Thursday, April 5, 2012

ASN Weighs In on Overutilization and the Choosing Wisely Campaign

An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.

To spark these conversations, nine specialty societies created lists of "Five Things Physicians and Patients Should Question" — evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation.

American Society of Nephrology's Contribution

Top 5 List

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

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