Choosing Wisely®: Five More Things Physicians and Patients Should Question

As obstetrician-gynecologists, we understand the importance of providing safe, high quality care for our patients. But as the nation focuses on better ways to provide this care, the overuse of resources is an issue of considerable concern and many experts agree that the current way health care is delivered in this country contains too much waste and inefficiency. It’s crucial that providers across all specialties and patients work together to have conversations about wise treatment decisions. That’s why ACOG is a proud partner of Choosing Wisely®, a campaign led by the American Board of Internal Medicine (ABIM) Foundation, with a goal of advancing a national dialogue on avoiding unnecessary medical tests, treatments and procedures.  The key word here is “unnecessary.”

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The Easy Way to Keep Up with Advances in Practice

In a perfect world, ACOG’s evidence-based practice guidelines would be issued and physicians would instantly start to incorporate them into practice, allowing patients to quickly begin reaping the benefits of the newest, most relevant research. In reality, changes in practice don’t happen overnight and it can take a while until new recommendations are widely adopted. A recent study on oophorectomy, or ovary removal, at the time of hysterectomy suggests that physicians haven’t caught up with ACOG’s current practice guidance. Previous studies have found the same to be true for other recommendations such as breast cancer screening, bed rest during pregnancy, HPV vaccination, and Pap screenings.

A major component of improving the care we provide our patients is using the latest scientific research findings and medical advances in daily practice. Ob-gyns on the front line of research and patient-care serve on the ACOG committees that develop our practice guidelines. When necessary, committees call on the assistance of additional subject area experts to enrich the recommendations and ensure that the most recent and relevant data are included. The result: solid, evidence-based clinical guidelines. However, the widespread adoption of new guidance can be challenging.

Besides those who disagree with what we’re recommending, there are also people who aren’t aware of new guidance or who prefer to take a wait-and-see approach. Confusion about new recommendations contributes to slow acceptance, as can complex recommendations that make it hard for doctors to choose how they will treat or screen for certain conditions. No matter the reason, not following the latest guidelines can deprive our patients from receiving the best contemporary care.

ACOG guidelines are not mandates, and there are no ACOG police that enforce their use. However, staying abreast of new research, recommendations, and standards of care is the hallmark of engaged and committed professionals. We owe it to our patients to be up to date on discussions that may affect their health care.

I know that in busy practices, it can be challenging to keep up with research. I urge Fellows to read through new guidelines as they are issued each month in the Green Journal. If you find yourself with guideline-related questions, ACOG’s Practice Division available to assist you.

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With Routine Medical Tests and Procedures, Choose Wisely

Hal C. Lawrence III, MD, ACOG Vice President, speaking during the press briefing.

Hal C. Lawrence III, MD, ACOG Executive Vice President, speaking during the press briefing.

Open lines of communication are the basis of successful doctor-patient interactions. However, when it comes to medical tests and procedures, doctors and patients alike can easily slide into cruise control without taking the time to discuss what’s truly needed, appropriate, supported by evidence-based research, and in the best interest of the patient’s care.

With this in mind, ACOG has teamed up with the Choosing Wisely campaign—an initiative that aims to spark a conversation about commonly performed tests and exams in different areas of medicine. By taking a critical eye to routine health care practices, we can make better decisions on how to provide thorough and comprehensive care while avoiding unnecessary, redundant, or even risk-increasing procedures.

Today, at a joint press conference with 16 other partnering organizations, ACOG made the following recommendations:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average–risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems and to have appropriate screening with consideration of a pelvic examination.

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average–risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

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What’s Up, Doc?

Sometimes it seems you can’t go more than a few weeks without hearing about a medical organization changing recommendations about a particular health screening regimen or a tried-and-true treatment. From mammograms to prostate exams—not to mention the endless advice on which new or old medicines to take or avoid—it happens in every area of health and medicine. Just this week, two organizations released new advice on how often women should be screened for cervical cancer.

Each time a standard recommendation changes, I can expect a flurry of questions from my patients. The most common question is “Why should I switch from doing something that I know (eg, get a Pap test every year) to something that’s so different (eg, wait three to five years between cervical screenings)?” The answer will vary depending on the specific test or the recommendations involved, but it often comes down to the same concept: evidence-based medicine.

Evidence-based medicine combines research findings on how a disease works with real-life data and feedback on how that disease—and patients—respond to certain prevention and treatment strategies. This evidence provides a more complete picture of how a disease is best handled. Medical organizations like ACOG use it to develop practice recommendations and physicians rely on it as the foundation for how we treat patients.

Because new information is always being discovered, health recommendations need to be routinely updated. This is all part of the process of providing the patient with the best, most effective, and up-to-date care available.

If news of new recommendations leaves you feeling confused or frustrated, talk to your doctor.  He or she can explain the changes. And because every guideline does not apply to every patient, only you and your doctor can determine what impact, if any, it will have on you. It’s always ok to ask: “What’s up doc?”