Thursday, June 21, 2012

Choosing Wisely: AGS's List Open for Recommendations



AGS and AAHPM are teaming up with over a dozen other medical specialty societies to participate in the second wave of ABIM Foundation's Choosing Wisely Campaign.  So far, nine medical specialty organizations, along with Consumer Reports, have identified five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.

AGS is now accepting submissions for its list of five tests or procedures commonly used in their geriatrics, whose necessity should be questioned and discussed.  The Choosing Wisely list should provide specific, evidence-based recommendations to physicians and patients in order to make wise decisions about the most appropriate care based on their individual situation.

Please click on this link here to submit the top three tests and/or procedures that you feel should be included in AGS’ list. Submissions will be accepted until July 6th.

To help spark some ideas, I'll include some comments from our previous post that suggested the following tests or procedures that should be avoided:
  • Colorectal or breast cancer screening on patients with less than 10 year life expectancies (or at least not in those with less than 5 year LEs)
  • PSAs in everyone
  • PAP smears on elderly women who have had three consecutive normals.
  • Indiscriminate prescription of iron and PPIs associated with hospital admissions (or at minimum review the continued need for them).
  • Overselling cholinesterase inhibitors while underselling risks
  • Ongoing use of cholesterol medications when life expectany = months
  • Administering a Folstein MMSE
  • Prescribing docusate
  • Prescribing Colace and miralax for opioid related constipation
  • Prescribing more expensive benzodiazepine, e.g. midazolam when a less expensive one is available, e.g. lorazepam
  • Ordering Videofluoroscopic Swallowing Study to assess swallow function and need for PEG tube placement in individuals with advanced dementia.
  • Initiating hemodialysis in an elderly patient without a thorough discussion of risks and benefits (especially the discussion of likely functional decline).
  • Ordering albumin/prealbumin to check for malnutrition
  • Ordering 'therapeutic' diets for folks with very limited life expectancy or advanced dementia
  • Insulin sliding scales
  • Fingerstick glucose checks for folks who won't benefit from tight control, especially on those with limited life expectancy 
  • Use of Aricept and other drugs in this class in patients who are bed bound with advanced dementia. Ditto Namenda. 
  • Continuing cholesterol lowering medications and Plavix in patients with a 6 month life expectancy. 
  • Ordering plain CT scans of the head for elderly patient with a documented history of dementia who are delirious if they are awake without focal findings 
  • Fosamax/antibone resorptive medications for patients with dementia or bed bound patients. 
  • PPI use or continued usage without reviewing indications 
  • Lipid, EKG, HbA1c mandatory testing by pharmacists for patients on antipsychotics in severely demented patients or those on hospice care
  • Using more expensive analgesics without evidence of superiority to less expensive alternatives 

Although not specifically asked for in the Choosing Wisely Campaign, I'll also throw in one thing that was recommended that we should do:
  • Institute a nationwide POLST paradigm, and give people who complete one a coupon to Denny's.
If you have more suggestions please add them below to the comments section, but please also be sure to  go to the AGS survey and submit them as recommendations (click here for the survey)

by: Eric Widera (@ewidera)

12 comments:

Bruce Scott MD said...

Did I miss the memo on Miralax? Is there reason to believe that it is ineffective, unsafe, or too expensive? I've shifted a fair bit away from Senna-S and toward Miralax, and I'd like to know if I'm screwing up.

Bruce Scott MD said...

It's pretty hard for me to pick just three. They are asking for MOST over-utilized or potentially harmful. I guess I'd be leaning toward:

1) too many CT scans for delirium in patients with known dementia (although I suspect that not all our colleagues will agree...since I see some geriatricians I respect ordering them way more often than I would). How often are we finding an abnormality on CT scanning that will change our management in acute confusional states in dementia patients in absence of focal neurologic deficit?

2)video swallow then PEG in advanced dementia. (Expected natural history of disease, not likely to provide information that allows a useful intervention. No benefit shown to tube placement. Moves focus away from one of the few remaining pleasures these patients can partake in.)

3)cancer screening in those with limited life expectancy. (Need at least 5 years if not 10 to show benefit from screening for colon and breast, and screens and the follow-up testing they drive are neither benign nor cheap.)

I think I'll wait to submit to mull it over for a bit and see if anyone here makes a good case for another choice being more harmful or wasteful (or argue that one of the above isn't really as harmful as I'm making it out to be).

(I like parentheses.)

Helen Chen, MD said...

I agree--picking 3 is tough, so I'm going to cheat a little:

1) Just say no to tight (glycemic) control for seniors with limited life expectancy (and/or advanced dementia, but you could argue that people with advanced dementia already have limited life expectancy) This measure would include no therapeutic diets and no insulin sliding scale/fingersticks.

2) How about a hospice Beers list which would include statins, cholinesterase inhibitors, Namenda, bisphosphonates for osteoporosis, etc?

3) No cancer screening in patients with limited life expectancy/advanced dementia.

BTW, why Denny's for POLST?

Helen

Bruce Scott MD said...

No particular reason for Denny's. Just envisioned it as a place that our patient population might like to go for dinner at about 4:30 PM. I'm sure I thought it was hilarious at the time.

Imagine the attempts to get a national POLST through anything remotely resembling the current Legislature.

Mary Poole said...

I agree with the entire list. I would also like to add the uneccessary waste the whole emergency response team (Police, Ambulance and Fire Dept) arriving for every 911 call. Maybe thats only in Texas, talk about overkill. I also love the nationwide POLST idea

joshuy said...

Multivitamins in NH patients

joshuy said...
This comment has been removed by the author.
joshuy said...

Can't help myself...
BB/ACE-i for diastolic CHF
Plavix beyond a year for any indication
Bisphosphonates past 5-10 years
Aspirin for primary prevention of anything
Aspirin for secondary prevention beyond the acute phase of a MI/CVA (i.e. beyond a year)
Aggrenox over aspirin
Triple anticoagulation (i.e. asa plavix coumadin)
Expensive statins over generic ones

Eric Widera said...

Bruce,

People have different views on the effectiveness of Miralax. Pallimed writes about it here http://www.pallimed.org/2007/08/mortality-quality-whole-brain-radiation.html (its the third topic on the page). There are some more recent but lower quality studies that suggest it's still better than lactulose. To be honest I haven't spent a lot of time researching the Miralax issue.

Tim McCurry said...

Bruce: Mirilax is all Mush and no Push at least as we think about opiod bowel programs. I always use it in combination with a stimulant in opioid use.

Bruce Scott MD said...

Thanks Tim and Eric for the thoughts on Miralax. I'd been using it with folks that had cramping with Senna/Colace. Nobody likes lactulose, so I rarely use it unless there is a hepatic encephalopathy reason as well.

All Mush, No Push was always what I'd been taught (and subsequently have been teaching) about Colace alone.

Perhaps I should reevaluate my teaching, which had been to pick from amongst: 1) Senna-S; 2) Lactolose/sorbitol; 3) Miralax. (With Yakima Valley Fruit Paste for rare cases.)

I wonder if anyone has experimented with diabetic candies (sorbitol containing). They seemed to be pretty good at getting my diabetics an accidental bowel cleanse if they exceeded serving sizes. I think I'd rather be on the diabetic chocolate turtle bowel regimen than Senna-S when I get my horrible metastatic cancer.

Bruce Scott MD said...

Getting close to the deadline (July 6th) for submission for AGS version of Choosing Wisely!

Will you be opening up a new post to talk about submissions for the AAHPM version of Choosing Wisely? Deadline July 13th.