Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely™

Amanda Kost; Inginia Genao; Jay W. Lee; Stephen R. Smith

doi:10.3122/jabfm.2015.05.140332

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Table 1. Choosing Wisely Recommendations; Study Sites; Inclusion, Exclusion, and Appropriate Decision Criteria; and Recommendation Adherence for a 6-Month Time Period Before and After the Intervention^*

Recommendation (Specialty Society)	Study Sites	Criteria				Before Intervention Percent Appropriate	After Intervention Percent Appropriate	P Value
Recommendation (Specialty Society)	Study Sites	Inclusion	Exclusion	Appropriate Decision	Inappropriate Decision	Before Intervention Percent Appropriate	After Intervention Percent Appropriate	P Value
Low-back pain (AAFP and ACP): Don't do imaging for low back pain within the first six weeks, unless red flags are present.	Yale,^{^†} Long Beach,^{^‡} Seattle^{^§}	ICD-9 codes 724.4, 724.3, 724.02, 724.4, 724.5, 722.1, 722.2, 722.5, 722.51, 722.9, 846.0, 847.2	Age <18 years, prior visit for acute back pain within the prior 3 months, preexisting chronic back pain, temperature >38°C, new-onset bowel or bladder symptoms, “saddle” anesthesia, prior cancer diagnosis, current IV drug use, unexplained weight loss	No imaging ordered for back pain	Imaging ordered for back pain	87.8 (108/123)	87.8 (81/94)	.99
Sinusitis (AAFP): Don't routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for ≥7 days OR symptoms worsen after initial clinical improvement.	Long Beach, Seattle	ICD-9 codes 461.0, 461.1, 461.3, 461.8, 461.9	Age <12 years, prior visit for sinusitis within 3 months, temperature of 38°C, symptom duration >7 days, double sickening, severe pain or tenderness over sinuses, another diagnosis requiring antibiotics	No antibiotics prescribed	Antibiotics prescribed	45.4 (10/22)	100 (21/21)	<.00
Pap tests (AAFP): Don't perform Pap tests on women <21 years old or women who have had a hysterectomy for noncancer disease.	Long Beach, Seattle	All pap smears performed	—	Patient age >21 years, Pap performed on patient with hysterectomy for prior malignancy	Patient age <21 years or Pap done on patient with hysterectomy for noncancer indication	98.8 (237/240)	99.3 (272/274)	.55
ECG (AAFP and ACP): Don't order annual ECGs or any other cardiac screening for low-risk patients without symptoms.	Yale, Long Beach, Seattle	All ECGs performed	—	ECG ordered for cardiac or pulmonary symptoms, or for patients with hypertension, diabetes mellitus, or other clinical indication	ECG ordered for screening purposes	99.2 (119/120)	99.2 (129/130)	.96
DEXA scanning (AAFP and ACP): Don't use DEXA screening for osteoporosis in women <65 years old or men <70 years with no risk factors.	Yale, Long Beach, Seattle	All DEXAs ordered	Patient age <18 years	Women >65 years old, men >70 years old, patients of any age with an underlying medical condition that increases osteoporosis risk	Women <65 years old without risk factors, men <70 years old without risk factors	66.7 (8/12)	90.0 (36/40)	.049
All decisions	—	—	—	—	—	93.2 (482/517)	96.5 (552/572)	.02

↵* The preintervention period included clinical decisions made between July 1 and December 31, 2011; the postinterventionperiods included clinical decisions made between April 26 and October 26, 2012.
↵† Yale Primary Care Center, New Haven, CT, is the outpatient clinic for the Internal Medicine Residency.
↵‡ Long Beach Memorial Family Medicine Residency, Long Beach, CA.
↵§ Harborview Medical Center Family Medicine Clinic is a satellite clinic for University of Washington Family Medicine Residency, Seattle, Washington.
AAFP, American Academy of Family Physicians; ACP, American College of Physicians; DEXA, dual-energy X-ray absorptiometry; ECG, electrocardiogram; ICD-9, International Classification of Diseases, Ninth Revision; IV, intravenous.