Choosing Wisely: Medical Tests and Treatments You Probably Don’t Need

Jennifer Yttri
August 2013

 

When you walk into the doctor’s office, your first thought might not be “what questions should I ask my doctor” but maybe it should be. Many tests are over-used, adding to the cost for patients and even possibly harming them. What is beneficial for one person isn’t worth the risks for another.

The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

Consumer Reports magazine and the ABIM Foundation are working with medical specialty societies to create lists of “5 Things Physicians and Patients Should Question” as part of a Choosing Wisely campaign (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists are based on scientific evidence compiled by experts. Here is the full list of their recommendations.

 

Abdominal pain

CT scans are not recommended for patients with abdominal pain unless the results will change the course of treatment. CT scans of the abdomen expose patients to one of the highest levels of radiation from medical tests, equivalent to hundreds of chest x-rays or 3 years of background radiation. Unless the test is in response to major changes in symptoms and can lead to differences in treatment, CT scans are not worth the increased cancer risk from radiation.

 

Allergy Tests

Skin or blood tests for allergies should only be used if a patient has allergic symptoms that are not controlled by over-the-counter medications or if a doctor suspects an allergy. Allergy tests are costly and can detect allergic responses that may never happen in real life. Allergy tests should not be used to figure out why someone has chronic hives, as those do not normally result from allergies.

 

Antibiotics for viral infections

Antibiotics kill bacteria but do not kill viruses, such as a cold or flu. Most respiratory infections, such as bronchitis and sinusitis, are caused by viruses and will clear up on their own in 1 or 2 weeks. Taking antibiotics when they won’t work can cause serious side effects for the patient, and also lead to antibiotic resistance of bacteria. Do not take antibiotics for infections unless symptoms last beyond two weeks or come back soon after getting better—these can be signs of a serious bacterial infection.

 

Antibiotics in elderly

Not all bacteria are bad for you. Elderly patients should not use antibiotics to get rid of bacteria detected in urine unless they are experiencing symptoms of a urinary tract infection. The antibiotics can cause more harm than the bacteria.

 

Antibody replacement therapy for recurrent infections

Unless a patient has a condition known as primary immunodeficiency disease, where they cannot make antibodies on their own, giving a patient replacement antibodies (also called immunoglobulins) is not recommended. Replacement therapy is expensive and a patient can have a serious allergic reaction or develop an infection. The only patients who should consider antibody replacement therapy are those who have frequent, unusual infections and very low antibody levels in their blood, certain immune disorders, or can’t make antibodies in response to vaccines.

 

Anti-nausea gels

A topical drug is easy to apply and therefore is an attractive therapy. But, topical gels should not be used to treat nausea because they are not readily absorbed through the skin and have not proven to be effective. Other therapies should be used instead.

 

Medications for patients with dementia

Antipsychotic medications (such as Abilify, Seroquel, Zyprexa, Geodone, Risperdal, and Haldol) should not be used to treat behavioral symptoms of dementia or Alzheimer’s disease. Antipsychotics do not treat the cause of these diseases and can cause very serious complications, including stroke or death.

 

Asthma

Asthma should not be treated or diagnosed without measuring lung function. Lung function can be tested with spirometry. This simple breathing test is much better at diagnosing asthma than having a patient provide a history of symptoms or doing a physical exam. Diagnosis without spirometry can lead to prescribing asthma medication to people who don’t have asthma. Spirometry testing should be done a few months after starting treatment and at least once every two years.

 

Autoantibody testing (ANA testing)

ANA testing is often performed to detect autoimmune diseases or immune system disorders, like multiple sclerosis or lupus. If a patient is negative for ANA (anti-nuclear or autoantibodies), further testing of antibodies is not recommended. If a patient is positive for ANAs, further testing should be based on disease symptoms which can help a doctor predict what specific types of antibodies to test for. This strategy reduces unnecessary testing.

 

Barrett’s esophagus

Patients diagnosed with Barrett’s esophagus as a consequence of gastroesophageal reflux disease (GERD) should get their esophagus lining examined for signs of abnormal cells once every 3 years. These cellular changes, which can result in a type of cancer called adenocarcinoma, take a long time to develop and therefore more frequent screening is not recommended, especially in younger patients.

 

Ovarian cysts

Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed.  A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.

 

Enlarged Prostate or benign prostatic hyperplasia (BPH)

As men age, it’s common for their prostate to become enlarged, a condition called benign prostatic hyperplasia or BPH. Usually BPH does not cause problems until men are near age 60.  If patients are having problems urinating with limited or no other symptoms, evaluation beyond the standard prostate exam is not recommended. Patients are unlikely to have problems in the future due to their current condition. Should symptoms change, follow up tests, such as ultrasound, biopsy, or cystoscopy, may be useful for deciding on treatment.

 

Bleeding time test

The bleeding time test was designed to measure how long it takes for a patient’s blood to clot. This is an old, unreliable test that also leaves a forearm scar.  The bleeding time test has been replaced with a coagulation test that more accurately predicts a patient’s risk of bleeding during surgery. Therefore, the bleeding time test should no longer be performed.

 

Blood drawing for testing

Frequent blood draws can cause anemia. Repeated blood draws for testing of hospitalized patients is not recommended if there is no change in symptoms or test results.

 

Blood transfusion

Blood transfusion is not recommended for hospitalized patients who are in stable condition and do not have symptoms other than low hemoglobin levels. Blood transfusions should be given as sparingly as possible.

 

Breast cancer screening

Breast cancer screening is done through mammograms, which are like x-rays.  A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back.  Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.

 

Bronchiolitis and respiratory infections in children

Respiratory tract infections are common in children. Corticosteroids and bronchodilators are not recommended for treating lower respiratory tract infections or bronchiolitis in children, because they are not proven effective and have risks that can be harmful. Chest x-rays, used to diagnose some respiratory infections like TB, are not recommended for diagnosing bronchiolitis or common childhood respiratory infections.  Physical exams and patient history are much more reliable ways to diagnose these. Chest x-rays should not be used to diagnose a child with asthma-like symptoms (see asthma above).

 

Cancer therapy

The first round of cancer therapy works best at reducing or eliminating a tumor. Multiple treatments, including chemotherapy, will not always help get rid of cancer, especially more advanced cancers or tumors that return. After three different treatments, another round is unlikely to improve quality or length of life. It is better to stop therapy and not suffer through the side effects of treatment.  (In fact, there is some evidence that patients live longer, with better quality of life, if they stop aggressive treatments earlier.)

 

Cardiac screening

There are many tests to measure heart function and screen for heart disease. Usually these tests fall into two categories: tests performed while at rest, which measure normal function, or tests performed when the heart is working hard (under stress), such as after exercise. Electrocardiogram (EKG), radionucleotide imaging, echocardiogram, CT, and other cardiac screening, either resting or stressed, are not recommended for patients without symptoms or who are at low risk for developing heart disease. These tests are often inaccurate at diagnosing minor or moderate heart disease. Imaging tests often provide misleading information when used as a wellness test or as part of routine follow up testing for patients who do not have changes in their symptoms. These tests are also not recommended for assessment prior to low or medium-risk non-cardiac surgery or before and after surgery for patients who have no history or symptoms of heart disease. Such screening is more likely to result in false positives (results that indicate heart problems when the patient doesn’t really have any) and unnecessary procedures than to detect problems or change medical care. Patients with risk factors or a history of heart disease, or with symptoms related to heart disease, should get resting tests and possible stress tests. Imaging tests are recommended five years after bypass surgery or two years after a stent procedure.

 

Carotid stenosis or carotid artery disease

Carotid artery stenosis is a problem when plaque accumulates on the inside of arteries. It can be fixed by a surgical procedure to remove the plaque and damaged artery called carotid endarterectomy (CEA). CEA is not recommended for patients who may have plaque build-up but no symptoms. The CEA procedure is surgery and can have complications, including risk of stroke or death within 5 years of surgery, though in a small number of patients. Only patients with 70% blockage, a low risk for complications, and life expectancy at least 3-5 years should consider the surgery.

 

Cervical cancer screening

Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year.   See below for information about HPV testing. Pap smears (see below) should be used to screen for cervical cancer.

 

Chest X-rays before surgery

Patients without signs or symptoms of heart or lung disease do not need a chest x-ray before surgery. Chest x-rays are not costly but they do expose patients to a small amount of radiation and can lead to expensive follow-up tests if a problem is detected. Chest x-rays are recommended before surgery for anyone having heart, lung or chest surgery and for patients over 70.

 

Children with Febrile Seizures

Febrile seizures happen when children have a high fever. Doctors should try to identify the cause of the fever when treating infants or children who have had a febrile seizure. CT and MRI scans of the brain are not recommended for children who have had a febrile seizure. CT scans use radiation and exposing children to radiation can increase their risk of developing cancer. MRI scans are very costly and require sedation, which exposes children to unnecessary risks.

 

Chronic kidney disease

Chronic kidney disease (CKD) takes years to develop and symptoms rarely appear before the late stages (stages 3-5). Once symptoms develop, patients usually have other health problems caused by CKD. It is very important for patients with CKD and their families to talk with their doctors about which tests and treatments will improve or increase their life.  Here are three examples:

  • ·         CKD can cause anemia, which means the number of red blood cells is low. Sometimes drugs that help make more red blood cells (called erythropoiesis-stimulating agents or ESAs) are prescribed before patients develop serious anemia. ESAs, however, are not recommended to prevent anemia because they are expensive and can put patients at risk for strokes, heart failure, and heart attacks. ESAs should only be used for patients who already have symptoms of anemia and very low levels of red blood cells.
  • ·         Patients in hospitals may have a catheter inserted into the vein of an arm to help nurses draw blood for tests and give IV medications. These catheters are not recommended for patients with late stage CKD as veins in the arms may be needed for hemodialysis. Catheters can damage these veins or cause scarring that makes it impossible to use the veins for hemodialysis.
  • ·         As CKD progresses, some patients may consider long term dialysis to perform the functions of kidneys. However, long term dialysis has not been proven to extend or improve life for patients with serious complications or short life expectancy. Dialysis also does not provide a benefit to patients with early stage kidney failure.

 

Colon cancer screening

For people who are at an average risk for developing colon cancer, tests such as stool tests and sigmoidoscopy can be used instead of colonoscopy to screen for colon cancer. Abnormal results from these tests require follow-up with a colonoscopy. The plasma test named methylated Septin 9 (SEPT9) is an alternative screening test but it is not recommended unless the more conventional tests and colonoscopy are not feasible.

 

Colonoscopy

Screening colonoscopies are recommended every 10 years following a normal result in low-risk adults starting at age 50. Colonoscopies are very good at detecting small, low-risk polyps (less than 1 cm) that grow slowly. More frequent screening is not recommended because colonoscopies and polyp removal are expensive and risky. Colonoscopies should be repeated no more than once every 5 years for monitoring patients who have had larger polyps that were previously removed. Routine checks are not needed after age 75.

 

Continuous telemetry monitoring of cardiac function

Sometimes hospitals will attach a device to a patient so they can move around and still have constant monitoring of their heart function. This telemetric monitoring is not recommended if patients have a normal electrocardiogram and are at low risk for cardiac problems.

 

Coronary artery calcium scoring

The level of calcium in coronary arteries can predict coronary artery disease. Calcium is found in plaque that builds up in and blocks arteries. Calcium levels in arteries in the heart are measured by computed tomography (CT) scans. However, coronary calcium scans are not recommended for diagnosing or evaluating development of coronary artery disease in patients without symptoms, family history, or those who enter the ER with chest pain. Calcium scoring is not recommended as a preoperative test or for individuals who already have stents and bypass grafts as it will not provide new information that can change treatment.

 

Cough and cold medications for children

Cough and cold medicines can have serious side effects and often contain more than one active ingredient. Research studies have concluded that these medications offer little benefit to children and can have risks of accidental overdose. Therefore they are not recommended for children under age 4.

 

Cryptorchidism

Ultrasound is not recommended for boys with cryptorchidism, a condition where the testes do not descend into the scrotum. A physical exam is more effective at locating testes.

CT scans in children

Computed tomography or CT scans use radiation for imaging. Exposing children to radiation is especially risky for increasing their lifetime risk of cancer because their tissues are sensitive to radiation. CT test are not recommended for children who are being treated for minor head injuries, febrile seizure, or abdominal pain including appendicitis.

 

Deep vein thrombosis (DVT)

DVT is very common. However, lab tests to detect a clotting disorder like DVT are not recommended as the results will not alter treatment of a venous blood clot. An ultrasound to evaluate how a patient is responding to therapy is also not recommended because the result will not change the treatment.

 

Dementia and Alzheimer’s disease

Memory loss is a natural consequence of aging. Memory loss alone, however, is not a reason to get tested for dementia or Alzheimer’s. A PET scan takes an image of the brain looking for plaques that are associated with Alzheimer’s. However, imaging is not recommended for evaluating dementia or reasons for memory loss. Plaques on a PET image do not mean you have Alzheimer’s and lack of plaques does not mean you won’t develop it in the future. Instead, have a doctor who specializes in dementia and Alzheimer’s give you a medical evaluation first.

 

Dialysis

The choice to start dialysis can be a difficult one. Long term dialysis is very unpleasant and may not improve survival or quality of life for older adults. Patients, families, and physicians should spend time discussing whether long term dialysis makes sense given a patient’s age, overall health, and life expectancy.

 

Ear infections

Oral antibiotics are not good at treating infections of the outer ear or infections from having a tube inserted to drain fluid from the inner ear. If antibiotics are needed for these ear infections, only topical antibiotics should be used.

 

Early labor induction or Cesarean delivery

Unless there is a clear medical reason, do not schedule delivery before 39 weeks and avoid scheduling delivery before 41 weeks. Babies born before 39 weeks are not fully developed and are at increased risk for learning disabilities, illness, and death. Mothers who deliver early are more likely to experience postpartum depression and may have complications from medicines needed to start labor.

 

Erectile dysfunction

Testosterone treatment is not effective as therapy for erectile dysfunction in men with normal testosterone levels. Erectile dysfunction is rarely caused by low testosterone levels. Testosterone therapy is costly and has high risks, including enlarged prostate, lower fertility, heart disease, and more aggressive prostate cancer.

 

Eye injections

Topical antibiotics, including antibiotic eye drops, are not recommended for use before or after eye injections. The risks of allergic reactions and antibiotic resistance are high.

 

Eye disease

Imaging tests are not recommended for patients who do not show signs of significant eye disease. A patient’s history and a physical examination by an eye doctor are all that are needed to detect eye disease or see if it is getting worse.

 

Eye surgery

When a patient goes in for a complicated surgery, they may be given a battery of tests before the surgery takes place. Eye surgeries are usually short and uncomplicated. Therefore, these preoperative tests are not recommended for eye surgeries unless a patient has a pre-existing condition that justifies a test.

 

Fainting

Fainting will happen to 40% of people during their lifetime. Unless a patient has other neurologic symptoms, imaging of the carotid arteries to identify a reason for fainting is not recommended because a block in the arteries does not cause fainting. The cause will remain unknown after the expensive test.

 

Colony stimulating factors (CSFs) for febrile neutropenia

Febrile neutropenia, or severe fever with a low number of white blood cells, is sometimes a complication of chemotherapy. One in five patients will experience febrile neutropenia after chemotherapy but CSFs are frequently prescribed for all patients getting chemotherapy treatments. CSFs are only recommended for patients who are at high risk of infection, over 65, have a weak immune system, or have a greater than 20% risk of febrile neutropenia.

 

Feeding patients who have dementia

Using a feeding tube can cause distress to patients. If feeding tubes don’t work, this can cause ulcers or may require use of physical and pharmacological restraints that add to patients’ distress. Instead, patients with dementia should have someone help feed them, which makes sure they get nutrients and provides positive human interaction.

 

Gastroesophageal reflux (GERD) in infants

Antacids are not recommended to treat GERD in infants. It is not effective in reducing GERD symptoms and can produce adverse effects.

 

Heartburn, acid reflux disease, and gastroesophageal reflux (GERD)

There are many options for treating heartburn and GERD. Usually, treatment is based on getting rid of symptoms, not controlling or reducing disease. The most powerful drugs are proton pump inhibitors (PPIs), such as Nexium, Prevacid, or Prilosec. These drugs should only be used if heartburn happens more than twice a week or after a diagnosis of GERD. The lowest effective dose of a PPI should be used for the shortest amount of time. For less severe heartburn, changes in diet and lifestyle, antacids, or H2 blockers like Pepcid AC and Zantac can be effective without the risks associated with PPIs.

 

Heart valve disease

Valve disease can be very serious and should be monitored. However, if the disease is mild and not causing symptoms, echocardiograms, a simple ultrasound of the heart, are not recommended. Mild valve disease doesn’t usually cause problems. Echocardiograms are recommended if a heart murmur is strong, gets worse, or symptoms develop. Tests should also be used if a valve has been replaced.

 

Headaches

Migraines are painful and can last a long time. Sometimes doctors prescribe strong pain medicines for migraines, such as an opioid (narcotic) or a barbiturate (sedative) called butalbital. These drugs usually do not help migraines and can make them worse. Instead, take medications specifically approved for migraines. Doctors may want to diagnose headaches using CT or MRI imaging. This is not recommended as it is costly and is no better than clinical evaluation. Imaging should only be done if a doctor can’t confidently diagnose headaches based on symptoms and a neurologic exam or if the exam has an abnormal result.

 

Hives

Skin and blood testing for allergies are not recommended for patients with chronic hives, hives that last for weeks. The tests are costly and may not help determine an underlying cause as chronic hives are rarely related to allergies.

 

Hoarseness

Patients suffering from hoarseness should have their larynx examined by a doctor. If there is evidence of damage or a lesion, CT or MRI scans can be used. Because of the high costs and potential radiation exposure, CT or MRI scan should not be done without a doctor’s examination first.

 

HPV testing

HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.

 

Implantable cardioverter-defibrillator (ICD)

ICDs are small, battery-powered defibrillators, similar to pacemakers, used in patients with irregular heartbeats. However, there are no guidelines for deactivating ICDs. Defibrillation can be unpleasant and there is no reason to continue their use if a patient is dying because it will not benefit the patient. It is recommended that ICDs be deactivated when patients no longer want this medical care.

 

Increasing blood circulation

Surgery to increase blood circulation to normally functioning heart, organs like liver and kidneys, or limbs will not prevent disease. Surgery to improve circulation is not recommended unless it will improve symptoms or is to remove a blockage.

 

Lower back pain

Patients experiencing lower back pain should not have imaging tests, such as MRI, X-ray, or CT scans, to diagnose pain. These tests are costly, expose patients to radiation, and don’t help patients get better faster. Imaging tests are useful if patients have signs of severe nerve damage, have serious underlying problems like cancer and spinal infection, or if symptoms don’t improve in a few weeks.

Lyme disease

Patients suffering from arthralgias, myalgias or fibromyalgia should not be tested for Lyme disease unless they have other symptoms of Lyme disease, such as a bulls-eye rash, and reason to believe they have been exposed through a tick bite. Also, Lyme disease tests have a high rate of false positives (results that indicate a person has Lyme when he or she doesn’t) so patients who may have been exposed to Lyme disease should be examined by a qualified doctor for signs and symptoms before being tested.

 

Monitoring oxygen during respiratory illness

Pulse oximetry measures oxygen levels in the blood through a sensor. It is important for situations where blood oxygen levels need to be monitored or can change rapidly, like during surgery, in emergency or intensive care, or when on oxygen support. Continuous pulse oximetry is not recommended for monitoring children with respiratory illnesses unless they are on support oxygen.

 

Multiple sclerosis (MS)

Interferon-beta and glatiramer acetate (or Cop-1) are common MS medications. Both only work to reduce relapses and should not be given to patients with progressive, non-relapsing MS. The drugs do not stop the progression of disabilities related to MS and both are costly and have frequent side effects.

 

Nonsteroidal anti-inflammatory drugs (NSAIDS)

NSAIDS are drugs that relieve pain and inflammation. Common examples are ibuprofen (Advil and Motrin), naproxen (Aleve), and celecoxib (Celebrex). NSAIDS should not be used by patients with hypertension, heart failure, or chronic kidney disease. NSAIDS can react with drugs for hypertension, elevate blood pressure, and further decrease kidney function. Over-the-counter low dose acetaminophen (Tylenol) or short term use of narcotic painkillers may be safer choices.

 

Osteoporosis

DEXA (dual energy x-ray absorption) is an expensive bone-density screening test. While DEXA can detect osteoporosis, many people will be put on osteoporosis drugs without needing them. Osteoporosis drugs have risks and are unlikely to benefit most patients who have only mild bone loss. DEXA is not recommended for women under 65 or men under 70 unless they have a history of risk factors for weak bones. Healthy men (over 70) and women (over 65) can be screened every 10 years as long as risk factors do not change.

 

Ovarian cancer screening

Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.

 

Pain relief (palliative care)

Patients with severe illness who experience physical, psychological, social, or spiritual distress because of treatment should get palliative care. Palliative care is proven to reduce pain, control symptoms, and improve family satisfaction without high costs or risk of death.

 

Palliative care for bone metastasis

Cancers that spread to bones are often very painful. Local radiation is sometimes used to treat patients with one or a few bone metastases, but some doctors question if the increased risk of cancer warrants radiation as treatment for pain. The American Society for Radiation Oncology recommends using one dose of radiation to relieve pain from any bone metastasis. While another dose might be needed in the future, starting with one dose makes sense, since patients with bone cancer have a short life expectancy.

 

Pap smears

Pap smears detect cervical cancer. They are not recommended for women under 21. They also are not recommended for women who have had their cervix removed during a hysterectomy and have no history of cancer. Most abnormalities in young women go away without treatment. For women who have had a hysterectomy for reasons unrelated to cancer, Pap smears do not provide any useful information. Pap smears are recommended every 3 years for women aged 21-65. Women over 65 who have had normal Pap tests can stop having them done.

 

Pink eye

Pink eye can be caused by a virus or bacteria. Antibiotics should not be used to treat viral pink eye. A doctor should confirm that moderate to severe infections are caused by bacteria before prescribing antibiotics. Pink eye caused by a virus will clear up on its own.

 

Preoperative testing for low risk surgeries

Preoperative tests, like measuring blood count or glucose levels, are not recommended for healthy or clinically stable patients.  Test results rarely influence a low-risk, elective surgery procedure or have any effect on patient recovery. Patients who have symptoms or risk factors that may complicate surgery should get appropriate preoperative diagnostic testing.

 

Prostate cancer screening

Gleason and PSA tests are used to measure how aggressive prostate cancer is and how likely it will spread. Imaging tests can then be performed to identify exactly where cancer has spread. These imaging tests, such as bone scans, PET, and CT, are not recommended for detecting disease in men who are newly diagnosed with low-grade prostate cancer. Imaging tests are expensive, can expose men to high levels of radiation, and are unlikely to provide more information about early prostate cancer. Only men with Gleason scores above 7 and PSA levels above 10 nanograms/mL should consider imaging tests.

 

Prostate specific antigen (PSA)

High PSA levels may be a sign of prostate cancer. However, having a low PSA level does not prevent prostate cancer nor does it mean there is no cancer. It was thought that antibiotics might lower PSA and protect men from prostate cancer. This has not been proven in clinical tests and is not recommended as an alternative preventive therapy.

 

Pulmonary embolism

CT scan is not recommended for diagnosing a pulmonary embolism in young women. Instead a radionuclide ventilation/perfusion (V/Q) imaging study should be used, because it can detect a pulmonary embolism with a lower dose of radiation to the breast.

 

Punctal plugs for dry eyes

Punctal plugs are put into tear ducts to keep liquid from draining away from the eye.  Mild dry eyes should be treated with artificial tears before trying punctal plugs.  Punctual plugs can cause inflammation of the eye and make symptoms worse, so they should only be used for more severe cases of dry eye that do not respond to simpler treatment.

 

Rheumatoid Arthritis (RA)

MRI is not recommended for diagnosing or monitoring RA.  While there are cases where an MRI may provide more information than other methods of assessment, it is not cost-effective in comparison to physical exams, lab tests, and x-rays, and therefore is not recommended as general practice. After a diagnosis, it is recommended that RA be treated with methotrexate or other conventional non-biologic antirheumatic drugs for at least 3 months before considering biologic drugs. Biologics may be better options for patients with aggressive disease and poor prognosis.

 

Sedatives in elderly

Sedatives like benzodiazepines should not be used to treat insomnia, agitation, or delirium, especially in the elderly as they are least likely to benefit from such treatment. Instead, sedatives may increase elderly patients’ high risk for accidents, falls and hip-fractures, which can result in hospitalization and possibly death.  Sedatives should only be given to patients with alcohol withdrawal or anxiety disorders who do not respond to behavioral or psychological therapy.

 

Sinusitis

Sinusitis is diagnosed based on symptoms (e.g., nasal drainage, pressure, and nasal blockage) and is usually related to allergies or the common cold. Some doctors will want to order a CT scan of nasal passages but this is unnecessary for diagnosis. Antibiotics should not be used to treat sinusitis because they usually don’t work. However, if symptoms are serious (high fever, rash, extreme pain) or they last for more than a week or keep coming back, generic amoxicillin, a very inexpensive antibiotic, is the best choice for treatment.

 

Stage 1 non-small cell lung cancer (NSCLC)

Lung cancer is the most common type of cancer to spread to the brain. However, the chance of patients with Stage 1 lung cancer developing brain metastasis is very low. Because of the rate of false positives is much higher than the actual rate of brain metastasis, brain imaging by MRI or CT is not recommended for patients with stage 1 NSCLC unless they have neurologic symptoms.

 

Stents in myocardial infarction

Stents are put into blocked arteries as a way to restore blood flow. However, stents are not recommended for patients who are undergoing angioplasty or percutaneous coronary intervention (PCI) for uncomplicated stable myocardial infarction (STEMI). Only one treatment is needed for uncomplicated cases, and adding stents may increase surgical complications and can even be fatal.  Stents are also not recommended to improve blood circulation in arms and legs.  Increasing blood flow in arteries that are not blocked will not prevent disease. However, stents and angioplasty in combination can be beneficial in patients who do not have stable blood flow.

 

Peripheral artery disease (PAD)

PAD develops when arteries in the legs and feet get blocked, restricting blood flow. Surgery and angioplasty are not recommended to treat PAD. Both procedures can only treat severe symptoms, like pain when walking, and do not prevent future problems. Safer and more effective ways to reduce symptoms from PAD are quitting smoking, walking daily, and controlling diabetes, blood pressure, and cholesterol.

 

Prophylactic treatment of stress ulcers

Medications to prevent stress ulcers (such as proton pump inhibitors or PPIs) are not recommended for hospitalized patients (non-ICU) unless they are at high risk for gastrointestinal tract problems. These costly medications can leave patients susceptible to bacterial infections, which are much more likely to develop in hospitals than stress ulcers.

 

Sudden hearing loss

CT scans are not recommended for patients suffering from sudden hearing loss. CT scans should only be used for patients with a history of trauma, chronic ear infection, or neurologic symptoms.

 

Thyroid scans

Radioactive iodine is absorbed by the thyroid and can be used to give doctors a picture of what the thyroid looks like, how it is functioning, and if there are any nodules in the area. Imaging with radioactive iodine is not recommended for determining whether thyroid nodules are benign or cancerous unless the patient is hyperthyroid. Nodules should be biopsied if the thyroid functions normally.

 

Type-2 diabetes

Medications that treat diabetes by controlling blood glucose levels are only effective at lowering risk of death and artery clots after long-term use. The dose of medication prescribed for patients depends on how much is needed to maintain a specific level of glucose in the blood. For adult patients that are relatively healthy and have a long life expectancy, using medication for strong glycemic control may be worthwhile. However, as patients age (over 65) and develop other illnesses, patients are unlikely to benefit from strict control of blood sugar and are at high risk of complications from hypoglycemia.

 

Urinary catheters

Catheters are not recommended for treatment of incontinence, for monitoring bladder or kidney output for non-critically ill patients, or for convenience.  They can do more harm than good when they are not medically necessary, because catheters cause urinary tract infections that can result in serious or even fatal illness, as well as increasing health care costs. Medical guidelines provide instructions on how to properly insert and maintain catheters for critically ill patients and recommendations on when to stop use or replace a catheter.

 

Venous thromboembolism (VTE) and Pulmonary Embolism (PE) screening

Patients with a low probability of VTE and PE should be initially diagnosed using a D-dimer measurement. This test is highly sensitive and if the results are negative (nothing suspicious found), there is no need for more costly imaging tests.

 

Vitamin-D testing

Routine lab testing for vitamin D is not recommended as vitamin D deficiency is common in many people, like those living at high altitudes, those with little sun exposure, and also to some extent during winter months. Vitamin D deficiency is easily fixed with over-the-counter supplements and by being in the sun.