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Experts Issue 'Top 5' List for Better Primary Care

By Amanda Gardner
HealthDay Reporter

MONDAY, May 23 (HealthDay News) -- Cutting back on unnecessary antibiotics, delaying wasteful imaging for lower back pain and foregoing annual ECG screenings for healthy, low-risk patients are among the actions that could help streamline primary care, experts say.

Perhaps taking a page from David Letterman's Top 10 list, the authors of a new report came up with a "Top 5" list of action items for each of the primary care disciplines -- family medicine, internal medicine and pediatrics -- to help save money and conserve health resources.

Many physicians are already behind the suggestions, according to the report, which appears online May 23 in the Archives of Internal Medicine.

"I have seen many instances where I thought clinicians were not making the right and wisest decisions in ways that were not good for patients' health and not good for prudent use of finite resources," said Dr. Stephen Smith, one of the report's authors and professor emeritus of family medicine at the Warren Alpert School of Medicine at Brown University in Providence, RI.

Smith is also a member of the National Physicians' Alliance (NPA), a group of 22,000 doctors promoting affordable and quality healthcare, which put together the lists.

None of the suggestions are particularly new, having been validated by scores of studies, yet few clinicians seem to be implementing them, Smith said.

Here are the Top Five recommendations for each discipline:

For family medicine:

  • Avoid imaging for lower back pain for six weeks unless red flags are present.
  • Cut back on prescribing antibiotics for sinus infections, since most are viral.
  • Avoid cardiac screening in patients who are low risk and have no symptoms.
  • Do not do Pap tests for cervical cancer in women under 21 or those who have had a hysterectomy for benign disease.
  • Confine bone density scans known as dual-energy X-ray absorptiometry (DEXA) for osteoporosis to women aged 65 and over and for men 70 and older who also have risk factors, such as those who have already had fractures .

For internal medicine:

  • Defer imaging for lower back pain.
  • Do not order blood chemistry panels (a set of 8 blood tests to assess kidney function, blood sugar and other health indicators) or urinalysis in healthy adults with no symptoms, since blood lipids (fats) tests alone yield most positive results.
  • Forego cardiac screening in healthy patients.
  • Prescribe generic statins (cholesterol-lowering drugs) before brand-name ones
  • Limit bone-density screening to older, at-risk patients .

In pediatrics:

  • Avoid giving antibiotics for sore throats unless a test definitely turns up the bacteria Streptococcus (strep throat)
  • Avoid imaging for minor head injuries without risk factors such as loss of consciousness.
  • Take a wait-and-see attitude towards middle-ear infections before referring the patient to a specialist.
  • Recommend that parents not give their children over-the-counter cough-and-cold medicines.
  • Make sure patients with asthma are using corticosteroid medicines properly, as this will cut down on episodes.

The report was funded by a grant from the American Board of Internal Medicine Foundation.

Several of the items -- those involving cardiac screening, overuse of antibiotics, bone-density scans and lower-back imaging -- appeared in more than one category.

But one item -- not doing blood chemistry panels and urinalysis among healthy adults without symptoms -- enjoyed only weak support from the practicing physicians who field-tested the suggestions.

The Top 5 lists will now be distributed to all NPA members. The researchers are also hoping to get funding to set up demonstration sites, creating training videos to help physicians hone their communication skills and finding ways to get patients on board, Smith said.

"These are certainly important issues," said Dr. Lawrence C. Kleinman, a primary care physician and associate professor of pediatrics at Mount Sinai School of Medicine in New York City.

But he also pointed out that "the lists were done with some nuance, which [is] valuable and important to incorporate in the understanding of this."

As the report authors point out, Kleinman noted, it's not that all antibiotic use is bad, just that, in the case of sore throats, there should be a verification that the infection is really strep throat before prescribing them. Similarly, imaging for head injuries would need to be done for children with loss of consciousness or other risk factors.

More information

Find a primary doctor through the American Medical Association's Doctor Finder.

SOURCES: Stephen R. Smith, M.D., professor emeritus of family medicine, Warren Alpert School of Medicine, Brown University, Providence, RI; Lawrence C. Kleinman, M.D., a primary care physician and associate professor of pediatrics at Mount Sinai School of Medicine in New York City; May 23, 2011 online edition, Archives of Internal Medicine

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