Clinical Question: What common neurologic practices have strong evidence of no clinical benefit or of harm?
Although this Top Five list is intended for neurologists, many conditions are also managed by primary care physicians who are often guilty of referring patients for useless tests or interventions. We all need to stop useless and harmful practices.
- Don’t order electroencephalograms for patients with headaches;
- Don’t order carotid studies for patients with simple faints;
- Reserve opiates and barbiturates as a last resort for treating migraines;
- Don’t prescribe interferon-? or glatiramer for patients with stable multiple sclerosis; and
- Don’t recommend endarterectomy for asymptomatic carotid artery stenosis unless the rate of complications is less than 3%. (LOE = 5)
The United States spends more on medical care than any other country on the planet, yet the health outcomes rank near the bottom of most measures. Among the explanations include an underemphasis on primary care and wasteful spending for services that are unlikely to benefit patients. In response to a challenge from Howard Brody, Director of the Institute for Medical Humanities, the medical societies and Consumer Reports have convened panels to identify common practices that meet the following criteria: the procedure offers no benefit to most patients or is harmful; in aggregate, the service is expensive; and eliminating the practice or shifting to a more appropriate alternative is within the control of physicians. The American Academy of Neurology (AAN) convened a group with expertise in evidence-based medicine and guideline development to serve on the Choosing Wisely Working Group. The members, unfortunately, had many ties to industry. The Working Group e-mailed all members of the AAN to obtain submissions for candidate wasteful practices. This yielded an amazing 178 possible candidates! The Working Group then used electronic means to implement a modified Delphi process to cull this list down to 11 “finalists.” These finalists addressed various forms of imaging or other testing for syncope, headaches, fainting, and various treatments for back pain, headaches, carotid stenosis, and stable multiple sclerosis. The Working Group then weighed the evidence behind these and generated the Top Five list. It remains to be seen how these recommendations are implemented and if actual cost savings are realized.
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI