1. THINGS PHYSICIANS SHOULD QUESTION WWW.CHOOSINGWISELY.ORG Mary Puttmann-Kostecka, MD 3.7.13

2. Choosing Wisely Campaign  Started via ABIM grant to the National Physicians Alliance.  Created lists for internal medicine, family medicine and pediatrics  Goal is to provide care that is:  Supported by evidence  Doesn’t duplicate information  Truly necessary  Reduced harm

3. Objectives  Be able to list three studies or procedures that may be common practice but are not indicated.  Be able to explain why some of these studies are excessive.  Explain incidences where you might want to order the study or test anyways.  Apply the guidelines to clinical situations

4. Case  60yo woman comes for a well adult exam. She requests a bone scan for osteoporosis. She’s been menopausal for 11 years.  You get a TE from the mother of your 15yo patient. She has her usual sinusitis again. It’s day 3 and they want to ‘nip this in the butt’ and get antibiotics on board before it gets worse.  ….you know from past experience she’ll just go to the ED if you don’t prescribe the antibiotics…

5. AAFP

7. AAP

9. Case  38yo G3P2 @ 40 weeks by early US who has been miserable the whole pregnancy and is just done with being pregnant. It’s her due date and she really wants to be induced. You check her cervix – it’s midposition and soft, about 60% effaced and 3cm dilated, -2 station. No contractions.  Induce?

10. ACOG

11. Case  68yo lady, overweight, underwent hip surgery.  You’re paged by the RN: she’s up 10kg from baseline and tachypneic with a slightly increased O2 requirement.  You go examine her: she as crackles at the bases – you decide to diurese her with lasix  While you write the order the nurse comes by and says she has had several episodes of incontinence overnight and just can’t mobilize herself to the bathroom quickly. …..the nurse suggests a foley – at least the patient can get some sleep…….

12. Society of Hospital Medicine: Adult Medicine

13. Cases – who needs tele?  68yo woman with atrial fibrillation rate controlled on BB admitted for a COPD exacerbation.  70yo admitted for CHF exacerbation, rales and SOB on exam.  55yo male, smoker, no hyperlipidemia, crushing chest pain, admitted for rule out ACS  Patient presented with elevated troponins, NSTEMI, also found to have a diabetic ulcer and needs IV abs

14. Soc of Hosp Medicine: Adults

15. American Society for Clinical Pathology

16. Am Academy of Allergy, Asthma and Immunology

17. American Academy of Neurology

18. American Academy of Opthalmology

19. American Academy of Otolaryngology

20. American College of Physicians

21. Case  26yo patient with a simple cyst of 3cm on her left ovary incidentally discovered. Does she need a follow-up US?  60yo post-menopausal woman with a 6mm cyst found incidentally on an ED abdominal US. Does she need follow-up?

22. American College of Radiology

23. American College of Rheumatology

24. American Geriatrics Society

25. American Society of Nephrology

26. American Urological Association

27. Society for Vascular Medicine

28. References  www.choosingwisely.org www.choosingwisely.org  Drew, B. et al. “Practice Standards for Electrocardiographic Monitoring in Hospital Settings: An American heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical care Nurses. Circulation. 2004; 110:2721-2746. doi:10.1161/01.CIR.0000145144.56673.58  Greenlee, R. et all. “Prevalence, incidence and natural history of simple ovarian cysts among women over age 55 in a large cancer screening trial. Am J Obstet Gynecol. 2010 April: 202(4): 373.e1-373.e9. doi 10.1016/j.ajog.2009.11.029.  Sasaki, H et al. “Follow-up of women with simple ovarian cysts detected by transvaginal ultrasonography in the Tokyo metropolitan area. Br J Obstet Gynaecol. 1999 Mary;106(5):415-20.