Making decisions about which tests, procedures, or protocols to perform is a process that involves both the patient and the physician. But some physicians understandably struggle to talk about appropriate tests and treatments with their patients—and many patients demand care they might not need.
To foster conversations between patients and physicians about what care is really necessary, the AAOS recently released a list of five specific tests or procedures that are commonly ordered but not always necessary. The effort is part of the Choosing Wisely® campaign, an initiative of the ABIM Foundation, an organization established to advance medical professionalism into clinical practice.
“Our participation in Choosing Wisely will help shape patient-physician dialogue, which, as we all know, is the cornerstone of optimal care,” said AAOS President Joshua J. Jacobs, MD. “The AAOS has invested substantial resources in evidence-based tools such as clinical practice guidelines (CPGs) and appropriate use criteria (AUC) that reflect our expertise in caring for musculoskeletal conditions. This growing portfolio of quality products helps to define what works and what doesn’t work, based on systematic reviews of the literature.”
The Choosing Wisely lists provide targeted, evidence-based interventions to help physicians and patients have conversations about making wise choices about health care and avoiding inappropriate tests or procedures that provide little to no benefit. Each recommendation is supported by a statement that outlines the evidence base.
The Academy’s Choosing Wisely list was developed after months of careful consideration and review, using the most current evidence about management and treatment options. The final topics selected for this campaign were derived from the Academy’s previously developed CPGs. It should be noted that these are not firm recommendations that the practitioner should follow, but are topics that should be discussed with patients.
“The Choosing Wisely campaign offers the AAOS the opportunity to play a leadership role in defining appropriate care for patients with musculoskeletal disease. Our participation in this campaign demonstrates our commitment to high-quality, cost-effective, evidence-based care for our patients,” said Kevin J. Bozic, MD, MBA, chair of the AAOS Council on Research and Quality.
The five recommendations are as follow:
- We recommend against performing routine postoperative deep vein thrombosis (DVT) ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
Support statement: Since ultrasound is not effective at diagnosing unsuspected DVT and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine postoperative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.
- We recommend against the use of needle lavage to treat patients with symptomatic osteoarthritis (OA) of the knee for long-term relief.
Support statement: The use of needle lavage in patients with symptomatic OA of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling.
- We recommend against the use of glucosamine and chondroitin to treat patients with symptomatic OA of the knee.
Support statement: Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic OA of the knee.
- We recommend against the use of lateral heel wedges to treat patients with symptomatic OA of the knee.
Support statement: In patients with symptomatic OA of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as are comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from OA of the knee.
- We recommend against the use of postoperative splinting of the wrist after carpal tunnel release for long-term relief.
Support statement: Routine postoperative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes, or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.
“The Academy has shown tremendous leadership by releasing its list of tests and procedures they say are commonly done in orthopaedics, but aren’t always necessary,” said Richard J. Baron, MD, president and CEO of the ABIM Foundation. “The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what care they need, and what we can do to reduce waste and overuse in our health care system.”
To date, more than 80 national and state medical specialty societies, regional health collaboratives, and consumer partners have joined the conversations about appropriate care. Over the next year, more than 30 other specialty society partners will release Choosing Wisely lists. With the release of these new lists, the campaign will have covered more than 250 tests and procedures that the specialty society partners say are overused and inappropriate and that physicians and patients should discuss.
The Choosing Wisely campaign is also creating resources and tools, such as patient-friendly guides being developed by Consumer Reports, to help patients understand the recommendations. The materials help explain the scientific basis for decisions, describe patient options, and articulate the risks and benefits of respective tests, treatments, and procedures so that patients and physcians can engage in informed conversations.
In addition, interactive instructional modules are being developed in partnership with the Drexel University College of Medicine and specialty societies to enhance physician and patient communication.
“As orthopaedic surgeons, our duty to our patients is to restore mobility and improve their quality of life through evidence-based, high-quality treatment,” said Dr. Jacobs. “Identifying tests, procedures, or treatments that show little to no value not only helps our patients by preventing unnecessary care, but will end up saving health care dollars.”
To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit www.choosingwisely.org