Family Medicine
College of Family Physicians of Canada Last updated: September 2023
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Treating Asymptomatic Bacteriuria (ASB) does not improve clinical outcomes (including altered mental state) but may increase adverse events from 1% to 7%. In older patients with ASB and altered mental state, antibiotics should be avoided without clear signs/symptoms of infection.
Sources:
Young J, Pasay D, Allan G M. Asymptomatic bacteriuria in the elderly: Don’t drug the bugs? Tools for Practice, March 6, 2023.
Nicolle LE, Gupta K, Bradley SF et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. PMID: 30895288.
See other Choosing Wisely Recommendations : Nursing, Geriatrics, Urology, Hospital Medicine, Medical Microbiology, Pathology, Long Term Care.
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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.
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. PMID: 35292455.
Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845.
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The immediate postoperative period or acute episodes of pain typically refers to a time period of three days or less, and rarely more than seven days. Prescribe the lowest effective dose and number of doses required to address the expected pain. This recommendation does not apply to individuals already on long term or chronic opioids or opioid agonist treatment.
Sources:
Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain [Internet]. 2017 Aug 29 [cited 2017 Oct 6].
Scully RE, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surg. 2017 Sep 27. PMID: 28973092.
Shah A, et al. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 17;66(10):265-269. PMID: 28301454.
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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.
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.
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.
The periodic health examination. Canadian Task Force on the Periodic Health Examination. Can Med Assoc J. 1979 Nov 3;121(9):1193-254. PMID: 115569.
US Preventive Services Task Force Guides to Clinical Preventive Services. The Guide to Clinical Preventive Services 2012: Recommendations of the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012.
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
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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 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.
Sources:
Canadian Task Force on Preventive Health Care. Fragility Fractures (2023). [Internet]. Available from: https://canadiantaskforce.ca/guidelines/published-guidelines/fragility-fractures/
Related Resources:
Patient Pamphlet: Bone Density Tests: When you need them and when you don’t
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Routine self-monitoring of blood glucose in patients with Type 2 diabetes who do not use insulin has no clinical benefits, is not cost effective, and may reduce quality of life. Its use in patients with Type 2 diabetes using insulin and those with gestational diabetes may be individualized. Though many suggest using it in patients with newly diagnosed diabetes, there is no evidence for improved glycemic control and it may increase depressive symptoms.
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.
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The primary rationale for screening asymptomatic non-pregnant 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 in non-pregnant adults 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.
Sources:
Allan M, Young J. Helping physicians fatigued by TSH Screening and Subclinical Hypothyroidism. Tools 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. PMID: 31740537.
Best Practice Advocacy Centre New Zealand. Management of thyroid dysfunction in adults [Internet]. BPJ. 2010 Dec;(22):22-33 [cited 2014 Sep 25]. Available from: https://bpac.org.nz/BPJ/2010/December/thyroid.aspx.
U.S. Preventive Services Task Force. Screening for thyroid disease: recommendation statement. Ann Intern Med. 2004 Jan 20;140(2):125-7. PMID: 14734336.
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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.
Sources:
Canadian Association of Radiologists. The 2012 CAR diagnostic imaging referral guidelines [Internet]. 2012 [cited 2017 May 9].
Chou R, et al. Imaging strategies for low-back pain: Systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918.
Centre for Effective Practice. Core Back Tool including Red flags and Yellow flags. [Internet]. 2016.
Williams CM, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010 Feb 8;170(3):271-7. PMID: 20142573.
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001;322(7283):400-405. PMID: 11179160.
Related Resources:
Patient Pamphlet: Imaging Tests for Lower Back Pain: When you need them and when you don’t
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Bacterial infections of the respiratory tract, when they do occur, are generally a secondary problem caused by complications from viral infections such as influenza. While it is often difficult to distinguish bacterial from viral sinusitis, nearly all cases are viral. Though cases of bacterial sinusitis can benefit from antibiotics, evidence of such cases does not typically surface until after at least seven days of illness. Not only are antibiotics rarely indicated for upper respiratory illnesses, but some patients experience adverse effects from such medications.
Sources:
American Academy of Allergy Asthma and Immunology. Sinus infections account for more antibiotic prescriptions than any other diagnosis [Internet]. 2013 Aug 28 [cited 2017 May 9].
Desrosiers M, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2,1492-7-2. PMID: 21310056.
Hirschmann JV. Antibiotics for common respiratory tract infections in adults. Arch Intern Med. 2002 Feb 11;162(3):256-64. PMID: 11822917.
Low D. Reducing antibiotic use in influenza: Challenges and rewards. Clin Microbiol Infect. 2008 Apr;14(4):298-306. PMID: 18093237.
Schumann SA, et al. Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”. J Fam Pract. 2008 Jul;57(7):464-8. PMID: 18625169.
Related Resources:
Patient Pamphlet: Treating Sinusitis: Don’t rush to antibiotics
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There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Chest X-rays for asymptomatic patients with no specific indications for the imaging have a trivial diagnostic yield, but a significant number of false positive reports. Potential harms of such routine screening exceed the potential benefit.
Sources:
Canadian Association of Radiologists. 2012 CAR diagnostic imaging referral guidelines. Section F: Thoracic.
Bouck Z, Calzavara AJ, Ivers NM, et al. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med. 2020 Jul 1;180(7):973-983. PMID: 32511668.
Tigges S, et al. Routine chest radiography in a primary care setting. Radiology. 2004 Nov;233(2):575-8. PMID: 15516621.
U.S. Preventive Services Task Force (USPSTF). Screening for coronary heart disease with electrocardiography. [Internet]. 2012
Related Resources:
Patient Pamphlet: ECG (Electrocardiogram): When you need it and when you don’t
Canadian Task Force on Preventive Health Care: Lung Cancer – 1000 Person Tool
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- Don’t do screening Pap smears annually in those with previously normal results
- Don’t do Pap smears in those who have had a hysterectomy for non-malignant disease.
The potential harm from screening younger than 25 years of age outweighs the benefits and there is little evidence to suggest the necessity of conducting this test annually when previous test results were normal. Those who have had a full hysterectomy for benign disorders no longer require this screening. Screening should stop at age 70 if three previous test results were normal.
Sources:
Canadian Task Force on Preventive Health Care, et al. Recommendations on screening for cervical cancer. CMAJ. 2013 Jan 8;185(1):35-45. PMID: 23297138.
Related Resources:
Patient Pamphlet: Pap Tests: When you need them and when you don’t
Canadian Task Force on Preventive Health Care: Who should be screened for Cervical Cancer?
Canadian Task Force on Preventive Health Care: Should you be screened for Cervical Cancer?
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There is little evidence to indicate there is value in routine blood tests in asymptomatic patients; instead, this practice is more likely to produce false positive results that may lead to additional unnecessary testing. The decision to perform screening tests, and the selection of which tests to perform, should be done with careful consideration of the patient’s age, sex and any possible risk factors.
Sources:
Allan GM, Morros MP, Young J. Subclinical hypothyroidism and TSH screening. Can Fam Physician. 2020;66(3):188. PMID: 32165467.
Allan M, Young J. CFPCLearn. CBC (Confusing Broad Check) for Screening?. May 15, 2017.
Boland BJ, et al. Yield of laboratory tests for case-finding in the ambulatory general medical examination. Am J Med. 1996 Aug;101(2):142-52. PMID: 8757353.
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
Dr. Mike Evans Video: Do More Screening Tests Lead to Better Health?
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Because Canada is located above the 35° North latitude, the average Canadian’s exposure to sunlight is insufficient to maintain adequate Vitamin D levels, especially during the winter. Therefore, measuring serum 25-hydroxyvitamin D levels is not necessary because routine supplementation with Vitamin D is appropriate for the general population. An exception is made for measuring Vitamin D levels in patients with significant renal or metabolic disease.
Sources:
Lindblad AJ, Garrison S, McCormack J. Testing vitamin D levels. Can Fam Physician. 2014 Apr;60(4):351. PMID: 24733326.
British Columbia Guidelines and Protocol Advisory Committee. Vitamin D testing protocol [Internet]. 2013 Jun 1 [cited 2014 Sep 25].
Ontario Association of Medical Laboratories. Guideline for the Appropriate Ordering of Serum Tests for 25-hydroxy Vitamin D and 1,25-dihydroxy Vitamin D [Internet]. 2010 Jun [cited 2014 Sep 25].
Toward Optimized Practice (TOP) Working Group for Vitamin D. Guideline for Vitamin D Testing and Supplementation in Adults [Internet]. Edmonton (AB): Toward Optimized Practice; 2012 Oct 31 [cited 2014 Sep 25].
Related Resources:
Patient Pamphlet: Vitamin D Tests: When you need them and when you don’t
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The mammography recommendation is currently under review. If you have questions, please reach out to info@choosingwiselycanada.org.
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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.
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:
- The College of Family Physicians of Canada Linking Learning to Practice (up to five Mainpro+® certified credits)
- Royal College of Physicians and Surgeons MOC Section 3 credits (Reflecting on your data)
- The College of Physicians and Surgeons of Ontario QI/QA Program
If you have questions or need help getting started, email info@choosingwiselycanada.org.
Bye Bye PPI
A toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings.
Drowsy Without Feeling Lousy
A toolkit for de-prescribing benzodiazepines and other sedative hypnotics in primary care.
Understand the Gland
A toolkit for appropriate ordering practices of free thyroid hormone testing.
Bone Density Tests
When you need them and when you don’t.
ECG (Electrocardiogram)
When you need it and when you don’t.
Health Check-ups
When you need them and when you don’t.
Imaging Tests for Lower Back Pain
When you need them and when you don’t.
Pap Tests
When you need them and when you don’t.
Vitamin D Tests
When you need them and when you don't.