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The Society of General Internal Medicine, or SGIM, has revised its list of recommendations on tests and procedures that are commonly requested but not always necessary in general medicine.
“We believe that general internists have an important role to play in helping patients make informed decisions about exams and procedures that may otherwise be used too frequently,” SGIM CEO Eric B. Bass, MD, MPH, said in a press release. “We are happy to update these recommendations to ensure they are consistent with the most recent evidence on the topics.”
According to the updated list, the SGIM does not recommend:
- daily home glucose monitoring in patients with type 2 diabetes mellitus who are not using insulin;
- performing routine annual exams, unless patients can benefit, and performing comprehensive physical exams or lab work during exams;
- perform preoperative testing before low-risk surgical procedures;
- cancer screening in adults with a life expectancy of less than 10 years; and
- place or leave peripherally inserted central catheters (PICCs) for patient or provider convenience.
The recommendations are part of the ABIM Foundation’s “Choose with Wisdom” initiative. This is the first time SGIM has updated its Choosing Wisely list since 2017, according to the organization. Each recommendation is based on recent management and treatment reviews.
Self-monitoring of blood glucose
The SGIM said it does not recommend daily home glucose monitoring in patients with type 2 diabetes not using insulin because, while statistically significant, it does not produce “clinically important” changes in glucose control. It can also pose a burden for elderly patients with cognitive and visual impairments or neurological diseases, and has been linked to higher depression scores. Self-monitoring also eliminates “the most important cardiovascular risk factors such as hypertension and hyperlipidemia,” the SGIM review authors wrote.
Routine annual exams
While annual exams are not recommended for all patients, the SGIM noted several factors that would make a patient likely to benefit. These include patients who:
- are overdue for recommended care;
- are at high risk of undiagnosed chronic disease;
- rarely sees a primary care provider;
- having low self-rated health; or
- has a high degree of concern.
Patients who do not have any of the factors, as well as younger patients and those at low risk of chronic disease, are unlikely to benefit from screening and should discuss the frequency of testing with their physician as per the SGIM.
In conversation with Healio, Jeffrey A. Linder, MD, MPH, FACP, a professor of internal medicine at Northwestern University Feinberg School of Medicine and co-author of the SGIM recommendation review, said there are other reasons not listed that may warrant annual exams.
“One might be if the patient is concerned about their health and wants to get it every year,” he said. “A lot of people have insurance programs where you get something out of your premium if you see your doctor once a year. That’s a valid reason to see your doctor.”
Linder acknowledged that there was some initial misinterpretation of this recommendation, emphasizing that the SGIM is not telling patients and physicians not to receive and perform annual exams.
“It’s just thinking a little bit more about what you’re doing and the potential to accomplish something productive, both for the doctor and, more importantly, for the patient when you have a checkup,” he said.
The SGIM also advises against performing comprehensive physical exams or routine laboratory tests during annual exams. Instead, Linder said doctors should review a patient’s medical history, medications, family history and any changes in a person’s social history, such as smoking, diet, drinking and exercise.
“All of this is much more important than people believe, compared to many things that people associate with a doctor’s visit, like a physical exam or blood test,” he said.
Linder also highlighted necessary conductive testing, such as cancer screenings for adults as recommended by the US Preventive Services Task Force, periodic cholesterol testing every 5 years, and HIV and hepatitis C testing at least once, according to the CDC.
Ultimately, “the reason we don’t check everything all the time is that asymptomatic adults are much more likely to discover something that really will never be a problem for them than we are to find something that is actually happening. to improve your health and help you live longer or better,” he said.
Linder noted that these tests can lead to increased anxiety, inconvenience and danger for the patient, “because we often have to keep track of these things and often get to more invasive tests that can expose people to real harm when the potential benefit It’s very, very small.”
Preoperative testing for low-risk procedures
The SGIM noted that preoperative testing prior to low-risk operations does not improve surgical outcomes and may result in additional costs, delayed testing and surgery, which can harm the patient.
“Preoperative evaluation prior to low-risk procedures should be restricted to a careful history and physical examination and review of chronic medical conditions,” the review authors wrote.
Unnecessary preoperative tests may include blood tests, urine tests, electrocardiograms and chest X-rays.
Cancer screening in patients with low life expectancy
While cancer screenings can be life-saving in the right situations, the SGIM noted that screenings for adults with a life expectancy of less than 10 years are unlikely to live long enough to benefit from screening. Additionally, time-limited patients are more likely to be harmed due to frailty, making them vulnerable to complications from examinations and treatments.
For some patients, disregarding a cancer screening can result in distrust and other negative emotions. The SGIM recommended an approach that focuses on the harms versus benefits of screening in the context of the patient’s health and other factors.
According to the SGIM review, evidence suggests that PICCs are associated with an increased risk of bloodstream infections in hospitalized patients and an increased risk of deep vein thrombosis of the upper extremities and pulmonary embolism.
Results can be related to several factors, which include device characteristics, patient characteristics, and provider characteristics. Because PICCs often involve patients at high risk for these conditions, the SGIM said there is a continuing need to improve PICC utilization.
Furthermore, the SGIM noted that the use of PICCs is increasing in non-ICU settings, “imposing challenges for monitoring centralline-associated infections and for assembling homogeneous care teams.”
“The use of the PICC in non-intensive care settings requires fundamental shifts in existing care paradigms. Furthermore, as patients frequently transition PICCs to outpatient care, fragmentation and non-uniform post-discharge care pose dangers to safe PICC use,” the authors wrote. “There is a need to raise awareness of these issues to help ensure positive outcomes and patient safety.”
- As part of the “Choosing Wisely” campaign, the SGIM releases an updated list of commonly used tests and treatments for questioning. https://www.sgim.org/about-us/news-and-initiatives/sgim-choosing-wisely-recommendation-updates. Published January 17, 2023. Accessed January 18, 2023.
- Do not place, or leave in place, peripherally inserted central lines for patient or provider convenience. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–PICC-update-061422.final.pdf. Accessed January 20, 2023.
- Do not perform routine annual exams unless patients can benefit; frequency of testing should be based on risk factors and individual preferences. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely—Checkups-Recs-20220923.final.authors—web-version.pdf. Accessed January 20, 2023.
- Do not perform routine preoperative testing prior to low-risk surgical procedures. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–Preop-092022.final.112822_DZ_final.pdf. Accessed January 20, 2023.
- Do not recommend daily home glucose monitoring in patients with type 2 diabetes mellitus not using insulin. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely–SMBG.092022final.pdf. Accessed January 20, 2023.
- Do not recommend cancer screening in adults with a life expectancy of less than 10 years. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely-Cancer-Screening-061022.final.pdf. Accessed January 20, 2023.
- Five things doctors and patients should question. https://www.choosingwisely.org/society/society-of-general-internal-medicine/.