Choosing Wisely in pulmonary medicine means fewer CTs amid low risk


The American College of Chest Physicians has released its list of common but not always necessary tests in pulmonary medicine.

The list was a result of the collaborative efforts of the AACP and the American Thoracic Society, and is part of the ABIM Foundation’s Choosing Wisely campaign, which aims to educate patients and physicians about unnecessary and potentially harmful testing and treatment. The list was released during CHEST 2013, the annual meeting of the ACCP, which is being held in Chicago.

The ACCP’s recommendations are:

• Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines. In patients with no cancer history, solid nodules that have not grown over a 2-year period have a very low risk of malignancy. Also, repeating CT scans has not been shown to improve outcomes, and exposes patients to increased radiation over time.

• Do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting form left heart disease or hypoxemic lung diseases. There is no established benefit of vasoactive agents for patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung disease.

• For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia. Hypoxemia often resolves after recovery from an acute illness, and continued supplemental oxygen incurs unnecessary costs.

• Do not perform CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive d-dimer assay. Clinical practice guidelines indicate that the potential harms of CT angiography outweigh the benefits for patients with a low pretest probability of pulmonary embolism.

• Do not perform CT screening for lung cancer among patients at low risk for lung cancer. Low-dose chest CT screening has the potential to reduce lung cancer death in high-risk patients, but could potentially cause adverse effects such as radiation exposure, high false-positive rates, harms related to downstream evaluation of pulmonary nodules, and overdiagnosis of indolent tumors. Hence, it should be reserved only for patients at high risk of lung cancer (people aged 55-74 with at least a 30 pack-year history of tobacco use, who are either still smoking or quit within the past 15 years).*

The ACCP recommendations and detailed explanations for each will be published in the journal CHEST in 2014. For more information about the Choosing Wisely campaign, click here.

*Correction, 10/29/13: An earlier version of this story misstated the definition of those considered at high risk of lung cancer.

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