'Top 5' list helps primary care doctors make wiser clinical decisions

A physician panel in the primary care specialty of internal medicine has identified common clinical activities where changes in practice could lead to higher quality care and better use of finite clinical resources.

The study identifying the Top 5 list of activities appears online in the Archives of Internal Medicine.

"Our aim was to come up with a list of best practices via consensus from actual practitioners, said Jeffrey R. Jaeger, MD, FACP, associate professor of Internal Medicine in the Perelman School of Medicine at the University of Pennsylvania, who led the internal medicine panel which produced the list of the top five recommendations in that specialty. "These practices deliver superior patient care while at the same time save resources by eliminating unnecessary testing and procedures."

"Top 5" List for Internal Medicine

1. Don't Overimage: Don't do imaging for low back pain within the first six weeks unless red flags are present.
is the fifth most common reason for all physician visits. Imaging of the lumbar spine before six weeks does not improve outcomes but does increase costs. Red flags include severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.

2. Don't Overscreen: Don't obtain blood chemistry panels (e.g. CMP, SMA-7, and BMP) or urinalyses for screening in asymptomatic, healthy adults.
Only lipid screening yielded significant numbers of positive results among asymptomatic patients, physicians should screen for in asymptomatic adults with hypertension

3. Don't Over-order Cardiac Tests: Don't order annual electrocardiograms or any other cardiac screening for asymptomatic, low-risk patients.
There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for improves health outcomes. Moreover, false-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis.

4. Use Generic Statins: Use only generic statins when initiating lipid-lowering drug therapy.
All statins are effective in decreasing mortality, heart attacks, and strokes when dosage is titrated to effect appropriate LDL-cholesterol reduction. Physicians should switch to more expensive brand-name statins such as Lipitor or Crestor only if generic statins cause clinical reactions or do not achieve LDL-cholesterol goals.

5. Limit use of bone density scans to older patients, when appropriate: Don't use Dual Energy X-ray Absorptiometry (DEXA) screening for osteoporosis in women under age 65 or men under 70 with no risk factors.
DEXA is a means of measuring bone mineral density. The DEXA scan is typically used to diagnose and follow osteoporosis. It is not cost effective in younger, low-risk patients, but is cost effective in older patients. Risk factors include fractures after age 50, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, and a thin and small build.

The research is based on the premise that physicians can best adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. It grew out of a National Physicians Alliance project entitled "Promoting Good Stewardship in Clinical Practice" that aimed to develop a list of the "Top 5" activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved and resources saved.

In the study, working groups of NPA members in each of the three primary care specialties generated preliminary lists of "best practice" activities in their respective fields. A total of 255 internal medicine specialists were then asked to rank the top five activities identified by the internal medicine panel. In addition, they were given the opportunity to add their own recommendations that were not on the initial list.

Field-testing that identified the recommendations was carried out under the auspices of the National Physicians Alliance, the nation's leading community of physicians promoting civic engagement for its members. All "Top 5" lists are published together in the May 22 issue of the .

More information: Arch Intern Med. 2011; doi:10.1001/archinternmed.2011.231

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