An OB/GYN perspective on Choosing Wisely

From ACOG comes five new cautions, part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, to eliminate wasteful and unnecessary medical interventions that can actually cause harm. All the recommendations are evidence-based and have broad consensus.

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age. Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

I agree. However, while,”medically necessary” is generally agreed upon, there will always be cases that fall outside the agreed upon parameters, and we need to respect physician judgement, patent autonomy and informed consent. But when the parameters are exceeded, there should be documentation as to what the medical reasoning is and that the patient is well informed.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

I agree. Again, there needs to be room for physician judgement and informed choice. Not every pregnancy can be as accurately dated as we’d like, even though it may seem obvious using the retrospectoscope, so we need to be reasonable with this and the first recommendation to allow for a realistic range of error.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age. In average-risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems, and have appropriate screening with consideration of a pelvic examination.

I sort of agree. I have to admit that I am still having a little trouble with this one. I once diagnosed a very very tiny, early invasive cancer in a woman who had no history of abnormal paps and whose last pap was just a year prior. Not that anecdotes make for good healthcare. I am using HPV testing to assist in the decision to back off on annual screens (If the test is negative, you can go 3-5 years between paps.) The recommendation has made me much more comfortable in reassuring patients, many of whom express guilt at being “late for my annual”, that they have not done themselves any harm. (Currently writing an upcoming post on the demise of the annual exam…)

4. Don’t treat patients who have mild dysplasia of less than two years in duration. Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average-risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

I agree. I have already been doing this for some time now in almost all patients, the exception being the occasional women with no recent new partners who is past childbearing, has visible lesions on colposcopy and would prefer treatment to follow up.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk. In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

I strongly agree. I’ve been trying to do this for a long time, and fighting my patients all the way on this one. I hope that the publicity around it will lead to less requests for routine ovarian cancer screening.

The Choosing Wisely campaign is joined by nine medical societies, each of whom has identified 5 areas where wiser choices can lead to better health outcomes – and probably significant cost savings. It’s a reasoned approach to the spiraling costs of healthcare.

Unfortunately, in some cases, not performing a test requires more time on the doctor’s part in educating the patient as to why that test is unnecessary. Trust me on this – it takes 5 times as long to talk a patient out of a CA125 screening test for ovarian cancer than it does to order one.