Top 5 Recommendations for Improving Primary Care Issued Today by National Physicians Alliance

The National Physicians Alliance (NPA), an organization of 22,000 physicians in the U.S., has developed and issued today, three lists of “Top 5″ recommended changes in common clinical practices in primary medicine. They say, based on scientific literature and professional opinion of the participating physicians, that these changes could improve care, lower risks for patients, and lower costs. The three “Top 5″ Lists issued today relate to three primary care specialties: family medicine, internal medicine, and pediatrics.

The “Top 5″ Lists in Primary Care were published today in the May 23, 2011 issue of the Archives of Internal Medicine, a journal of the American Medical Association.

The “Top 5″ Lists to Improve Primary Care

Here are the lists of The Top 5 Recommended Changes in clinical practice issued by NPA for Family Medicine and Internal Medicine, as published in the Archives of Internal Medicine today:

Top 5 List in Family Medicine:

1. Don’t do imaging for low back pain within the first 6 weeks unless red flags∗ are present

• Imaging of the lumbar spine before 6 weeks does not improve outcomes but does increase costs
• Low back pain is the fifth most common reason for all physician visits
Red flags include but are not limited to severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected
Sources: AHCPR and Cochrane

2. Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions AND maxillary pain or facial or dental tenderness to percussion) last for 7 or more days OR symptoms worsen after initial clinical improvement

• Most maxillary sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own
• Despite consistent recommendations to the contrary, antibiotics are prescribed in over 80% of outpatient visits for acute sinusitis
• Sinusitis accounts for 16 million office visits and $5.8 billion in annual healthcare costs
Source: Cochrane and Ann IM

3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients

• Little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes
• False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment, and misdiagnosis
• Potential harms of this routine annual screening exceed the potential benefit
Source: USPSTF

4. Don’t perform Pap tests on patients younger than 21 years or in women status post hysterectomy for benign disease

• Most dysplasia in adolescents regresses spontaneously; therefore, screening Pap tests done in this age group can lead to unnecessary anxiety, morbidity, and cost
• Pap tests have low yield in women after hysterectomy (for benign disease), and there is poor evidence for improved outcomes
Sources: ACOG (for age), USPSTF (for hysterectomy)

5. Don’t use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors∗

• Not cost-effective in younger, low-risk patients, but cost-effective in older patients
Risk factors include but are not limited to fractures after age 50 years, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking,
alcoholism, thin and small build
Sources: NOF, USPSTF, AACE, ACPM

Top 5 List in Internal Medicine:

1. Don’t do imaging for low back pain within the first 6 weeks unless red flags are present

• Imaging of the lumbar spine before 6 weeks does not improve outcomes but does increase costs
• Low back pain is the fifth most common reason for all physician visits
Red flags include but are not limited to severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected
Sources: AHCPR and Cochrane

2. Don’t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in asymptomatic, healthy adults

• Only lipid screening yielded significant numbers of positive results among asymptomatic patients
• Screen for type 2 diabetes mellitus in asymptomatic adults with hypertension
Source: USPSTF

3. Don’t order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients

• Little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes
• False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis
• Potential harms of this routine annual screening exceed the potential benefit
Source: USPSTF

4. Use only generic statins when initiating lipid-lowering drug therapy

• All statins are effective in decreasing mortality, heart attacks, and strokes when does is titrated to effect appropriate LDL cholesterol reduction
• Switch to more expensive brand-name statins (atrovastatin [Lipitor] or rosuvastatin [Crestor]) only if generic statins cause clinical reactions or do not achieve LDL
choleste rol goals
Sources: CURVES12 and MERCURY 13 trials and metanalyses

5. Don’t use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors∗

• Not cost-effective in younger, low-risk patients, but cost-effective in older patients
Risk factors include but are not limited to fractures after age 50 years, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking,
alcoholism, thin and small build
Sources: NOF, USPSTF, AACE, ACPM

The Top 5 List for Pediatrics is available, along with the full NPA report on The “Top 5″ Lists in Primary Care, in the May 23, 2011 issue of the JAMA journal, Archives of Internal Medicine.

As illustrated above, three of the recommendations (nos. 1, 3 and 5 in the lists above) overlap for Family Medicine and Internal Medicine.

Who Developed the “Top 5″ Lists and How they were Developed

The “Top 5″ Lists were developed by working groups of physicians in the three listed specialties from such institutions as Johns Hopkins School of Medicine, University of California, University of Pennsylvania School of Medicine, Stanford University School of Medicine, the Medical School of Brown University, University of Connecticut School of Medicine, University of Maryland School of Medicine, Case Western Reserve School of Medicine, Cleveland, University of Colorado Health Sciences Center, and others, as part of a NPA-sponsored project called “Promoting Good Stewardship in Clinical Practice.” Funding for the project was provided by the American Board of Internal Medicine Foundation.

Three working groups of 15 physicians each, in the specialties of family medicine, internal medicine, and pediatrics, developed the initial drafts of the Top 5 lists, with the assistance of research assistants who validated the scientific evidence for or against the changes in practices recommended by the physicians. The initial lists were then submitted, by specialty, to a group of 83 physicians for initial testing. After modification based on the initial feed-back, the revised lists were submitted to a larger group of 172 physicians in the respective specialties, for final testing.

The testing physicians rated the recommended changes in clinical practice on the lists on a five point scale as to (i) extent that the recommended change in practice would improve quality of care either by improved outcomes or lowered patient risk, (ii) the strength of the scientific evidence in medical literature supporting the recommended change, (iii) the extent that the recommended change in practice would lower costs, and (iii) the ease or difficulty of implementing the suggested change in their own practice.

With one exception, where initial testing resulted in changing one of the recommendations in the family medicine area, all of the recommendations of the initial working groups received majority support of all of the testing physicians.

During the development of the Top 5 lists, Dr. Stephen R. Smith, lead author and principal investigator for the project, who is a professor and former dean at Warren Alpert Medical School of Brown University, and serves on the board of directors and as treasurer of NPA, wrote an article, “Top 5″ Lists for Good Stewardship in Primary Care,” published in the November 14, 2010 issue of Primary Care Progress Notes, in which he recounted the personal impact the Top 5 lists were having in his medical practice as a primary care physician.

“I can vouch for the impact these lists have on physician behavior,” Dr. Smith wrote. “Since helping to create the lists, I find myself changing my practice to adhere to the recommendations, for example by not ordering routine blood chemistries on low-risk patients. I also feel more confident in continuing to do what I’ve always done, for example not prescribing antibiotics for pharyngitis unless the patient tests positive for strep.”

Cautions

The NPA report issued today indicates that these Top 5 Lists are intended for use by physicians, and cautions that “the items generated by the 3 working groups reflect the opinions of the physicians serving on the working groups.” “A different group of physicians might have elaborated a different list.” The report further cautions that “a larger sample of physicians selected to reflect the demographic characteristics of the specialties might have responded differently to the survey questions.”

Next Steps

The NPA report states that the Top 5 Lists will be distributed to all NPA physicians in the referenced primary care specialties, and the NPA will support physicians’ efforts to implement the recommended changes in their practices.

As part of the planned activities to support implementation of the changes, NPA will produce training videos both for physicians and for patients.

“Videos will also be produced specifically for patients, explaining the rationale for the recommendations by clarifying that risks outweigh benefits, and the link between overutilization and increases in insurance premiums,” the report states.

More Information

The full report, The “Top 5″ Lists in Primary Care, is available in the May 23, 2011 issue of the Archives of Internal Medicine, a journal of the American Medical Association.

For more information about the National Physicians Alliance (NPA) and its ““Promoting Good Stewardship in Medicine” project, see the NPA website.

For news and information about issues concerning Health Care Reform, see our VoicesForCare™ section.

For links to information about common medical conditions faced by Seniors and related matters see our resource pages on:

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Copyright © 2011 Care-Help LLC

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