January 24, 2023
4 minute read
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The Society for General Internal Medicine, or SGIM, has revised its list of recommendations on tests and procedures that are commonly ordered but not always necessary in general medicine.
“We believe general internists have an important role to play in helping patients make informed decisions about tests and procedures that might otherwise be used too often,” said SGIM’s CEO. Eric B. Bass, MD, MPH, said in a statement. “We are happy to update these recommendations to ensure they are consistent with the latest evidence on the subjects.”
According to the updated list, SGIM advises against:
- daily home blood glucose monitoring in patients with type 2 diabetes mellitus who are not on insulin;
- perform routine annual health checks unless patients are likely to benefit from them and perform comprehensive physical examinations or lab work during health checks;
- perform preoperative tests before low-risk surgeries;
- cancer screening for adults with a life expectancy of less than 10 years; and
- placing or leaving peripherally inserted central catheters (PICCs) for the convenience of the patient or provider.
The recommendations are part of the ABIM Foundation’s “Choosing Wisely” initiative. This is the first time SGIM has updated its Choosing Wisely list since 2017, according to the organization. Each recommendation is based on recent management and treatment reviews.
Self-monitored blood glucose
SGIM said it does not recommend daily home glucose monitoring in patients with type 2 diabetes who are not on insulin because, although statistically significant, it does not produce ‘clinically important’ changes. in glycemic control. It can also be a burden for older patients with cognitive and visual impairments or neurological diseases, and it has been associated with higher depression scores. Self-monitoring also eliminates “the most important cardiovascular risk factors such as hypertension and hyperlipidemia,” the authors of the SGIM review wrote.
Routine annual checks
While annual checkups are not recommended for all patients, SGIM noted several factors that would make a patient likely to benefit from one. These include patients who:
- are late for recommended care;
- are at high risk of undiagnosed chronic disease;
- rarely see a primary care provider;
- having poor self-rated health; or
- have a high degree of anxiety.
Patients with none of the factors, as well as younger patients and those at low risk for chronic disease, are unlikely to benefit from checkups and should discuss the frequency of checkups with their clinician, according to SGIM. .
Speaking to Healio, Jeffrey A. Linder, MD, MPH, FACP, a professor of internal medicine at Northwestern University Feinberg School of Medicine and co-author of the SGIM recommendations review, said there are other unlisted reasons that may warrant annual checkups.
“It could be if the patient is concerned about their health and wants to get it every year,” he said. “A lot of people have insurance programs where you get a reduction in your premium if you see your doctor once a year. This is a valid reason to consult your doctor.
Linder acknowledged that there was an initial misinterpretation of this recommendation, pointing out that SGIM does not tell patients and physicians not to receive and carry out annual checks.
“It’s just about being a bit more thoughtful about what you’re doing and the potential to accomplish something productive, both for the doctor and, more importantly, for the patient during an exam” , did he declare.
SGIM also advises against performing comprehensive physical exams or routine lab tests during annual health checkups. Instead, Linder said doctors should review a patient’s medical history, medications, family history, and any changes in a person’s social history, such as smoking, dieting, drug use. alcohol and exercise.
“These are way more important than what people attribute to them, compared to a lot of things that people associate with a doctor’s visit like a physical exam or a blood test,” he said.
Linder also highlighted necessary conductive exams like cancer screenings for adults, as recommended by the U.S. Task Force on Preventive Servicesperiodic cholesterol testing every 5 years and testing for HIV and hepatitis C at least once, according to the CDC.
Ultimately, “the reason we don’t check everyone all the time is that asymptomatic adults were much more likely to find something that will never be a problem for them than we’re going to find something that actually goes for improve your health and help you live longer or better,” he said.
Linder noted that such exams can lead to increased anxiety, inconvenience and danger to the patient, “because we often have to track these things and often move on to more invasive tests that can expose people to real harm, while the potential for benefit is large, much smaller.”
Preoperative tests for low-risk procedures
SGIM noted that preoperative testing before low-risk operations does not improve surgical outcomes and can lead to additional costs, testing, and delayed surgery, all of which can harm the patient.
“Preoperative evaluation before low-risk procedures should be limited to a careful history and physical examination and review of chronic medical conditions,” the review authors wrote.
Unnecessary preoperative tests may include blood tests, urine tests, electrocardiograms, and chest X-rays.
Screening for cancer in patients with low life expectancy
While cancer screenings can save lives in the right situations, SGIM noted that screeners for adults with a life expectancy of less than 10 years are unlikely to live long enough to benefit from screening. Additionally, patients with little time left are more likely to suffer harm due to their frailty, making them vulnerable to complications from testing and treatment.
For some patients, ignoring a cancer screening can lead to mistrust and other negative emotions. SGIM recommended an approach that emphasizes the harms versus the benefits of screening in the context of patient health and other factors.
Risks of PICC
According to the SGIM review, evidence suggests that PICCs are associated with an increased risk of bloodstream infections in hospitalized patients and an increased risk of upper extremity deep vein thrombosis and pulmonary embolism.
Results may be related to several factors, including device characteristics, patient characteristics, and vendor characteristics. Because PICCs frequently involve patients at high risk for these conditions, SGIM stated that there is a continued need to improve the use of PICCs.
Additionally, SGIM noted that the use of PICCs is increasing in non-critical care settings, “posing challenges for monitoring central line-associated infections and building seamless care teams.”
“The use of PICCs in non-critical care settings requires fundamental shifts in existing care paradigms. Additionally, as patients frequently transition with PICCs to outpatient treatment, fragmentation and inconsistent care after discharge pose perils to safe use of PICCs,” the authors wrote. “Awareness of these issues is necessary to help ensure positive outcomes and patient safety.”
- As part of the Choosing Wisely Canada campaign, SGIM is releasing an updated list of commonly used tests and treatments to question. https://www.sgim.org/about-us/news-and-initiatives/sgim-choosing-wisely-recommendation-updates. Published January 17, 2023. Accessed January 18, 2023.
- Do not place or leave in place peripherally inserted central lines for the convenience of the patient or provider. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–PICC-update-061422.final.pdf. Accessed January 20, 2023.
- Do not perform routine annual examinations unless patients are likely to benefit from them; the frequency of checkups should be based on individual risk factors and preferences. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely—Checkups-Recs-20220923.final.authors—web-version.pdf. Accessed January 20, 2023.
- Do not perform routine preoperative tests before low-risk surgical procedures. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–Preop-092022.final.112822_DZ_final.pdf. Accessed January 20, 2023.
- Do not recommend daily home blood glucose monitoring in patients with type 2 diabetes mellitus who are not using insulin. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–SMBG.092022final.pdf. Accessed January 20, 2023.
- Do not recommend cancer screening for adults with a life expectancy of less than 10 years. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely-Cancer-Screening-061022.final.pdf. Accessed January 20, 2023.
- Five things doctors and patients should question. https://www.choosingwisely.org/societies/society-of-general-internal-medicine/.