Groups Urge Caution on 45 Standards of Care

Cheryl Clark, for HealthLeaders Media , April 5, 2012

American Society of Clinical Oncology
31. Don't use cancer-directed therapy for solid tumor patients who have low performance status (3 or 4), no benefit from prior evidence-based interventions, are not eligible for a clinical trial, and for whom there is no strong evidence supporting the value of further anti-cancer treatment. The care plan should include appropriate palliative and supportive care.

32. Don't perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer patients at low risk for metastasis. Evidence is lacking that they improve survival or detection of metastatic disease.

33. Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis. These tests are often used in staging low-risk cancers despite a lack of evidence they improve survival or detection of metastatic disease.

34. Don't perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent. Serum tumor markers may have clinical value for some cancers such as colorectal, but not breast, and false positives can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation and misdiagnosis.

35. Don't use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication. 

American Society of Nephrology
36. Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms unless they are transplant candidates. This includes mammography, colonoscopy, PSA testing, and pap smears. It is neither cost-effective nor does it improve survival.

37. Don't administer erythropoiesis-stimulating agents to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dl without symptoms of anemia. ESAs have no survival or cardiovascular disease benefit and may be harmful. They should be used to maintain hemoglobin at lowest levels that minimize need for transfusion.

38. Avoid nonsteroidal anti-inflammatory drugs in people with hypertension or heart failure or chronic kidney disease of all causes, including diabetes. This can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function. Acetaminophen, tramadol, or short-term narcotic analgesics may be safer.

39. Don't place peripherally inserted central catheters in stage III-V chronic kidney disease patients without consulting nephrology. Excessive venous puncture damages veins. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis.

40. Don't initiate chronic dialysis without ensuring a shared decision-making process between patients, families, and physicians. Limited observational data suggest survival may not differ for older adults with multiple co-morbidities who initiate chronic dialysis versus those who manage their disease conservatively.

American Society of Nuclear Cardiology
41. Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present. Asymptomatic, low-risk patients account for up to 45% of inappropriate stress testing, which should be performed only with patients with the following findings: diabetes in patients older than 40, peripheral arterial disease, and greater than 2% yearly coronary heart disease event rate.

42. Don't perform cardiac imaging for low-risk patients. Chest pain patients at low risk of cardiac death and myocardial infarction based on history, physical exam, electrocardiogram, and cardiac biomarkers do not merit stress radionuclide myocardial perfusion imaging or stress echocardiography initially if they have a normal Electrocardiogram and are able to exercise.

43. Don't perform radionuclide imaging as part of routine follow-up in asymptomatic patients. This practice may lead to unnecessary invasive procedures and excess radiation exposure without improving outcomes.

44. Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low or intermediate risk non-cardiac surgery.

45. Use methods to reduce radiation exposure in cardiac imaging, including not performing such tests when limited benefits are likely.

The Congressional Budget Office estimates that up to 30 percent of care delivered in the United States goes toward unnecessary tests, procedures, doctor visits, hospital stays, and other services that may not improve health.

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