Family Medicine

Thirteen Tests and Treatments to Question

by
College of Family Physicians of Canada
Last updated: May 2023

Don’t test urine in elderly patients with a change in mental status unless there is clear evidence of infection.
1
Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes.

It is not confirmed that Asymptomatic Bacteriuria (ASB), or even Urinary Tract Infection is clearly associated with altered mental state. Treating ASB does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In elderly patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection.

Co-Benefits:
1. Harm: Overuse and misuse of antibiotics contributes to the rising threat of antibiotic resistance and spread of superbugs.
2. System: Reduces potential for antibiotic shortages for when these medications are truly needed.
3. Climate: Reduce medical waste from packaging and carbon emissions associated with drug manufacturing.
Sources:

Young J, Pasay D, Allan G M. Asymptomatic bacteriuria in the elderly: Don’t drug the bugs? Tools for Practice, March 6, 2023.

Nicholle L, Gupta K, Bradley S et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2019:68 (15 May).

See other Choosing Wisely Recommendations : Nursing, Geriatrics, Urology, Hospital Medicine, Medical Microbiology, Pathology, Long Term Care.

Related Resources:

Using Antibiotics Wisely
Don’t initiate opioids long-term for chronic pain. Recommend and help support physical activity as the foundation for managing osteo-arthritis and chronic low back pain.
2
Opioid use in osteoarthritis and low back pain beyond 4 weeks duration did not show statistically significantly more responders than placebo beyond 4 weeks’ duration, suggesting that the short-term benefit may not persist. Opioids also demonstrated the highest risk of adverse effects, including a number needed to harm (NNH) of 8 to 10 for withdrawal due to adverse effects. No included trials assessed long-term adverse effects including opioid misuse, opioid use disorder, and overdose.

Exercise based programmes showed meaningful pain relief in patients with low back pain and osteoarthritis compared with control.

Co-Benefits:
1. Harm: Chronic or misuse of opioids can lead to physical or psyhciological dependence and increase the risk of overdose.
2. System: Avoid contributing to the opioid crisis.
3. Climate: Reduce medical waste from packaging and carbon emissions associated with drug manufacturing.
Sources:

Korownyk T, Montgomery L, Young J et al. PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care. Canadian Family Physician March 2022, 68 (3) 179-190.

Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189(18):E659-66.
Don’t do annual physical exams on asymptomatic adults with no significant risk factors.
3
Annual health exams for asymptomatic people have not been shown to decrease mortality, change blood pressure and body weight significantly, nor change smoking status. Preventive health visits, used by many family physicians, increase uptake of preventive health interventions like PAP test and colon cancer screening and may decrease patient worry. Other means of achieving cancer screening are being implemented by various provincial programs.

Co-Benefits:
1. Harm: Avoid downstream or unwarranted testing/invesigtations.
2. System: Avoid shortages of medical supplies or labratory technician time in processing tests.
3. Climate: Reduce travel and transportation to medical appointments.
Sources:

Krogsbøll LT, et al. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012 Nov 20;345:e7191. PMID: 23169868.

Boulware LE, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007 Feb 20;146(4):289-300. PMID: 17310053.

Si S, et al. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract. 2014 Jan;64(618):e47-53. PMID: 24567582.

Related Resources:

Patient Pamphlet: Health Check-ups: When you need them and when you don’t

College of Family Physicians of Canada Infographic: Rethinking the Annual Physical Exam and Screening Tests
Don’t order Dual-Energy X-ray Absorptiometry (DEXA) screening for osteoporosis on low-risk patients. Use “risk-assessment first” screening before ordering DEXA.
4
Screening may help reduce the risk of fragility fractures in females over 65 years. The Canadian Task Force on Preventive Health Care (2023) recommends “risk assessment-first” screening for females aged ≥ 65 years as follows:
- Use the results from the Canadian clinical FRAX risk assessment tool results to facilitate a discussion on preventive medication. At this initial assessment, bone mineral density (BMD) measurement is not required.
- After this discussion, if preventive medication is being considered, perform a BMD measurement. Then re-calculate fracture risk by adding the BMD T-score into the FRAX assessment tool.
Screening is not recommended for females under 65 years or for males as evidence was indirect or very uncertain and did not establish a benefit.

Co-Benefits:
1. Harm: Reduce unnecessary exposure to radition from x-rays and CT scans
2. Resources: Reduce imaging wait times and contributing to backlogs in the system
3. Climate: Fewer imaging tests can reduce carbon emissions due to heavy electricity use by imaging equipment.
Don’t advise non-insulin requiring diabetics to routinely self-monitor blood sugars between office visits.
5
Routine self-monitoring of blood glucose in Type 2 diabetics who do not use insulin has no clinical benefits, is not cost effective, and may reduce quality of life. Its use in type 2 diabetics using insulin and those with gestational diabetes may be individualized. Though many suggest using it in newly diagnosed diabetics, there is no evidence for improved glycemic control and it may increase depressive symptoms.
1. Harm: Reduce stress and anxiety associated with checking blood glucose.
2. Resources:
3. Climate: Fewer disposal strips and packaging can reduce medical waste as well as supply costs from production and manufacturing of materials.
Sources:

Allan M, Korownyk T, Turgeon R. Self-Monitoring in Type 2 Diabetics Not Using Insulin: Is it Bitter Sweet? Tools for Practice. August 19, 2016.

Canadian Agency for Drugs and Technologies in Health (CADTH). Optimal therapy recommendations for the prescribing and use of blood glucose test strips. CADTH Technol Overv. 2010;1(2):e0109. PMID: 22977401.

Gomes T, et al. Blood glucose test strips: options to reduce usage. CMAJ. 2010 Jan 12;182(1):35-8. PMID: 20026624.

O’Kane MJ, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008 May 24;336(7654):1174-7. PMID: 18420662.
Don’t order thyroid function tests in asymptomatic patients.
6
The primary rationale for screening asymptomatic patients is that the resulting treatment improves health outcomes when compared with patients who are not screened. There are no RCT or controlled observational studies to assess the value of screening. Treating subclinical hypothyroidism (TSH ~4-10 IU/L and normal T3/T4) showed no benefits in any patient-oriented outcome such as mortality or cardiovascular disease, fatigue, weight, depression, cognitive function or quality of life.

TSH can vary up to 50% between tests and even up to 26% in one day in the same patient. The prevalence of subclinical hypothyroidism is 4-10% in the developing world.
1. Harm: Reduce downstream invesigtations that lead to additional testing/treatments.
2. Resources: Reduce frequency of office visits and need for lab monitoring.
3. Climate: Fewer disposal strips and packaging can reduce medical waste as well as supply costs from production and manufacturing of materials.
Sources:

Allan M, Young J. Helping physicians fatigued by TSH Screening and Subclinical Hypothyroidism. Tool For Practice December 9, 2019.

Birtwhistle R. Morissett K, Dickinson J et al. Recommendation on screening adults for asymptomatic thyroid dysfunction in primary care. CMAJ November 18, 2019;191: (46) E1274-E1280; DOI: https://doi.org/10.1503/cmaj.190395

Best Practice Advocacy Centre New Zealand. Management of thyroid dysfunction in adults [Internet]. BPJ. 2010 Dec;(22):22-33 [cited 2014 Sep 25].

U.S. Preventive Services Task Force. Screening for thyroid disease: recommendation statement. Ann Intern Med. 2004 Jan 20;140(2):125-7. PMID: 14734336.
How the list was created

Recommendations 1-5
The Canadian Medical Association’s (CMA) Forum on General and Family Practice Issues (GP Forum) is a collective of leaders of the General Practice sections of the provincial and territorial medical associations. To establish its Choosing Wisely Canada Top 5 recommendations, each GP Forum member consulted with their respective GP Section members to contribute candidate list items. Items from the American Academy of Family Physicians’ Choosing Wisely® list were among the candidates. All candidate list items were collated and a literature search was conducted to confirm evidence-based support for the items. GP Forum members discussed which of the thirteen items that resulted should be included. Agreement was found on eight of them. Family physician members of the CMA’s e-Panel voted to select five of the eight items. These five items were then approved by the provincial and territorial GP Sections. The College of Family Physicians of Canada is a member observer of the GP Forum and was involved in this list creation process. The first four items on this list are adapted with permission from the Five Things Physicians and Patients Should Question, © 2012 American Academy of Family Physicians.

Recommendations 6 – 11
Items 6 – 11 were selected from ten candidate items that were originally proposed for items 1 – 5. GP Forum members discussed which of these items should be included and agreement was found on eight of them. As was done for the first wave, family physician members of the CMA’s e-Panel voted to select five of the eight items; however, subsequent discussions by the GP Forum resulted in six items being chosen. Feedback on these six items was then obtained from the provincial/territorial GP Sections. The College of Family Physicians of Canada is a member observer of the GP Forum and was involved in this list creation process.

The GP Forum was dissolved as of August 2015.

Recommendations 12 and 13
In late 2016, Choosing Wisely Canada partners – the College of Family Physicians of Canada and the Canadian Medical Association – formed the Pan-Canadian Collaborative on Education for Improved Opioid Prescribing, with the goal to reduce harm from opioids, decrease the variability in prescribing practices, and improve pain management for patients. The Collaborative formally reached out to Choosing Wisely Canada (CWC) in early 2017, requesting its involvement, citing the important role played by CWC in convening professional societies representing different clinical specialties to tackle unnecessary care. As a result, the ‘Opioid Wisely’ was launched in March of 2018 and items 12 and 13 were added to the preexisting family medicine list of 11 things patients and clinicians should question.

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Overuse of Tests and Treatments in Canada

Using Antibiotics Wisely in Primary Care

A campaign to help primary care clinicians use antibiotics wisely in practice.

Opioid Wisely

Encouraging thoughtful conversations about the harms associated with opioid prescribing.

Quality improvement is an important and integral competency for clinicians in Canada’s health care system. Choosing Wisely Canada has a suite of toolkits that can help kick-start your efforts to reduce overuse in primary care settings.

These toolkits can be applied for CPD in the following ways:

If you have questions or need help getting started, email info@choosingwiselycanada.org.