Philadelphia, PA 19107. Address correspondence to V. M. Rao ([email protected]).
2
HealthHelp, Inc., Houston, TX.
AJR 2014; 202:358–361 0361–803X/14/2022–358 © American Roentgen Ray Society
358
t is generally accepted that one of the causes of the high cost of medical care in the United States is the excessive and often unnecessary use of tests and procedures. Imaging has been identified as one of those categories of tests that is overused. A 2008 report by the influential group America’s Health Insurance Plans (AHIP) [1], which represents the major health insurance companies, claimed that between 20% and 50% of all advanced imaging might be unnecessary. Another influential organization, the Medicare Payment Advisory Commission [2], also expressed concern about the rapid growth in imaging in its report to the Congress in June 2011. At the 2012 Annual Meeting and Chapter Leadership Conference of the American College of Radiology (ACR), Bruce J. Hillman [3] presented a lecture on the issue of the uncritical use of imaging. Other leaders in the radiology community have commented on this issue as well [4–8]. During 2012, important initiatives were announced by two major organizations within internal medicine to try to restrict the use of unnecessary tests and procedures: One was by the American College of Physicians (ACP) and the other by the American Board of Internal Medicine (ABIM) Foundation. The ACP Initiative In January 2012, Qaseem et al. [9] reported on the first of the two initiatives. The ACP had convened a work group of experienced internists from different subspecialties. The work group was charged with developing a list of screening and diagnostic
tests that they thought are overutilized. To make the list, a test had to be chosen unanimously. The resulting list contained 37 tests, of which approximately half were imaging. Of the 37 tests, 13 are imaging tests typically performed by radiologists and another five are imaging tests typically performed by cardiologists [7]. The Choosing Wisely Initiative of the ABIM Foundation In early April 2012, the Choosing Wisely campaign of the ABIM Foundation (working in conjunction with Consumer Reports) was announced to considerable fanfare. The story was covered on the front page of the New York Times [10] and by many other news media. The ABIM Foundation brought nine other leading national medical organizations into the campaign, one of which was the ACR. Each of the nine was asked to identify five tests or procedures in its purview that it thought are overused. As might be expected, all five items chosen by the ACR were imaging tests, but so were many others chosen by the eight other organizations. Among the complete list of 45 tests [7], we found that 24 were directly related to imaging. The ACR had made a wise decision to participate in the campaign, and it garnered some favorable publicity for doing so. A few days later, a New York Times editorial [11] discussed the Choosing Wisely initiative and stated: In some cases, the groups showed admirable statesmanship by proposing cuts that would affect their incomes, as when radiologists proposed limits on various tests they perform and gastro-
AJR:202, February 2014
Downloaded from www.ajronline.org by Cornell University Library on 06/09/14 from IP address 132.236.27.217. Copyright ARRS. For personal use only; all rights reserved
The Choosing Wisely Initiative enterologists proposed limits on the frequency of colonoscopies. Since our report on the deliberations of the original nine participating organizations and their choices of imaging tests, much has happened. Over the next year, a number of other national medical organizations joined Choosing Wisely. By late February of 2013, 17 new societies had joined the original nine. All 26 organizations had chosen their five overused tests or procedures except the American Academy of Family Physicians, which chose 10. For this article, we analyzed this expanded list of 135 tests to determine how many pertain to imaging. Imaging and the Choosing Wisely Initiative For their five options, 21 of the 26 societies chose at least one imaging test that they thought was overused or was often unnecessary. Among the 135 tests or procedures on the list, 61 (45%) totally or primarily pertained to imaging. There were some duplications and overlap between the various organizations. In some instances, different terms were used to describe what was essentially the same or a very similar test. After we combined and adjusted for these redundancies, 49 discrete imaging tests remained on the list. Six were echocardiography examinations, which are performed only rarely by radiologists. Eliminating those tests left 43 imaging examinations commonly performed by radiologists. We categorized the 43 into body system categories and pediatric imaging commonly used by radiologists. The complete list of 43 is shown in Appendix 1. Eleven were cardiac, 10 were head or neck, five were pediatric, four were musculoskeletal, four were abdomen or pelvis, four were vascular, two were chest, two were breast, and one was whole body. We also show which medical organization or organizations selected each examination. Will Choosing Wisely Impact Radiology? Many radiologists are familiar with the Image Gently and Image Wisely campaigns that were launched a few years ago by the ACR, the Radiological Society of North America, and several other organizations. Those campaigns have done a valuable service to medicine in the United States and abroad by emphasizing the need to minimize radiation exposure to children and adults. But the Choosing Wisely campaign is considerably different, and we believe many ra-
diologists are not familiar with it. By identifying specific tests and procedures that are often overused, unnecessary, inappropriate, or ineffective, Choosing Wisely places the onus on physicians to reduce use. The 26 medical organizations participating in the campaign are estimated to represent 350,000 physicians [12], and it is reasonable to assume that those organizations will try to discourage their members from indiscriminate use of the tests they targeted. Momentum is building in other ways as well. In late March 2013, the ABIM Foundation and the Robert Wood Johnson Foundation announced that funding had been awarded to 21 state and specialty medical societies and a regional health collaborative to support projects aimed at reducing unnecessary tests and procedures [13]. These projects include sponsoring educational sessions for patient advocacy groups, conducting public awareness campaigns, collecting data on physician ordering patterns, developing mobile applications for physicians, and creating various web tools for both patients and physicians. The involvement of Consumer Reports guarantees widespread dissemination of the material relating to overused tests. It seems inevitable that public and physician awareness of the Choosing Wisely initiative will only grow over time. Because imaging is so prominently featured in the initiative, radiologists must carefully consider their response. The former Chief Executive Officer of the ABIM Foundation, Christine Cassel, recently stated [12]: Our goal is nothing less than a culture shift, to teach Americans that more is not always better. This culture shift will likely lead to fewer referrals to imaging facilities for examinations they frequently performed in the past, which might be seen as bad for radiologists. However, there is no question that minimizing the use of these examinations is the right thing for patients and for our health care system. Long before the advent of Choosing Wisely, Swensen and Johnson [8] pointed out that we radiologists had not done our job at controlling overutilization and that the utilization management movement grew up as a consequence. That failure also helped reinforce the perception among some that radiology is just a commodity. We should not make that mistake again. If radiologists are to truly provide value-based imaging care, we must behave
more like consulting physicians and assess the appropriateness of requests for imaging when they come in rather than just automatically doing them. Whether this goal is accomplished by educational sessions for our medical colleagues, consultations with our medical colleagues, the use of clinical decision support, or other means is beyond the scope of this article, but one way or another, we must be better gatekeepers. The ACR took the high road by participating in Choosing Wisely, and it is now up to individual radiology groups to do likewise. References 1. America’s Health Insurance Plans (AHIP). Ensuring quality through appropriate use of diagnostic imaging. Washington, DC: AHIP, 2008 2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare and the health care delivery system. Washington, DC: MedPAC, June 2011 3. Hillman BJ. Too much of a good thing! The uncritical use of medical imaging. http://amclc.acr.org/linkclick.aspx?fileticket=hr-bpkdqmby%3d&tabid=124. Accessed March 27, 2013 4. Dunnick NR, Applegate KE, Arenson RL. The inappropriate use of imaging studies: a report of the 2004 Intersociety Conference. J Am Coll Radiol 2005; 2:401–406 5. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol 2010; 7:192–197 6. Guite KM, Hinshaw JL, Ranallo FN, Lindstrom MJ, Lee FT Jr. Ionizing radiation in abdominal CT: unindicated multiphase scans are an important source of medically unnecessary exposure. J Am Coll Radiol 2011; 8:756–761 7. Rao VM, Levin DC. The overuse of diagnostic imaging and the Choosing Wisely initiative. Ann Intern Med 2012; 157:574–576 8. Swensen SJ, Johnson CD. Flying in the plane you service: patient-centered radiology. J Am Coll Radiol 2010; 7:216–221 9. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012; 156:147–149 10. Rabin RC. Doctor panels recommend fewer tests for patients. New York Times website. www.nytimes.com/2012/04/04/health/doctor-panels-urgefewer-routine-tests.html. Published April 4, 2012. Accessed April 4, 2012 11. [No authors listed]. Do you need that test? (editorial). New York Times website. www.nytimes. com/2012/04/09/opinion/do-you-really-need-that-
AJR:202, February 2014 359
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Rao and Levin medical-test.html. Published April 8, 2012. Accessed April 9, 2012 12. O’Reilly KB. Campaign on unneeded tests targets “more is better” mindset. American Medical News website. www.amednews.com/article/20130304/ profession/130309979/6/. Published March 4, 2013. Accessed March 27, 2013 13. [No authors listed]. 21 Organizations to engage phy-
sicians and patients in conversations on overuse of medical tests and procedures. ABIM Foundation News website. www.abimfoundation.org/news/ ABIM-Foundation-News/2013/ABIM-Foundationawards-grants-to-advance-choosing-wisely.aspx. Published March 21, 2013. Accessed April 2, 2013 14. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American Col-
lege of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics 2009; 124:1233–1243 15. Rome Foundation website. Rome III disorders and criteria. www.romecriteria.org/criteria/. Accessed October 10, 2013
APPENDIX 1: Imaging Tests Thought to Be Overused The following list shows imaging tests that are thought to be overused and often unnecessary by medical organizations. The organization or organizations that made these recommendations are shown for each test. Cardiac Imaging 1. Stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (American College of Cardiology [ACC], American Society of Nuclear Cardiology [ASNC]) 2. Annual stress cardiac imaging or advanced noninvasive imaging as part of the routine follow-up in asymptomatic patients. (ACC, ASNC) 3. Stress cardiac imaging or advanced noninvasive imaging for preoperative assessment of patients undergoing low-risk noncardiac surgery. (ACC, ASNC, Society of Thoracic Surgeons [STS], Society for Vascular Medicine [SVM]) 4. Cardiac imaging in patients at low risk for cardiac death or myocardial infarction based on history, physical examination, ECG, and cardiac biomarkers. (ASNC) 5. Any imaging test involving radiation when limited benefits are likely. (ASNC) 6. CT coronary calcium scoring in patients with known coronary artery disease, such as patients with a coronary stent and those with a history of coronary bypass surgery. (Society of Cardiovascular Computed Tomography [SCCT]) 7. CT coronary calcium scoring for preoperative evaluation for any surgery irrespective of patient risk. (SCCT) 8. CT coronary calcium scoring for screening of low-risk, asymptomatic individuals except those with a family history of premature coronary artery disease. (SCCT) 9. Coronary CT angiography for screening asymptomatic individuals. (SCCT) 10. Coronary CT angiography of high-risk patients presenting to the emergency department with acute chest pain. (SCCT) 11. Routine annual stress testing after a coronary revascularization procedure. (Society of Nuclear Medicine and Molecular Imaging [SNMMI]) Head and Neck Imaging 12. Sinus CT for uncomplicated rhinosinusitis. (American Academy of Allergy, Asthma & Immunology) 13. Screening for carotid artery stenosis in asymptomatic adults. (American Academy of Family Physicians [AAFP]) 14. Imaging of the carotid arteries or the brain for patients with simple syncope and no other neurologic symptoms. (American Academy of Neurology [AAN], American College of Physicians [ACP]) 15. CT of the head for sudden hearing loss. (American Academy of Otolaryngology–Head and Neck Surgery [AAO-HNS]) 16. CT or MRI of patients with hoarseness before examining the larynx. (AAO-HNS) 17. Imaging for uncomplicated headache. (American College of Radiology [ACR]) 18. Nuclear medicine thyroid scanning to evaluate thyroid nodules in patients with normal thyroid function. (SNMMI) 19. PET in the evaluation of dementia unless the patient has been assessed by a specialist in this area. (SNMMI) 20. Routine evaluation for possible carotid artery disease before cardiac surgery in the absence of symptoms or high-risk criteria. (STS) 21. Brain imaging of patients with suspected or biopsy-proven stage I non–small cell lung carcinoma in the absence of neurologic symptoms. (STS) Pediatric Imaging 22. CT of the head to evaluate minor head injuries; instead, use the Pediatric Emergency Care Guidelines [14]. American Academy of Pediatrics [AAP]) 23. CT or MRI of children with simple febrile seizures. (AAP) 24. CT in the routine evaluation of abdominal pain; consider ultrasound first to rule out appendicitis. (AAP, ACR) 25. Chest radiography of children with uncomplicated asthma or bronchiolitis. (Society of Hospital Medicine) 26. Ultrasound of boys with cryptorchidism. (American Urological Association [AUA])
(Appendix 1 continues on next page)
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APPENDIX 1: Imaging Tests Thought to Be Overused (continued) Abdominal and Pelvic Imaging 27. Screening for ovarian cancer in asymptomatic women at average risk. (American College of Obstetricians and Gynecologists) 28. Follow-up imaging for clinically inconsequential adnexal cysts < 5 cm in premenopausal women or < 1 cm in postmenopausal women. (ACR) 29. Repeat CT of patients with functional abdominal pain syndrome (per the Rome III criteria [15]) unless there is major clinical change. (American Gastroenterological Association) 30. PET, CT, or radionuclide bone scanning for staging early prostate cancer at low risk of metastasis. (American Society of Clinical Oncology [ASCO], AUA) Musculoskeletal Imaging 31. Imaging of patients with low back pain within the first 6 weeks of pain onset unless red flags are present. (AAFP, ACP) 32. Dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women < 65 years old or men < 70 years old with no risk factors. (AAFP) 33. MRI of peripheral joints to routinely monitor inflammatory arthritis. (American College of Rheumatology) 34. Routinely repeated DEXA more than once every 2 years. (American College of Rheumatology) Vascular Imaging 35. Imaging as the initial test for suspected venous thromboembolism in patients with a low pretest probability; a D -dimer test should be performed first. (ACP) 36. Imaging for suspected pulmonary embolism without a moderate or high pretest probability. (ACR) 37. Performing follow-up imaging of patients with known deep vein thrombosis in the absence of a clinical change. (SVM) 38. Screening for renal artery stenosis in patients without resistant hypertension and with normal renal function even if known atherosclerosis is present. (SVM) Chest Imaging 39. Preoperative chest radiography in the absence of clinical suspicion for intrathoracic disease or abnormality. (ACP, ACR) 40. Chest CT angiography to diagnose pulmonary embolism in young women with normal findings on chest radiography; consider ventilation-perfusion scanning instead. (SNMMI) Breast Imaging 41. PET, CT, or radionuclide bone scanning for staging early breast cancer at low risk for metastases. (ASCO) 42. PET, CT, or radionuclide bone scanning of asymptomatic women who were treated for breast cancer with curative intent. (ASCO) Whole-Body Imaging 43. PET/CT for cancer screening in healthy individuals. (SNMMI)
AJR:202, February 2014 361
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Health Care Policy and Quality Review
The Choosing Wisely Initiative of the American Board of Internal Medicine Foundation: What Will Its Impact Be on Radiology Practice? Vijay M. Rao1 David C. Levin1,2 Rao VM, Levin DC
OBJECTIVE. The Choosing Wisely initiative is a large-scale effort to reduce the use of unnecessary tests and procedures, many of which involve imaging. CONCLUSION. By identifying specific tests and procedures that are often overused, unnecessary, inappropriate, or ineffective, Choosing Wisely places the onus on physicians to reduce their use.
I
Keywords: Choosing Wisely initiative, medical economics, overutilization of imaging, radiologists, radiology, socioeconomic issues, threats to radiology DOI:10.2214/AJR.13.11123 Received April 23, 2013; accepted after revision June 17, 2013. 1
Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, 132 S 10th St, Ste 1087, Philadelphia, PA 19107. Address correspondence to V. M. Rao ([email protected]).
2
HealthHelp, Inc., Houston, TX.
AJR 2014; 202:358–361 0361–803X/14/2022–358 © American Roentgen Ray Society
358
t is generally accepted that one of the causes of the high cost of medical care in the United States is the excessive and often unnecessary use of tests and procedures. Imaging has been identified as one of those categories of tests that is overused. A 2008 report by the influential group America’s Health Insurance Plans (AHIP) [1], which represents the major health insurance companies, claimed that between 20% and 50% of all advanced imaging might be unnecessary. Another influential organization, the Medicare Payment Advisory Commission [2], also expressed concern about the rapid growth in imaging in its report to the Congress in June 2011. At the 2012 Annual Meeting and Chapter Leadership Conference of the American College of Radiology (ACR), Bruce J. Hillman [3] presented a lecture on the issue of the uncritical use of imaging. Other leaders in the radiology community have commented on this issue as well [4–8]. During 2012, important initiatives were announced by two major organizations within internal medicine to try to restrict the use of unnecessary tests and procedures: One was by the American College of Physicians (ACP) and the other by the American Board of Internal Medicine (ABIM) Foundation. The ACP Initiative In January 2012, Qaseem et al. [9] reported on the first of the two initiatives. The ACP had convened a work group of experienced internists from different subspecialties. The work group was charged with developing a list of screening and diagnostic
tests that they thought are overutilized. To make the list, a test had to be chosen unanimously. The resulting list contained 37 tests, of which approximately half were imaging. Of the 37 tests, 13 are imaging tests typically performed by radiologists and another five are imaging tests typically performed by cardiologists [7]. The Choosing Wisely Initiative of the ABIM Foundation In early April 2012, the Choosing Wisely campaign of the ABIM Foundation (working in conjunction with Consumer Reports) was announced to considerable fanfare. The story was covered on the front page of the New York Times [10] and by many other news media. The ABIM Foundation brought nine other leading national medical organizations into the campaign, one of which was the ACR. Each of the nine was asked to identify five tests or procedures in its purview that it thought are overused. As might be expected, all five items chosen by the ACR were imaging tests, but so were many others chosen by the eight other organizations. Among the complete list of 45 tests [7], we found that 24 were directly related to imaging. The ACR had made a wise decision to participate in the campaign, and it garnered some favorable publicity for doing so. A few days later, a New York Times editorial [11] discussed the Choosing Wisely initiative and stated: In some cases, the groups showed admirable statesmanship by proposing cuts that would affect their incomes, as when radiologists proposed limits on various tests they perform and gastro-
AJR:202, February 2014
Downloaded from www.ajronline.org by Cornell University Library on 06/09/14 from IP address 132.236.27.217. Copyright ARRS. For personal use only; all rights reserved
The Choosing Wisely Initiative enterologists proposed limits on the frequency of colonoscopies. Since our report on the deliberations of the original nine participating organizations and their choices of imaging tests, much has happened. Over the next year, a number of other national medical organizations joined Choosing Wisely. By late February of 2013, 17 new societies had joined the original nine. All 26 organizations had chosen their five overused tests or procedures except the American Academy of Family Physicians, which chose 10. For this article, we analyzed this expanded list of 135 tests to determine how many pertain to imaging. Imaging and the Choosing Wisely Initiative For their five options, 21 of the 26 societies chose at least one imaging test that they thought was overused or was often unnecessary. Among the 135 tests or procedures on the list, 61 (45%) totally or primarily pertained to imaging. There were some duplications and overlap between the various organizations. In some instances, different terms were used to describe what was essentially the same or a very similar test. After we combined and adjusted for these redundancies, 49 discrete imaging tests remained on the list. Six were echocardiography examinations, which are performed only rarely by radiologists. Eliminating those tests left 43 imaging examinations commonly performed by radiologists. We categorized the 43 into body system categories and pediatric imaging commonly used by radiologists. The complete list of 43 is shown in Appendix 1. Eleven were cardiac, 10 were head or neck, five were pediatric, four were musculoskeletal, four were abdomen or pelvis, four were vascular, two were chest, two were breast, and one was whole body. We also show which medical organization or organizations selected each examination. Will Choosing Wisely Impact Radiology? Many radiologists are familiar with the Image Gently and Image Wisely campaigns that were launched a few years ago by the ACR, the Radiological Society of North America, and several other organizations. Those campaigns have done a valuable service to medicine in the United States and abroad by emphasizing the need to minimize radiation exposure to children and adults. But the Choosing Wisely campaign is considerably different, and we believe many ra-
diologists are not familiar with it. By identifying specific tests and procedures that are often overused, unnecessary, inappropriate, or ineffective, Choosing Wisely places the onus on physicians to reduce use. The 26 medical organizations participating in the campaign are estimated to represent 350,000 physicians [12], and it is reasonable to assume that those organizations will try to discourage their members from indiscriminate use of the tests they targeted. Momentum is building in other ways as well. In late March 2013, the ABIM Foundation and the Robert Wood Johnson Foundation announced that funding had been awarded to 21 state and specialty medical societies and a regional health collaborative to support projects aimed at reducing unnecessary tests and procedures [13]. These projects include sponsoring educational sessions for patient advocacy groups, conducting public awareness campaigns, collecting data on physician ordering patterns, developing mobile applications for physicians, and creating various web tools for both patients and physicians. The involvement of Consumer Reports guarantees widespread dissemination of the material relating to overused tests. It seems inevitable that public and physician awareness of the Choosing Wisely initiative will only grow over time. Because imaging is so prominently featured in the initiative, radiologists must carefully consider their response. The former Chief Executive Officer of the ABIM Foundation, Christine Cassel, recently stated [12]: Our goal is nothing less than a culture shift, to teach Americans that more is not always better. This culture shift will likely lead to fewer referrals to imaging facilities for examinations they frequently performed in the past, which might be seen as bad for radiologists. However, there is no question that minimizing the use of these examinations is the right thing for patients and for our health care system. Long before the advent of Choosing Wisely, Swensen and Johnson [8] pointed out that we radiologists had not done our job at controlling overutilization and that the utilization management movement grew up as a consequence. That failure also helped reinforce the perception among some that radiology is just a commodity. We should not make that mistake again. If radiologists are to truly provide value-based imaging care, we must behave
more like consulting physicians and assess the appropriateness of requests for imaging when they come in rather than just automatically doing them. Whether this goal is accomplished by educational sessions for our medical colleagues, consultations with our medical colleagues, the use of clinical decision support, or other means is beyond the scope of this article, but one way or another, we must be better gatekeepers. The ACR took the high road by participating in Choosing Wisely, and it is now up to individual radiology groups to do likewise. References 1. America’s Health Insurance Plans (AHIP). Ensuring quality through appropriate use of diagnostic imaging. Washington, DC: AHIP, 2008 2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare and the health care delivery system. Washington, DC: MedPAC, June 2011 3. Hillman BJ. Too much of a good thing! The uncritical use of medical imaging. http://amclc.acr.org/linkclick.aspx?fileticket=hr-bpkdqmby%3d&tabid=124. Accessed March 27, 2013 4. Dunnick NR, Applegate KE, Arenson RL. The inappropriate use of imaging studies: a report of the 2004 Intersociety Conference. J Am Coll Radiol 2005; 2:401–406 5. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol 2010; 7:192–197 6. Guite KM, Hinshaw JL, Ranallo FN, Lindstrom MJ, Lee FT Jr. Ionizing radiation in abdominal CT: unindicated multiphase scans are an important source of medically unnecessary exposure. J Am Coll Radiol 2011; 8:756–761 7. Rao VM, Levin DC. The overuse of diagnostic imaging and the Choosing Wisely initiative. Ann Intern Med 2012; 157:574–576 8. Swensen SJ, Johnson CD. Flying in the plane you service: patient-centered radiology. J Am Coll Radiol 2010; 7:216–221 9. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012; 156:147–149 10. Rabin RC. Doctor panels recommend fewer tests for patients. New York Times website. www.nytimes.com/2012/04/04/health/doctor-panels-urgefewer-routine-tests.html. Published April 4, 2012. Accessed April 4, 2012 11. [No authors listed]. Do you need that test? (editorial). New York Times website. www.nytimes. com/2012/04/09/opinion/do-you-really-need-that-
AJR:202, February 2014 359
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Rao and Levin medical-test.html. Published April 8, 2012. Accessed April 9, 2012 12. O’Reilly KB. Campaign on unneeded tests targets “more is better” mindset. American Medical News website. www.amednews.com/article/20130304/ profession/130309979/6/. Published March 4, 2013. Accessed March 27, 2013 13. [No authors listed]. 21 Organizations to engage phy-
sicians and patients in conversations on overuse of medical tests and procedures. ABIM Foundation News website. www.abimfoundation.org/news/ ABIM-Foundation-News/2013/ABIM-Foundationawards-grants-to-advance-choosing-wisely.aspx. Published March 21, 2013. Accessed April 2, 2013 14. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American Col-
lege of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. Pediatrics 2009; 124:1233–1243 15. Rome Foundation website. Rome III disorders and criteria. www.romecriteria.org/criteria/. Accessed October 10, 2013
APPENDIX 1: Imaging Tests Thought to Be Overused The following list shows imaging tests that are thought to be overused and often unnecessary by medical organizations. The organization or organizations that made these recommendations are shown for each test. Cardiac Imaging 1. Stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (American College of Cardiology [ACC], American Society of Nuclear Cardiology [ASNC]) 2. Annual stress cardiac imaging or advanced noninvasive imaging as part of the routine follow-up in asymptomatic patients. (ACC, ASNC) 3. Stress cardiac imaging or advanced noninvasive imaging for preoperative assessment of patients undergoing low-risk noncardiac surgery. (ACC, ASNC, Society of Thoracic Surgeons [STS], Society for Vascular Medicine [SVM]) 4. Cardiac imaging in patients at low risk for cardiac death or myocardial infarction based on history, physical examination, ECG, and cardiac biomarkers. (ASNC) 5. Any imaging test involving radiation when limited benefits are likely. (ASNC) 6. CT coronary calcium scoring in patients with known coronary artery disease, such as patients with a coronary stent and those with a history of coronary bypass surgery. (Society of Cardiovascular Computed Tomography [SCCT]) 7. CT coronary calcium scoring for preoperative evaluation for any surgery irrespective of patient risk. (SCCT) 8. CT coronary calcium scoring for screening of low-risk, asymptomatic individuals except those with a family history of premature coronary artery disease. (SCCT) 9. Coronary CT angiography for screening asymptomatic individuals. (SCCT) 10. Coronary CT angiography of high-risk patients presenting to the emergency department with acute chest pain. (SCCT) 11. Routine annual stress testing after a coronary revascularization procedure. (Society of Nuclear Medicine and Molecular Imaging [SNMMI]) Head and Neck Imaging 12. Sinus CT for uncomplicated rhinosinusitis. (American Academy of Allergy, Asthma & Immunology) 13. Screening for carotid artery stenosis in asymptomatic adults. (American Academy of Family Physicians [AAFP]) 14. Imaging of the carotid arteries or the brain for patients with simple syncope and no other neurologic symptoms. (American Academy of Neurology [AAN], American College of Physicians [ACP]) 15. CT of the head for sudden hearing loss. (American Academy of Otolaryngology–Head and Neck Surgery [AAO-HNS]) 16. CT or MRI of patients with hoarseness before examining the larynx. (AAO-HNS) 17. Imaging for uncomplicated headache. (American College of Radiology [ACR]) 18. Nuclear medicine thyroid scanning to evaluate thyroid nodules in patients with normal thyroid function. (SNMMI) 19. PET in the evaluation of dementia unless the patient has been assessed by a specialist in this area. (SNMMI) 20. Routine evaluation for possible carotid artery disease before cardiac surgery in the absence of symptoms or high-risk criteria. (STS) 21. Brain imaging of patients with suspected or biopsy-proven stage I non–small cell lung carcinoma in the absence of neurologic symptoms. (STS) Pediatric Imaging 22. CT of the head to evaluate minor head injuries; instead, use the Pediatric Emergency Care Guidelines [14]. American Academy of Pediatrics [AAP]) 23. CT or MRI of children with simple febrile seizures. (AAP) 24. CT in the routine evaluation of abdominal pain; consider ultrasound first to rule out appendicitis. (AAP, ACR) 25. Chest radiography of children with uncomplicated asthma or bronchiolitis. (Society of Hospital Medicine) 26. Ultrasound of boys with cryptorchidism. (American Urological Association [AUA])
(Appendix 1 continues on next page)
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The Choosing Wisely Initiative
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APPENDIX 1: Imaging Tests Thought to Be Overused (continued) Abdominal and Pelvic Imaging 27. Screening for ovarian cancer in asymptomatic women at average risk. (American College of Obstetricians and Gynecologists) 28. Follow-up imaging for clinically inconsequential adnexal cysts < 5 cm in premenopausal women or < 1 cm in postmenopausal women. (ACR) 29. Repeat CT of patients with functional abdominal pain syndrome (per the Rome III criteria [15]) unless there is major clinical change. (American Gastroenterological Association) 30. PET, CT, or radionuclide bone scanning for staging early prostate cancer at low risk of metastasis. (American Society of Clinical Oncology [ASCO], AUA) Musculoskeletal Imaging 31. Imaging of patients with low back pain within the first 6 weeks of pain onset unless red flags are present. (AAFP, ACP) 32. Dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women < 65 years old or men < 70 years old with no risk factors. (AAFP) 33. MRI of peripheral joints to routinely monitor inflammatory arthritis. (American College of Rheumatology) 34. Routinely repeated DEXA more than once every 2 years. (American College of Rheumatology) Vascular Imaging 35. Imaging as the initial test for suspected venous thromboembolism in patients with a low pretest probability; a D -dimer test should be performed first. (ACP) 36. Imaging for suspected pulmonary embolism without a moderate or high pretest probability. (ACR) 37. Performing follow-up imaging of patients with known deep vein thrombosis in the absence of a clinical change. (SVM) 38. Screening for renal artery stenosis in patients without resistant hypertension and with normal renal function even if known atherosclerosis is present. (SVM) Chest Imaging 39. Preoperative chest radiography in the absence of clinical suspicion for intrathoracic disease or abnormality. (ACP, ACR) 40. Chest CT angiography to diagnose pulmonary embolism in young women with normal findings on chest radiography; consider ventilation-perfusion scanning instead. (SNMMI) Breast Imaging 41. PET, CT, or radionuclide bone scanning for staging early breast cancer at low risk for metastases. (ASCO) 42. PET, CT, or radionuclide bone scanning of asymptomatic women who were treated for breast cancer with curative intent. (ASCO) Whole-Body Imaging 43. PET/CT for cancer screening in healthy individuals. (SNMMI)
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