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Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.   Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.   Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...
Cardiac Tests & Treatments to Avoid

Cardiac Tests & Treatments to Avoid

In collaboration with the American Board of Internal Medicine’s Choosing Wisely campaign, the Society for Cardiovascular Angiography and Interventions (SCAI) has issued a list of five specific, evidence-based recommendations that should be avoided in the care of patients who have cardiovascular disease (CVD) or are at risk for it. “This list should be used to spur conversations between patients and physicians so that wise decisions are made about care based on each patient’s individual situation,” says James C. Blankenship, MD. “It’s hoped that this list will improve care for patients and eliminate unnecessary tests and procedures.” Five Recommendations for Patients with CVD The list of tests and treatments to avoid from SCAI includes the following five recommendations: 1. Avoid routine stress testing after PCI without specific clinical indications. 2. Avoid coronary angiography in post-bypass surgery and post-PCI patients who are asymptomatic or who have normal or mildly abnormal stress tests and stable symptoms that do not limit quality of life. 3. Avoid coronary angiography for risk assessment in patients with stable ischemic CVD who are unwilling to undergo revascularization or who are not candidates for revascularization based on comorbidities or individual preferences. 4. Avoid coronary angiography to assess risk in asymptomatic patients with no evidence of ischemia or other abnormalities on adequate non-invasive testing. 5. Avoid PCI in asymptomatic patients with stable ischemic CVD without the demon­stration of ischemia on adequate stress testing or with abnormal fractional flow reserve testing. The list was based on guidelines and appropriate use criteria developed by SCAI, the American College of Cardiology, the American Heart Asso­ciation, and other professional societies. All of the...
Reducing  Poor Surgical  Oncology Practices

Reducing Poor Surgical Oncology Practices

As part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, the American College of Surgeons (ACS) and the Commission on Cancer (CoC) have developed lists of five measures focusing on tests or procedures that are commonly ordered but not always necessary in surgery and surgical oncology. Although the ACS and CoC developed their own sets of measures, each organization strongly supports the other, according to Stephen B. Edge, MD, FACS, an executive committee member of the CoC. “These measures address the care of different patients,” he says. “The CoC addresses cancer patients in many parts of their care, whereas the ACS addresses all surgical patients.” The Commission on Cancer Measures After vetting a long list of potential measures, the CoC arrived at the measures listed in Table 1. Strong evidence supports using needle biopsy to determine if an abnormal finding may be indicative of breast cancer. Needle biopsy for a worrisome finding on breast imaging or examination improves treatment outcomes when compared with a diagnostic surgical lumpectomy, says Dr. Edge. In 2006, the Institute of Medicine recommended that all patients completing cancer treatment be given a summary of the therapies they received as well as a survivorship care plan. “This recommendation, however, is not being followed for most cancer patients,” Dr. Edge says. “The reasons are multi-faceted and include the time and effort it takes to create these plans and the difficulty in defining exactly how they should be constructed.” He adds that a survivorship plan explaining what tests patients should expect—and informing them that having more tests performed will not help—may reduce anxiety, uncertainty, and...
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