Back Doctors Not “Choosing Wisely” When It Comes to Spinal Imaging

AbstractObjectivesChoosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians’ (CAEP) top five list of recommendations, and the process undertaken to generate them.MethodsThe CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus.ResultsThe top five CAEP CWC recommendations are: 1) Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.ConclusionsThe CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

Download Full-text

P091: Lumbosacral spinal imaging and narcotic prescription for patients presenting to the emergency department with non-traumatic low back pain

CJEM ◽

10.1017/cem.2019.282 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S96

Author(s):

L. Berezin ◽

C. Thompson ◽

V. Rojas-Luengas ◽

B. Borgundvaag ◽

S. McLeod

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Tertiary Care ◽

Traumatic Injury ◽

Cauda Equina ◽

Choosing Wisely ◽

First Episode ◽

Low Back ◽

Spinal Imaging ◽

Chronic Use

Introduction: Choosing Wisely Canada guidelines suggest that in the absence of red flags or clinical indicators suggestive of serious underlying conditions, physicians should not order radiological images for patients presenting with non-specific low back pain, and current recommendations do not endorse routine prescribing of opioids for this condition. The objective of this study was to determine how many patients presenting to the ED with non-traumatic low back pain have spinal imaging and how many are discharged home on opioids. Methods: We conducted a retrospective medical record review for adult (>17 years) patients presenting to an academic tertiary care ED with non-traumatic low back pain from April 1st 2014 to March 31st 2015 (pre-guideline) and April 1st 2017 to March 31st 2018 (post-guideline). Patients were excluded if they were >70 years old, were not discharged home, had a traumatic injury, features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, first episode of low back pain over 50 years of age, abnormal reflexes, loss of motor strength or loss of sensation in the legs. Results: 1060 (545 pre-guideline, 515 post-guideline) were included. Mean (SD) age was 39.6 (12.3) years and 549 (51.8%) were female. Pre-guideline, 45 (8.3%) patients had spinal imaging, compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% CI: −2.6% to 4.0%). Of the 84 (7.9%) patients who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline, compared to 10 (25.6%) patients post-guideline. The proportion of patients discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines (40.9% vs. 11.1%; Δ29.8%; 95% CI: 24.8% to 34.7%). Conclusion: Choosing Wisely Canada guidelines did not appear to alter the rate of imaging for patients presenting to the ED with non-traumatic low back pain. Overall the rate of spinal imaging was lower than expected. The proportion of patients who were discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines, however we don't know if this represents an overall trend in the reduction of opioid prescribing, or a specific change in practice related to the ED management of low back pain.

Download Full-text

Inwiefern werden Negativ-Kriterien (Choosing Wisely) bereits in der geburtshilflichen Praxis berücksichtigt?

10.1055/s-0037-1607645 ◽

2017 ◽

Author(s):

L Schradin ◽

N Timmesfeld ◽

B Misselwitz ◽

B Arabin

Keyword(s):

Choosing Wisely

Download Full-text

Klug entscheiden in der Rheumatologie

Arthritis und Rheuma ◽

10.1055/s-0037-1617734 ◽

2016 ◽

Vol 36 (06) ◽

pp. 402-406 ◽

Cited By ~ 4

Author(s):

M. Lakomek ◽

Ch. Specker ◽

H.-J. Lakomek

Keyword(s):

Rheumatoide Arthritis ◽

Deutsche Gesellschaft ◽

Choosing Wisely ◽

Innere Medizin ◽

Eine Hohe ◽

Typ 2 Diabetes ◽

International Medicine

ZusammenfassungIn Anlehnung an die amerikanische “Choosing wisely”-Initiative des American Board of International Medicine (ABIM-Foundation) aus dem Jahr 2012 hat die Deutsche Gesellschaft für Innere Medizin (DGIM) mit zwölf weiteren internistischen Schwerpunkt- bzw. assoziierten Fachgesellschaften und der AWMF im Jahr 2015 fachgebietsbezogene Gesundheitsbereiche mit einer Fehlversorgung identifiziert. Auch die Deutsche Gesellschaft für Rheumatologie hat hier jeweils fünf fachbezogene Aspekte der Unter- und Überversorgung beschrieben. Dies war Anlass für die Autoren, beispielhaft zu jeweils einer Positiv- (Unterversorgung) und einer Negativ-Empfehlung (Überversorgung) Stellung zu nehmen, um die Wichtigkeit der “Klug entscheiden”-Initiative für die akutstationäre Rheumatologie aufzuzeigen. Am Beispiel der Positiv-Empfehlung (+) “Das kardiovaskuläre Risikoprofil von Patienten mit entzündlich rheumatischen Erkrankungen soll bestimmt und ggfs. reduziert werden” wird für die rheumatoide Arthritis die Bedeutung der Beachtung dieser Komorbidität aufgezeigt. Zur Unterstützung einer hohen Behandlungsqualität ist die Diagnose einer Komorbidität wie die des metabolischen Syndroms und des Typ-2-Diabetes nicht nur für die Bewertung des kardiovaskulären Risikos von Menschen mit rheumatischen Erkrankungen äußerst wichtig, sondern es kann z. B. durch Veränderung des Lebensstils und die Auswahl bestimmter Immunsuppressiva auf die sich durch die Komorbidität ergebende Prognose, z. B. bei der rheumatoiden Arthritis, positiv Einfluss genommen werden. Am Beispiel der Negativ-Empfehlung (−) “Eine längerfristige Glukokortikoidtherapie mit einer Dosis von mehr als 5 mg/die Prednisonäquivalent soll nicht durchgeführt werden” – wird die Richtigkeit der vorgeschlagenen Zielsetzung mit dem ergänzenden Hinweis aufgezeigt, bei Absenkung einer längerfristigen Glukokortikoidtherapie auf das mögliche Vorliegen einer sekundären Nebennierenrindeninsuffizienz zu achten. Die Initiative “Klug entscheiden” auch in der Rheumatologie passt gut in den Kontext der aktuellen gesundheitspolitischen Aktivitäten, über die sektorale Patientenversorgung in Deutschland eine hohe Behandlungsqualität abzusichern.

Download Full-text