Society of General Internal Medicine revises guidelines on unnecessary procedures

The Society of General Internal Medicine, or SGIM, has revised its list of recommendations on tests and procedures that are commonly ordered but are not always necessary in general medicine.

“We believe that general internists have an important role to play in helping patients make informed decisions about tests and procedures that may otherwise be used too often,” SGIM CEO Eric B. Bass, MD, MPH, said in a press release. “We are happy to update these recommendations to ensure that they are consistent with the latest evidence on the topics.”

According to the updated list, SGIM does not recommend:

1. daily home glucose monitoring in patients with type 2 diabetes mellitus who are not on insulin;
2. performing routine annual checkups unless patients are likely to benefit and conducting comprehensive physical exams or lab work during checkups;
3. performing preoperative testing before low-risk surgical procedures;
4. cancer screening in adults who have a life expectancy of less than 10 years; and
5. placing or leaving peripherally inserted central catheters (PICCs) for patient or provider convenience.

The recommendations are part of the ABIM Foundation’s “Choosing Wisely” initiative. This is the first time that SGIM has updated its Choosing Wisely list since 2017, according to the organization. Each recommendation is based on recent reviews of management and treatment.

Self-monitoring blood glucose

SGIM said it does not recommend daily home glucose monitoring in patients with type 2 diabetes who are not on insulin because, while statistically significant, it does not produce “clinically important” changes in glucose control. It may also present a burden for elderly patients with cognitive and visual impairments or neurological diseases, and it has been linked to higher depression scores. Self-monitoring also takes away from “the more important cardiovascular risk factors such as hypertension and hyperlipidemia,” the SGIM review authors wrote.

Routine annual checkups

While annual checkups are not recommended for all patients, SGIM noted several factors that would make a patient likely to benefit. These include patients who:

• are overdue for recommended care;
• are at high risk for undiagnosed chronic illness;
• rarely see a primary care provider;
• have low self-rated health; or
• have a high degree of worry.

Patients who do not present any of the factors, as well as younger patients and those with a low risk for chronic conditions, are unlikely to benefit from checkups and should discuss how often checkups should occur with their clinician, according to SGIM.

Speaking to Healio, Jeffrey A. Linder, MD, MPH, FACP, a professor of internal medicine at Northwestern University Feinberg School of Medicine and co-author of SGIM’s recommendation review, said there are other reasons not listed that may warrant annual checkups.

“One could be if the patient is concerned about their health and wants to get it every year,” he said. “Plenty of people have insurance programs where you get something off of your premium if you see your doctor once a year. That is a valid reason to see your doctor.”

Linder acknowledged there has been some initial misinterpretation of this recommendation, emphasizing that SGIM is not telling patients and physicians not to receive and conduct annual checkups.

“It’s just being a little bit more thoughtful about what you’re doing and the potential for accomplishing something productive, both for the doctor and more importantly for the patient when you do have a checkup,” he said.

SGIM also advises against conducting comprehensive physical exams or routine lab testing during annual checkups. Instead, Linder said that physicians should go over a patient’s medical history, medications, family history and any changes in a person’s social history, such as smoking, dieting, drinking and exercise.

“These are all way more important than people give them credit for, versus a lot of the stuff people associate with a doctor’s visit like a physical exam or blood test,” he said.

Linder also highlighted necessary conductive exams like cancer screenings for adults as recommended by the U.S. Preventive Services Task Force, periodic cholesterol tests every 5 years, and HIV and hepatitis C testing at least once, per the CDC.

Ultimately, “the reason we don’t check everybody for everything all the time is that asymptomatic adults were much more likely to turn up something that is actually never going to be a problem for them than we’re going to find something that’s actually going to improve your health and help you live longer or better,” he said.

Linder noted such exams can lead to increased anxiety, inconvenience and danger for the patient, “because we often have to follow these things up and often get to more invasive testing that can expose people to real harms, when the potential for benefit is much, much smaller.”

Preoperative testing for low-risk procedures

SGIM noted that preoperative testing prior to low-risk operations does not improve surgical outcomes and may result in additional costs, testing and delayed surgery, all of which can harm the patient.

“Pre-operative assessment before low-risk procedures should be restricted to a careful history and physical examination and review of chronic medical conditions,” the review authors wrote.

Unnecessary preoperative tests can include blood testing, urine testing, electrocardiograms and chest radiographs.

Cancer screening in patients with low life expectancies

While cancer screenings can be lifesaving in the right situations, SGIM noted that screenings for adults with a life expectancy of less than 10 years are unlikely to live long enough to derive benefits from the screening. Additionally, patients with limited time left are more likely to experience harm due to frailty, making them vulnerable to complications from testing and treatment.

For some patients, disregarding a cancer screening may result in mistrust and other negative emotions. SGIM recommended an approach that focuses on harms vs. benefits of screening in the context of the patient’s health and other factors.

Risks of PICCs

According to SGIM’s review, evidence suggests that PICCs are associated with an increased risk for bloodstream infections in hospitalized patients and an increased risk for deep vein thrombosis of upper extremities and pulmonary embolism.

The outcomes can be related to several factors, which include device characteristics, patient characteristics and provider characteristics. Because PICCs frequently involve patients at high risk for these conditions, SGIM said there is an ongoing need to improve PICC utilization.

Additionally, SGIM noted that the use of PICCs is increasing in non-ICU settings, “posing challenges for monitoring central line-associated infections and assembling homogenous care teams.”

“PICC use in non-intensive care settings necessitates fundamental changes to existing paradigms of care. Moreover, as patients frequently transition with PICCs to outpatient treatment, fragmentation and non-uniform post-discharge care represent perils to safe PICC use,” the authors wrote. “It is necessary to raise awareness of these issues to help ensure positive outcomes and patient safety.”

References:

• As part of Choosing Wisely campaign, SGIM releases updated list of commonly used tests and treatments to question. https://www.sgim.org/about-us/news-and-initiatives/sgim-choosing-wisely-recommendation-updates. Published Jan. 17, 2023. Accessed Jan. 18, 2023.
• Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely--PICC-update-061422.final.pdf. Accessed Jan. 20, 2023.
• Don’t perform routine annual checkups unless patients are likely to benefit; the frequency of checkups should be based on individual risk factors and preferences. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely---Checkups-Recs-20220923.final.authors---web-version.pdf. Accessed Jan. 20, 2023.
• Don’t perform routine pre-operative testing before low-risk surgical procedures. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely--Preop-092022.final.112822_DZ_final.pdf. Accessed Jan. 20, 2023.
• Don’t recommend daily home glucose monitoring in patients with type 2 diabetes mellitus not using insulin. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely--SMBG.092022final.pdf. Accessed Jan. 20, 2023.
• Don’t recommend cancer screening in adults with life expectancy of less than 10 years. https://www.sgim.org/File%20Library/SGIM/Publications/Choosing-Wisely-Cancer-Screening-061022.final.pdf. Accessed Jan. 20, 2023.
• Five things physicians and patients should question. https://www.choosingwisely.org/societies/society-of-general-internal-medicine/.