Choosing Wisely Campaign

Question 1

What are the three Choosing Wisely guidelines regarding antibiotic use?

1. When to use -
2. Peri-surgical antibiotics -
3. Antibiotics started in hospitalized patients suspected to have an infection -

Answer 1

What are the three Choosing Wisely guidelines regarding antibiotic use?

1. Only use when there is convincing evidence of need.
2. Stop after patient leaves the OR.
3. Continue for no more than 72 hours unless there is clear evidence of infection.

Question 2

What are the Choosing Wisely guidelines regarding invasive devices (e.g., CVCs, urinary catheters, ET tubes)?

Answer 2

Avoid use and use for as short a time as possible.

Question 3

What are the Choosing Wisely guidelines regarding C. difficile testing?

Answer 3

Only test if patient has signs or symptoms of infection.

Question 4

What are the Choosing Wisely guidelines regarding routine inpatient CBCs and chemistries?

Answer 4

Discontinue repetitive phlebotomy in the face of clinical and lab stability.

Question 5

What are the Choosing Wisely guidelines regarding timing of routine inpatient care (e.g., lab testing)?

Answer 5

Do not wake patients for routine care.

Question 6

What are the Choosing Wisely guidelines regarding daily CXRs in the inpatient setting?

Answer 6

Do not order daily CXRs without specific clinical indications.

Question 7

What are the Choosing Wisely guidelines regarding inpatient use of continuous telemetry (outside the ICU)?

Answer 7

Don’t use without a specific protocol to guide continuation (of limited use in patients with normal EKG and/or low-risk chest pain).

Question 8

What are the Choosing Wisely guidelines regarding pharmacologic prophylaxis against stress ulcers in hospitalized patients (outside the ICU)?

Answer 8

Do not prescribe stress ulcer ppx routinely in medical inpatients (use increases pneumonia and C. difficile infection risk).

Question 9

What are the Choosing Wisely guidelines regarding VTE prophylaxis?

Answer 9

Do not routinely prescribe VTE ppx;

use an objective risk-stratification system to see if patients need ppx and/or if they have any bleeding risks.

Question 10

What are the Choosing Wisely guidelines regarding laboratory testing in work-up of AMI or another ACS?

Answer 10

Do not order CK-MB as a diagnostic parameter (only use troponins).

Question 11

What are the Choosing Wisely guidelines regarding titration of SpO₂ in patients receiving supplemental O₂?

Answer 11

SpO₂ should not exceed 96% while on supplemental O₂ (unless for CO poisoning, cluster headaches, sickle cell crises, or pneumothoraces).

(Excessive oxygen levels are associated with increased mortality.)

Question 12

What are the Choosing Wisely guidelines regarding pain management in hospitalized patients?

Answer 12

Do not use opioids unless pain is moderate-to-severe, acute, also being treated with non-opioids, and not expected to be chronic.

Question 13

What are the Choosing Wisely guidelines regarding RBC transfusions?

Answer 13

Avoid RBC transfusions based solely on arbitrary Hgb levels. (Take clinical picture into account.)

Question 14

What are the Choosing Wisely guidelines regarding the use of urinary catheters for incontinence or measurement of urine output?

Answer 14

Don’t place or leave in place UCs for incontinence, convenience, or measurement of UO (can use weights to monitor diuresis).

Question 15

What are the Choosing Wisely guidelines regarding preoperative laboratory testing?

Answer 15

Do not order routine preoperative testing prior to low-risk surgical procedures. (The determining parts of the preoperative evaluation are the history and physical examination.)

Question 16

What are the Choosing Wisely guidelines regarding screening in adults with life expectancy <10 years?

Answer 16

Discontinue routine cancer screenings in this population.

Question 17

What are the Choosing Wisely guidelines regarding daily home glucose testing in T2DM?

Answer 17

Daily testing is only indicated if patient is on insulin.

Question 18

What are the Choosing Wisely guidelines regarding PICC usage as a convenient option for central venous access?

Answer 18

Do not place or leave in place for provider/patient convenience.

Question 19

In their Choosing Wisely guidelines, for which patients does the Society of General Internal Medicine recommend against annual health visits that include comprehensive physical examination and laboratory testing?

Answer 19

Asymptomatic patients without:

• chronic medical conditions,
• mental health problems,
• or other health concerns

Question 20

What are the Choosing Wisely guidelines for imaging in the evaluation of syncope?

Answer 20

In a patient with simple syncope and normal neurological examination, don’t obtain brain imaging studies.

Question 21

What are the Choosing Wisely guidelines for imaging in the evaluation of non-specific low back pain?

Answer 21

Do not obtain imaging.

In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., non-specific low back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.

Question 22

What are the Choosing Wisely guidelines for exercise electrocardiogram as a tool for evaluating asymptomatic individuals at a low risk for coronary heart disease?

Answer 22

They recommend against use of exercise electrocardiograms in these patients.

Question 23

What are the Choosing Wisely guidelines for preoperative chest radiography?

Answer 23

Only if there is a clinical suspicion of intrathoracic pathology.

In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.

Question 24

What are the Choosing Wisely guidelines regarding imaging for VTE/PE in individuals at low risk?

Answer 24

Obtain D-dimer results first.

Question 25

What is the Choosing Wisely guideline regarding asymptomatic bacteriuria?

Answer 25

Do not prescribe antibiotics.

With the exception of pregnant patients, patients undergoing prostate surgery or other invasive urological surgery, and kidney or kidney pancreas organ transplant patients within the first year of receiving the transplant, use of antibiotics to treat ASB is not clinically beneficial and does not improve morbidity or mortality.

Question 26

What is the Choosing Wisely guideline regarding upper respiratory infections?

Answer 26

Avoid prescribing antibiotics.

The majority of acute upper respiratory infections (URIs) are viral in etiology and the use of antibiotic treatment is ineffective, inappropriate and potentially harmful. However, proven infection by Group A Streptococcal disease (Strep throat) and pertussis (whooping cough) should be treated with antibiotic therapy.

Question 27

What is the Choosing Wisely guideline regarding stasis dermatitis of the lower extremities?

Answer 27

Do not treat with antibiotics.

Question 28

What is the Choosing Wisely guideline regarding prophylaxis for mitral valve prolapse?

Answer 28

Avoid antibiotic prophylaxis.

Question 29

What is the Choosing Wisely guideline (paraphrased) regarding when providers should test for C. difficile infection?

Answer 29

Only when signs or symptoms are present

Question 30

What is the Choosing Wisely guideline regarding when providers should image patients with new-onset lower back pain and no red flags?

Answer 30

Not for at least 6 weeks

Question 31

What is the Choosing Wisely guideline regarding when providers should prescribe antibiotics for acute mild-to-moderate sinusitis?

Answer 31

If symptoms last ≥10 days or if symptoms worsen after initial clinical improvement

Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis.

Question 32

What is the Choosing Wisely guideline regarding which patients should undergo routine DEXA screening for osteoporosis?

Answer 32

Women >65 and men >70

(not cost-effective in younger patients without risk factors)

Question 33

What is the Choosing Wisely guideline regarding when providers should NOT provide cardiac screening (e.g., EKGs)?

Answer 33

Low-risk, asymptomatic patients are more likely to be harmed by cardiac screening than helped

Question 34

What is the Choosing Wisely guideline regarding when providers should screen for carotid artery stenosis in asymptomatic adults?

Answer 34

Screening should NOT be initiated in asymptomatic adults

Question 35

According to the AAFP’s Choosing Wisely guidelines, ____________ screening should be initiated in female patients at the age of 65, and ____________ screening should be stopped once female patients reach the age of 65.

Answer 35

According to the AAFP’s Choosing Wisely guidelines, DEXA bone scan** screening should be initiated in female patients at the age of 65, and **cervical cancer screening should be stopped once female patients reach the age of 65.

Question 36

According to the Choosing Wisely guidelines, Pap smears should NOT be performed on which female patients?

Answer 36

• Those >65 w/ adequate previous screening and who are not otherwise high-risk
• Those <21
• Those s/p hysterectomy for non-malignant disease

Question 37

According to the Choosing Wisely guidelines, elective induction of labor and elective C-sections should not be initiated prior to what gestational age?

Answer 37

39 weeks

Question 38

What is the ‘observation option’ recommended by the AAFP Choosing Wisely guideline for children aged 2-12 with non-severe otitis media?

Answer 38

48-72 hours without antibiotics

Obviously, the clinical decision is made based on the children’s age, diagnostic certainty, and illness severity. There obviously must be an open line of communication with the parents and ability for reevaluation as needed.

Question 39

What are the Choosing Wisely recommendations for voiding cystourethrograms in children aged 2 mo. - 24 mo. after their first UTI?

Answer 39

Defer until after 24 mo. or until their 2nd UTI

Question 40

What are the Choosing Wisely guidelines regarding PSA testing and DRE for prostate cancer screening?

Answer 40

• Do not routinely screen
• If patient wants to be screened, can engage in shared decision-making regarding PSA testing (note: PSA testing should NOT be performed in males >70)

Question 41

According to the Choosing Wisely guidelines, routine pelvic examinations are indicated in which asymptomatic, nonpregnant populations?

Answer 41

Only in those undergoing routine screening for cervical cancer

Question 42

According to the Choosing Wisely guidelines, what physical examination is indicated prior to prescribing oral contraceptive pills?

Answer 42

None

• Hormonal contraceptives are safe, effective and well-tolerated for most women. Data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications.*
• Hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement.*

Question 43

According to the Choosing Wisely guidelines, what asymptomatic populations should be routinely screened for genital HSV infection?

Answer 43

None

• Serologic testing for HSV infection has low specificity and a high false-positive rate, and no confirmatory test is currently available. The serologic tests cannot determine site of infection.*
• Given the prevalence of the infection in the United States, positive predictive value of the test is estimated at about 50%. A positive test can cause considerable anxiety and disruption of personal relationships.*

Question 44

According to the Choosing Wisely guidelines, when should asymptomatic adolescent and adult males be screened for testicular cancer?

Answer 44

Never!

• There is no benefit to screening for testicular cancer due to the low incidence of disease and high cure rates of treatment, even in patients who have advanced disease.*
• There are potential harms associated with screening, which include false-positive results, anxiety, and harms from diagnostic tests or procedures.*

Question 45

According to the Choosing Wisely guidelines, how should the following anemic patients be managed?

• those who are symptomatic
• those who are stable but have a hemoglobin <7

Answer 45

• Transfuse until no longer symptomatic
• Transfuse to get above 7

(i.e., do not over-transfuse)

Question 46

What are the Choosing Wisely guidelines regarding the following topics?

• Whole-body screenings for tumors
• Vitamins for prevention of cardiovascular disease or cancer

Answer 46

• Do not use full-body imaging to screen for tumors in asymptomatic patients
• Do not use prescribe vitamin E, carotene, and multivitamins for prevention of cardiovascular disease or malignancy

Question 47

The Choosing Wisely guideline is to always prescribe the less expensive, equally effective medication.

Is going with the generic version of a medication typically associated with a decrease in quality?

Answer 47

No.

On average, the cost of a generic drug is _80–85_% lower than the name-brand product, although generic drugs _are required to have the same active ingredients, strength and similar effectiveness_ as brand-name drugs.

Question 48

True/False.

The Choosing Wisely recommendations include that patients should be mobilized as soon as safely possible, and mechanical ventilation should be weaned as soon as safely possible.

Answer 48

True.

Patients can develop significant muscle weakness and atrophy (including the diaphragm) during their ICU stay due to immobilization. However, multidisciplinary facilitated early mobilization has been shown to be safe in the ICU setting. Numerous, patient-centered, clinically meaningful outcomes are supported by early mobilization of critically ill patients.

Although mechanical ventilation is frequently lifesaving, it is also associated with numerous complications. Discontinuation of mechanical ventilation support is frequently the rate limiting step in ICU discharge. Current guidelines recommend removing patients from mechanical ventilation support as soon possible, utilizing mechanical ventilation liberation and sedation interruption protocols in concert with structured multidisciplinary rounds.

Question 49

The Choosing Wisely recommendations include what regarding use of in-dwelling drains and catheters in the ICU setting?

Answer 49

Remove them as soon as no longer clinically indicated

(i.e., we should be frequently re-assessing their need)

Question 50

True/False.

The Choosing Wisely recommendations include that nursing home residents with insulin-dependent diabetes should be on sliding-scale insulin and NOT scheduled boluses.

Answer 50

False.

The Choosing Wisely recommendations include that nursing home residents with insulin-dependent diabetes should NOT be managed with sliding-scale insulin.

SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regimens, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic.

Question 51

Why do the Choosing Wisely guidelines recommend against urine screening in asymptomatic individuals?

Answer 51

Screening increases the risk of identifying asymptomatic bacteriuria →

antibiotics are given →

risks of complications like C. difficile go up

Question 52

The Choosing Wisely guidelines include what recommendation regarding feeding of patients with advanced dementia?

Answer 52

DON’T insert percutaneous feeding tubes;

offer oral assisted feedings instead

Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.

Question 53

According to the Choosing Wisely guidelines, should delivery of palliative care ever be delayed for a patient with a serious illness because the patient is focusing on disease-focused management?

Answer 53

No.

Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations.

Question 54

According to the Choosing Wisely guidelines, what should be done when a patient’s implanted cardioverter-defibrillator is no longer compatible with their goals of care?

Answer 54

Deactivate the ICD

Question 55

According to the Choosing Wisely guidelines, what medications should be avoided in managing nausea?

Answer 55

Lorazepam, diphenhydramine, and haloperidol gels

Question 56

According to the Choosing Wisely guidelines, how many fractions of palliative radiation should be offered to patients with uncomplicated bony metastasis?

Answer 56

Just 1

Question 57

According the the Choosing Wisely guidelines, why are C. difficile toxin tests problematic as methods for determining “cure” of the infection?

Answer 57

• C. difficile tests* may remain positive for as long as 30 days after symptoms have resolved.
• False positive “test-of-cure” specimens may complicate clinical care and result in additional courses of inappropriate anti-C. difficile therapy as well as prolonged isolation.*

Question 58

True/False.

For patients with limited life expectancy, the Choosing Wisely guidelines recommend against BOTH routine cancer screening and routine prescription of lipid-lowering medication use.

Answer 58

True.

Question 59

What are the Choosing Wisely guidelines for antipsychotic use as a tool in managing behavioral and psychological symptoms of dementia?

Answer 59

Don’t prescribe them unless:

• the symptoms are severely impacting QoL and/or anyone’s safety

AND

• work-up/management of underlying causes fails to resolve the symptoms

Question 60

What do the Choosing Wisely guidelines recommend knowing/exploring prior to recommending aggressive and/or hospital-level care to frail individuals?

Answer 60

The patient’s goals of care and possible benefits/burdens of care

Question 61

What do the Choosing Wisely guidelines recommend regarding glucose control in older patients with T2DM?

Answer 61

Avoid using medications other than metformin to achieve an A1c <7.5%

There is no evidence that using medications to achieve tight glycemic control in most older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.