ACS: Don't perform these tests/treatments

Orthopedic surgeons also release a list

The American College of Surgeons (ACS) and Commission on Cancer (CoC) have released separate lists of specific tests or procedures that are commonly ordered but not always necessary in surgery and surgical oncology. The list includes this recommendation: Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam (H&P).

The recommendations are part of the "Choosing Wisely" campaign, an initiative of the ABIM Foundation. The mission of the ABIM Foundation is to advance medical professionalism to improve the healthcare system. They collaborate with physicians and physician leaders, medical trainees, healthcare delivery systems, payers, policy makers, consumer organizations, and patients.

The list from each organization identifies five targeted, evidence-based recommendations that can support conversations between patients and physicians about what care is necessary. In addition to the recommendation on X-rays, the ACS set forth the following:

• Don't perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

• Avoid the routine use of "whole-body" diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

• Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia.

• Don't do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

"These recommendations will help to enhance the patient-surgeon relationship and heighten the quality of care surgical patients receive, which is one of our highest priorities," said David B. Hoyt, MD, FACS, ACS executive director.

The Commission on Cancer made the following five recommendations:

• Don't perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done.

• Don't initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan.

• Don't use surgery as the initial treatment without considering presurgical (neoadjuvant) systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life, or survival.

• Don't perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for postoperative pain control and pneumonia prevention.

• Don't initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment.

The ACS solicited recommendations from its Committee on Trauma and its advisory councils for colon and rectal surgery, general surgery, and pediatric surgery, as well as the Commission on Cancer. All of the recommendations collected from the ACS committees and councils were reviewed, and five items were identified.

The CoC appointed a multidisciplinary task force to develop its list. Recommendations for candidate interventions were solicited from panel members and other leaders from the Commission on Cancer. The panel voted on each intervention to select the final list of recommended interventions.

The American College of Surgeons and Commission on Cancer lists are posted online at: www.facs.org/choosingwisely.

AAOS releases Choosing Wisely list

The American Academy of Orthopaedic Surgeons (AAOS) has released a list of specific tests or procedures that are commonly ordered but not always necessary in orthopedics, as part of the Choosing Wisely campaign. The academy made the following five recommendations:

• Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.

• Don't use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.

• Don't use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

• Don't use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.

• Don't use postoperative splinting of the wrist after carpal tunnel release for long-term relief.

"More than one in four Americans require medical attention due to a musculoskeletal condition, and that number continues to grow," explained Joshua J. Jacobs, MD, AOS president. "As orthopedic surgeons, our duty to our patients is to restore mobility and improve their quality of life through evidence-based, high-quality treatment."

The Choosing Wisely lists are developed after months of careful consideration and review, using the most current evidence about management and treatment options. Over the next year, more than 30 other specialty society partners will release Choosing Wisely lists, including the American Society of Anesthesiologists and the American Society of Colon and Rectal Surgeons. For more on the Choosing Wisely campaign, go to http://www.choosingwisely.org.