II. Resources
- Clinical Practice Guidelines (NIH)
- National Guideline Clearinghouse (AHRQ)
- Institute of Medicine's Report Clinical Practice Guidelines We Can Trust (IOM)
- Practice Guideline Articles (AAFP)
- Emergency Care Research Institute Guidelines Trust (ECRI)
III. Precautions: Guideline Pitfalls
- Focused Interpretation
- Guideline development focuses on improvement of specific outcomes, with less focus on other related outcomes
- Guidelines should improve patient-oriented outcomes including harms versus benefits
- Speculation
- Expert opinion is inserted when evidence is lacking
- Guidelines should be based on systematic review of the research data, and graded with strength of evidence
- Extrapolation
- Recommendations are extrapolated beyond the original research focus
- Limited Representation
- Lack of stakeholder representation in the guideline development
- Key stakeholders (e.g. specialties, patients, payers, public health) should be involved in guideline development
- Oversimplification
- Guidelines may ignore nuances of confounding factors (disease severity, age, gender, comorbidity)
- Guidelines should apply to the patient population being treated
- Over-complication
- Guidelines are too complicated to reliably implement, with exceptions and numerous sub-pathways
- Recommendations should be clear and actionable
- Economically Unfeasible
- Costs of implementation (or the conflicts of interest by developers) may not be fully addressed
- Guideline development should not be industry sponsored and free of financial conflict of interest
- References
IV. Precautions: Emergency Medicine (Choosing Wisely)
- Minor Head Trauma imaging
- Avoid Head CT in minor Head Trauma when validated decision rules triage the patient to low risk
- Indwelling Urinary Catheters (Foley Catheters)
- Limit use to monitoring Urine Output in critically ill patients, urine obstruction, perioperative state and End-Of-Life Care
- Avoid indwelling Urinary Catheter in stable, voiding patients
- Not indicated for Urine Output monitoring in stable patients (void into measure container)
- Not indicated for convenience
-
Palliative Care and Hospice
- Engage Palliative Care and Hospice early when indicated in chronic disease or End-Of-Life Care
-
Skin Abscess management
- Avoid Antibiotics and wound cultures for uncomplicated skin and Soft Tissue Abscesses
- Assumes definitive Incision and Drainage and appropriate follow-up
-
Pediatric Dehydration Management
- Oral Rehydration Therapy should be the first-line intervetion in mild to moderate Pediatric Dehydration
- Intravenous replacement should be reserved for those who fail oral rehydration
- References
V. Precautions: Family Medicine (Choosing Wisely)
-
Low Back Pain imaging
- Avoid imaging in the first 6 weeks in uncomplicated Low Back Pain without red flags
-
Acute Sinusitis
Antibiotic management
- Avoid Antibiotics in mild to moderate Acute Sinusitis until >7 days of symptoms or symptom worsening after initial improvement
-
Osteoporosis Screening with DEXA Scan
- Delay DEXA Scan until age 65 years in women, 70 years in men unless Osteoporosis Risk Factors dictate otherwise
- Cardiac screening in asymptomatic, low risk patients
- Avoid cardiac screening (Electrocardiogram, stress test) in asymptomatic, low risk patients
-
Cervical Cancer Screening indications (Pap Smear and HPV screening)
- Avoid Pap Smear in women under age 21 years or following Hysterectomy for benign cause
- Avoid Pap Smear in women over age 65 years who had prior adequate prior screening and not high risk for Cervical Cancer
- Avoid HPV screening (with or without cytology) in women under age 30 years
-
Labor Induction and Cesarean Section scheduling
- Avoid scheduled Labor Induction or C-Section prior to 39 weeks unless medically indicated
-
Carotid Stenosis screening
- Avoid Carotid Artery Stenosis screening in asymptomatic patients
-
Otitis Media
Antibiotics
- Observation is the preferred protocol in children ages 2-12 years with non-severe Otitis Media symptoms, and other observation criteria met
-
Pediatric UTI imaging
- Avoid Voiding Cystourethrogram (VCUG) in children ages 2-24 months, with first febrile Urinary Tract Infection (UTI)
-
Prostate Cancer Screening
- Avoid universal Prostate Cancer Screening with Prostate-specific Antigen (PSA) test or Digital Rectal Exam
- Prostate Cancer Screening when performed should be accompanied by Informed Consent of risks and benefits
-
Scoliosis Screening
- Avoid screening asymptomatic teens for Idiopathic Scoliosis
-
Oral Contraceptive Prescribing
- Blood Pressure Measurements and medical history alone are sufficient to provide Oral Contraceptive prescriptions
- Avoid requiring pelvic exam or physical exam prior to writing for Oral Contraceptive medications
- References
VI. Resources
- ABIM Choosing Wisely Site