Choosing Wisely: Using a Handy Tool

What happens when American health care provider organizations representing more than one million providers work together to identify poor medical practices that could be easily remedied? The Philadelphia-based ABIM Foundation worked with dozens of professional organizations and Consumer Reports in a project called Choosing Wisely to do just that. The result is lists of Things Physicians and Providers Should Question and Patient-Friendly Resources from Specialty Societies and Consumer Reports. These documents are designed to stimulate conversations that improve care and eliminate unnecessary tests and procedures.

Each list includes specific, evidence-based recommendations providers and patients should discuss to make determine each individual patient’s most appropriate care. The lists cover unnecessary tests, procedures and drugs. They also describe methodology used.

The list developed by the Endocrine Society and American Association of Clinical Endocrinologists includes five points:

• Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia. This point stresses that once target control is achieved and self-monitoring results quite predictable, repeatedly testing is superfluous (and costly) for most patients. It, of course, identifies some exceptions to this “rule.”
• Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function. Measuring 1,25-dihydroxyvitamin D is not an accurate means to estimate vitamin D stores and test for vitamin D deficiency. When trying to assess vitamin D stores or diagnose vitamin D deficiency or toxicity, 25-hydroxyvitamin D is the correct test.
• Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality.
• Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients; in most patients a normal TSH indicates a correct dose of levothyroxine.
• Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.

Choosing Wisely reminds its audience that recommendations should not be used to establish coverage decisions or exclusions. The recommendations are guidelines to determine an appropriate treatment plan with input from the patient and the healthcare team. Endocrinologists will find the large assortment of patient handouts helpful for those situations where patient think they know what they want or need.