A time-honored medical practice was called into question last month when the US Preventive Services Task Force (USPSTF) issued draft guidance stating that there is insufficient evidence to recommend the routine use of pelvic examinations in asymptomatic, nonpregnant women. This leads us to ask: What other ubiquitous medical practices don't stand up to the evidence? Here are five common practices that some groups claim are no longer necessary. Do you agree that it's time to retire them? Tell us below. 1) Pelvic Exams During Routine Ob/Gyn Visits What does the evidence say? The USPSTF did their first-ever evidence review on routine pelvic exams and foundno studies evaluating the benefit of pelvic exam screening on all-cause mortality, disease-specific morbidity or mortality, or quality of life. The task force concluded that there isn't enough evidence to recommend screening pelvic exams in asymptomatic women for conditions other than cervical cancer screening, gonorrhea, and chlamydia. And last year, the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) both released guidelines advising against screening pelvic exams in asymptomatic, nonpregnant adult women. According to the ACP, routine pelvic exams aren't useful in screening for malignancies other than cervical cancer, may generate unnecessary evaluation and surgery, and can cause discomfort in women, leading them to forego gynecologic care.[1,2] Who defends this practice? The American College of Obstetricians and Gynecologists (ACOG) recommends annual pelvic examinations for patients 21 years of age or older. However, in a recent statement, ACOG president Thomas Gellhaus, MD, said that the society is reviewing the USPSTF recommendations and that the "limitations of the internal pelvic examination for screening should be recognized."[3]According to the statement, the women most likely to benefit from pelvic exams are those with possible genital tract problems, menstrual disorders, vaginal discharge, incontinence, infertility, or pelvic pain. What's actually being practiced? Most ob/gyns (98.4%) and general practitioners (89.5%) said they perform pelvic examinations during well-woman visits, according to a 2011 survey.[4] Is there a middle ground? Medscape expert commentator Andrew M. Kaunitz, MD,explained that while pelvic exams are not a good way to detect ovarian cancer, they are effective for picking up other irregularities, like pelvic prolapse and cervical polyps. He recently said that he continues to offer them to patients during well-woman visits, but for symptom-free patients in their 20s, he only performs pelvic examinations when indicated for cervical cancer screening. 2) Exercise Stress Tests for heart disease What does the evidence say? A 2012 USPSTF report determined that asymptomatic, low-risk adults should not be regularly screened for coronary artery disease with resting or exercise ECG. It also concluded that the current evidence is insufficient to assess the benefits and harms of using resting or exercise ECG to predict coronary heart disease in intermediate or high-risk patients. These recommendations, however, are currently under review.[5] Additionally, last year the ACP released an article urging recommending against routine testing for heart disease in asymptomatic, low-risk adults. Instead, the ACP encourages practitioners to promote lifestyle changes, such as regular exercise and healthy diets, to help patients reduce their risk for cardiac symptoms.[6] Who defends this practice? In an expert commentary published on Medscape in 2013, Thomas Allison, PhD, explained that stress testing has utility in certain cases. He discussed how oxygen treadmill exercise testing is a highly useful tool in distinguishing causes and types of cardiovascular disease in potential surgical candidates, but it may not be as useful for patients with some types of structural heart disease. What's actually being practiced? A 2010 Consumer Reports survey found that out of 1200 healthy respondents between the ages of 40 and 60 years, 39% had gotten an ECG and 12% had taken an exercise stress test during a period of 5 years.[7] Is there a middle ground? Even though exercise stress tests aren't completely foolproof, they can help detect chest pain and highlight appropriate courses of action for high-risk patients such as elderly men, says Harvard Medical School professor Deepak Bhatt, MD. Dr Bhatt specifically recommends the exercise stress test for sedentary older men looking to begin intensive exercise regimens.[8] Cardiologist Vladimir Vekstein, MD, agrees that stress tests may be appropriate when symptoms are present or when patients have particular predispositions to coronary artery disease or diabetes, or have a family history.[9] 3) Chest X-Rays Before Surgery What does the evidence say? The American College of Radiology (ACR) 2015 guidelines recommend against preoperative chest x-rays for average-risk patients. According to an ACR recommendation released as part of Choosing Wisely®, an ABIM Foundation campaign to identify uneconomical medical practices, only 2% of these x-rays initiate changes in treatment.[10-12] Similarly, the American Society of Anesthesiologists (ASA) concluded in their 2002 guidelines that routine preoperative testing has little value in patient management during the surgical process.[13] Studies published by the ACP and the AAFP also support the position that chest x-rays should not be routinely administered before noncardiac surgeries.[14,15] Who defends this practice? Routine chest x-rays are recommended by the American Heart Association for severely obese patients at risk for heart problems. Research shows that chest x-rays should also be done in patients over 60 or in those with potential heart or lung disease risk. This is because the chance of abnormal chest x-ray findings increases in older age. What's actually being practiced? Use of chest x-rays is high: 92% of patients had undergone one in the past quarter of the study period, according to a 2015 JAMA Internal Medicine study that examined rates of usage for various preoperative tests identified by Choosing Wisely.[16] Is there a middle ground? Although there is widespread agreement in the field that preoperative chest x-rays are unproductive for routine use, patients with some specific risk factors may benefit from them. The Institute for Clinical Systems Improvement's 2014 protocol recommended chest x-rays for surgical patients with new or unstable symptoms of cardiopulmonary disease.[17] The ASA also acknowledges that preoperative chest x-rays should be considered in patients who smoke or have symptoms of cardiac disease, COPD, or upper respiratory infection because x-rays may be more helpful in illuminating abnormalities. Still, the ASA clarifies that this does not mean that preoperative x-rays should be endorsed for routine use in average-risk patients.[13] 4) CT Scans for Headaches and Concussions What does the evidence say? In a 2014 JAMA study, researchers identified head CTs for headaches that don't meet certain severity criteria as one of the top five emergency medicine practices with little clinical value.[18] The ACR also included CTs for regular headaches on their list of practices to question, published in 2012 as part of Choosing Wisely. The ACR's Appropriateness Criteria specifically say that routine neuroimaging is "usually not warranted" even if headaches are chronic. They refer to the potential for false-positive results and the low yield of useful findings of CT scans for typical headaches with no concurrent neurologic symptoms.[19] The American Academy of Neurology and the American Headache Society also released a summary in 2014[20] in which they state that the majority of patients affected by headache pain do not need imaging tests. The European Federation of the Neurological Societies recommends the same.[21] Who defends this practice? Some data indicate that head CTs are effective in dispelling concerns of serious underlying conditions. A meta-analysis published this year in Stroke[22] demonstrated that for patients who have severe headaches known as thunderclap headaches, but show typical neurologic makeups, CT scans are extremely sensitive in ruling out subarachnoid hemorrhage when conducted within 6 hours of onset. What's actually being practiced? Clinicians order scans in 12% of headache cases, according to a 2014 study in JAMA Internal Medicine.[23] These high rates of usage cost the United States almost $1 billion per year, summing to a total of $3.9 billion over a 4-year period. In a study on mild traumatic brain injury published in 2014 by Gupta and colleagues,[24] over half of the 1.2 million patients studied who presented to emergency rooms with mild traumatic brain injuries underwent head CTs. The researchers found that one quarter of these were still deemed inappropriate even when physicians used clinical decision support technology to guide decision-making according to evidence. Another study, by Melnick and colleagues,[25] investigated qualitative reasons for this overuse. They determined that "human" factors such as patient anxiety, provider experience level, and time limitations often dictate scanning decisions. Is there a middle ground? According to clinical policy developed by the American College of Emergency Physicians and the CDC, head CTs are appropriate in certain cases of mild traumatic brain injury. According to that policy statement, patients should get head CTs if they have lost consciousness or memory and have additional symptoms such as headache or vomiting.[26] 5) Carotid Artery Ultrasounds to Assess Stroke Risk What does the evidence say? The USPSTF recommends against screening asymptomatic people for stroke risk with carotid artery ultrasound. Their report states that using ultrasonography often leads to false-positive results despite a prevalence rate of only 0.5%-1% for this type of stenosis in the general population. Additionally, the recommendation cites evidence that ultrasound screening can cause harm in the form of unneeded and invasive follow-up tests.[27] The AAFP and the Society for Vascular Surgery also recommend against the routine use of carotid artery ultrasound in asymptomatic people to assess stroke risk. According to their recommendation, the general population faces less than a 2% risk for adverse neurologic events from asymptomatic severe carotid artery disease.[28,29] A recent JAMA Internal Medicine study corroborates these recommendations. The study categorized 11.3% of the imaging tests for carotid artery screening tests done in a large sample of asymptomatic patients over 65 years old as inappropriate.[30] Who defends this practice? The American Heart Association's 2011 guidelines on screening of patients with varying risk factors, issued in conjunction with the American College of Cardiology and several other societies, recommends performing a routine ultrasound on people who have known or suspected carotid artery stenosis, even if they aren't exhibiting symptoms. They also suggest ultrasonography for patients with other types of artery disease, like atherosclerosis, or those with relevant risk factors.[31] What's actually being practiced? According to an analysis of Medicare claims from 2009, 5%-6% of a sample of 1.4 million beneficiaries underwent imaging tests for carotid artery stenosis despite lacking symptoms. This equates to between 1.3 and 1.6 million people in the total Medicare population who are asymptomatic but still get annual screenings.[32,33] Is there a middle ground? In an article published on Medscape earlier this year, lead researcher of the JAMA study, Salomeh Keyhani, MD, said that conflicting guidelines on the subject have created widespread overuse. In the article, David Spence, MD, told Medscape that carotid imaging should be employed only to fulfill specific goals, such as "enhancing medical management of atherosclerosis, not for the purpose of finding victims for appropriate carotid endarterectomy or stenting." Source
