American College of Physicians

HVC Recommendations

About High-Value Care

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations in MKSAP 16.

Cardiovascular Medicine Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Cardiovascular Medicine section of MKSAP 16.

  • Cardiac stress testing is most useful in patients with an intermediate probability of disease, in whom a positive test significantly increases disease likelihood and a negative test significantly decreases likelihood; do not perform cardiac stress testing in patients with either a low or a high pretest probability of disease (see Question 1 and Question 82).
  • Do not perform coronary artery calcium scoring in asymptomatic patients at very low or very high risk of a coronary event.
  • Reserve cardiac stress tests with imaging (echocardiographic or nuclear) for patients who are unable to exercise or have abnormalities on their resting electrocardiogram that may interfere with test interpretation (see Question 28, Question 92, Question 107, and Question 115).
  • Do not obtain echocardiography in asymptomatic patients with innocent-sounding heart murmurs, typically grade 1/6 or 2/6 short systolic mid-peaking murmurs that are audible along the left sternal border (see Question 3).
  • Perform coronary angiography in patients with a history of chronic stable angina in the setting of progressive symptoms despite optimal medical therapy, difficulty tolerating medical therapy, or high-risk findings on exercise testing; there is no role for routine periodic cardiac catheterization in patients with chronic stable angina and well-controlled symptoms as it has not been shown to improve outcomes and carries risk (see Question 99).
  • Do not order routine stress testing or routine electrocardiography for asymptomatic patients following successful percutaneous coronary intervention.
  • Do not order serial echocardiography for the assessment of chronic heart failure unless the patient’s clinical status changes.
  • Reserve the B-type natriuretic peptide (BNP) test to differentiate between a cardiac and pulmonary cause of dyspnea when the diagnosis is unclear; do not routinely measure BNP in patients with typical signs and symptoms of heart failure.
  • In patients who develop heart block following a myocardial infarction, delay the decision to implant a permanent pacemaker for several days to determine whether the heart block is transient or permanent.
  • Do not prescribe antibiotic prophylaxis before any procedure (including dental procedures) in patients with native valvular disease unless there is a history of endocarditis.
  • Perform echocardiography in patients with known mild aortic stenosis in the setting of new or progressive symptoms, but do not obtain routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3 to 5 years.
  • Do not routinely repeat echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function.
  • Avoid combination treatment with an antiplatelet agent and warfarin for the treatment of peripheral arterial disease because it is no more effective than antiplatelet therapy alone and carries a higher risk of life-threatening bleeding.
  • Treat patients with stable claudication symptoms with medical therapy and exercise and not percutaneous or surgical revascularization because the rate of progression to critical limb ischemia and limb loss is less than 5% annually (see Question 91).
  • Do not refer asymptomatic patients for patent foramen ovale closure to prevent stroke because the available procedures are not effective.
  • Do screen asymptomatic men aged 65 to 75 years who have ever smoked with a one-time abdominal ultrasonographic screening to look for abdominal aortic aneurysm; do not repeat this screening after a normal study.

Dermatology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Dermatology section of MKSAP 16.

  • Use white petrolatum to treat hand dermatitis because it is an inexpensive, readily available, and effective moisturizer.
  • Use over-the-counter topical antifungal agents (miconazole, clotrimazole, terbinafine) to treat superficial dermatophyte infections that do not involve the scalp, hair follicles, or nails (see Question 53).
  • Do not use serology for the diagnosis of herpes simplex virus infections as it is usually not helpful because most adults are seropositive.
  • Do not use topical antiviral treatment for herpes simplex virus infections because they are expensive and hasten wound healing only by a small margin; treatment with oral antiviral therapies is recommended when treatment is felt to be necessary.
  • Use a simple nonstick dressing over white petrolatum for the treatment of most simple cuts and scrapes and avoid many types of expensive wound dressings that are commercially available (see Question 69).
  • Do not use topical corticosteroids or antihistamines to treat neuropathic itch. Application of cool packs or ice may provide symptomatic relief (see Question 44).
  • Do not use prophylactic systemic antibiotics for patients with Stevens-Johnson syndrome or toxic epidermal necrolysis because of risks of antibiotic resistance and drug side effects without evidence of clinical benefit (see Question 22).
  • Treat onychomycosis only if it is bothersome or associated with an infectious risk. Oral antifungal therapy is the most effective approach when treatment is indicated (see Question 21).

Endocrinology and Metabolism Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Endocrinology and Metabolism section of MKSAP 16.

  • The older diabetic agents, such as insulin, the sulfonylureas, and metformin, have proven long-term glycemic control and cost effectiveness (see Question 35).
  • For most patients with type 2 diabetes mellitus, lifestyle modifications and metformin therapy are the best initial treatments (see Question 11).
  • Cost concerns are a factor in determining which pharmacologic agents for diabetes mellitus are used because the newer insulin preparations (insulin glargine, detemir, aspart, lispro, and glulisine) are far more expensive than regular insulin or neutral protamine Hagedorn (NPH) insulin (see Question 35).
  • Repeated or serial measurements of antithyroid antibody titers are not recommended in the management of thyroid disorders in most persons because the degree of a titer’s elevation does not indicate a need for treatment; only an abnormal TSH level does.
  • A thyroid scan and radioactive iodine uptake test are not useful in the evaluation of patients with hypothyroidism.
  • Ultrasonography is recommended for imaging thyroid nodules, with fine-needle aspiration biopsy reserved for nodules larger than 1 cm in diameter.
  • Patients with asymptomatic stable simple goiters can be serially monitored clinically; serial ultrasonography is not recommended for these goiters.
  • The best initial test for male hypogonadism is a morning (8 AM) measurement of the total testosterone level; if this level is normal, then hypogonadism is excluded (see Question 21 and Question 51).
  • Screening woman for osteoporosis with bone mineral density measurements (using dual-energy x-ray absorptiometry [DEXA]) should not begin before age 65 years unless the patient has a particularly high risk for osteoporosis (risk factors such as a previous fracture, glucocorticoid use, a family history of hip fracture, current tobacco use, alcoholism, or secondary osteoporosis).
  • Do not screen women who are premenopausal for osteoporosis.
  • Do not repeat bone mineral density testing before 10 years in patients with normal or low normal values on previous testing.
  • No clear benefit of newer bisphosphonate drugs has been demonstrated compared with older agents, which are available in generic form and may be more cost-effective for long-term therapy.

Gastroenterology and Hepatology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Gastroenterology and Hepatology section of MKSAP 16.

  • Use a trial of proton pump inhibitor therapy rather than endoscopy for patients with suspected gastroesophageal reflux disease without alarm symptoms (see Question 15 and Question 69).
  • Do not perform repeat endoscopy to confirm ulcer healing for uncomplicated duodenal ulcers unless the patient remains symptomatic despite treatment.
  • For patients who have a history or high risk of ulcer disease, use standard-dose proton pump inhibitors as first-line therapy for prophylaxis of NSAID-related ulcers because they are as effective as high-dose proton pump inhibitors (see Question 43).
  • Do not routinely perform stool studies (fecal leukocytes, stool culture, ova and parasites, Clostridium difficile toxin assay) for patients with acute diarrhea, because the vast majority of patients will have a self-limited viral gastroenteritis that responds to supportive care (see Question 4).
  • Do not repeat colonoscopy within 5 years of an index colonoscopy in asymptomatic patients with low-risk adenomas (1 to 2 adenomas, <1 cm, tubular morphology, and low-grade dysplasia).
  • Patients with a small number of hyperplastic polyps should be screened according to general population guidelines (every 10 years).
  • The best serologic test to screen for celiac disease is the tissue transglutaminase (tTG) IgA antibody, but the sensitivity (69%-93%) and specificity (96%-100%) vary significantly among laboratories (see Question 10).
  • Caution should be used when ordering tests for serologic and genetic markers for diagnosis of inflammatory bowel disease, because a false-positive result can lead to unnecessary testing and higher insurance premiums, and false negatives can lead to neglect of a proper evaluation.
  • Observation, not cholecystectomy, is recommended for adult patients with asymptomatic gallstones (see Question 42).

General Internal Medicine Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the General Internal Medicine section of MKSAP 16.

  • The value of the periodic health examination for healthy, asymptomatic adults is debatable and there is no consensus interval.
  • The U.S. Preventive Services Task Force recommends against screening for the following conditions: carotid artery stenosis, COPD, hereditary hemochromatosis, and peripheral arterial disease.
  • According to the U.S. Preventive Services Task Force, screening for coronary artery disease is not recommended in low-risk persons, and the evidence for screening highrisk persons is inconclusive, as is the evidence for screening using nontraditional risk factors, such as high-sensitivity C-reactive protein, homocysteine level, Lp(a) lipoprotein level, ankle-brachial index, carotid intima-media thickness, and coronary artery calcium score.
  • The U.S. Preventive Services Task Force recommends against routine screening for hepatitis C virus infection in the general population.
  • The U.S. Preventive Services Task Force recommends against screening for asymptomatic bacteriuria in men and nonpregnant women.
  • Evidence for the benefits of screening mammography is lacking for women age 75 years and older.
  • The American Cancer Society does not recommend using MRI for breast cancer screening in average-risk women and finds the evidence regarding breast self-examination to be insufficient.
  • Owing to poor specificity, cervical cancer screening with human papillomavirus (HPV) DNA testing alone is not recommended, although clinicians can consider using HPV DNA testing along with cervical cytology in women age 30 years and older to help guide further investigation and decrease the frequency of testing (see Question 34).
  • Owing to limitations of currently available screening tests and unclear benefits of screening, prostate cancer screening remains controversial (see Question 49).
  • The American College of Physicians and the American Academy of Family Physicians both recommend that clinicians have individualized discussions with their patients regarding obtaining prostate-specific antigen (PSA) measurements and support obtaining PSA levels after such discussions in patients 50 years and older who have life expectancies of at least 10 years (see Question 49).
  • Palliative care consultation programs are associated with significant hospital cost savings, with an adjusted net savings of $1696 in direct costs for patients discharged alive from the hospital and $4908 net savings for patients dying in the hospital as compared with patients who receive usual care (see Question 76).
  • Evidence suggests that more aggressive care at the end of life—whether prolonged hospitalization, intensive care unit admission, or performance of procedures—does not improve either quality or duration of life (see Question 89).
  • Feeding tubes are not recommended for terminal cancer.
  • There is no specific role for diagnostic testing in the assessment and management of chronic noncancer pain because abnormalities that are identified may not be the source of the patient’s pain (see Question 117).
  • Routine antibiotic treatment of uncomplicated upper respiratory tract infections and acute bronchitis in nonelderly immunocompetent patients is not recommended (see Question 13).
  • Patients with chronic fatigue for longer than 1 month rarely have abnormalities on either physical or laboratory evaluation; testing should thus be judicious and performed only when clearly indicated (see Question 7).
  • Patients with chronic fatigue syndrome should have regular follow-up to monitor their symptoms, for support and validation, and to avoid unnecessary diagnostic and treatment interventions.
  • Tests with the lowest likelihood of affecting diagnosis or management of syncope include head CT scan, carotid Doppler ultrasonography, electroencephalography, and cardiac enzyme levels; these studies may be indicated if symptoms point to specific etiologies but otherwise should be omitted from the work-up (see Question 86 and Question 156).
  • Neurocardiogenic and orthostatic syncope both are generally benign in nature and do not require hospitalization (see Question 86).
  • Patients with nonspecific low back pain and no symptoms or signs to suggest systemic illness should not routinely receive additional diagnostic testing (see Question 91).
  • Mechanical neck pain outside of the setting of acute trauma rarely requires imaging, although plain films can be helpful in patients older than 50 years to exclude malignancy and to assess for osteoarthritic changes (see Question 37).
  • A repeat lipid screening interval of 5 years is considered appropriate in low-risk patients, with a shorter interval in those with borderline results and a longer interval in those with consistently normal results.
  • Several nontraditional risk factors may be related to cardiovascular outcomes, including levels of Lp(a) lipoprotein, small LDL particles, HDL subspecies, apolipoproteins B and A-1, and the total cholesterol/HDL cholesterol ratio; however, the U.S. Preventive Services Task Force and updated National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines do not recommend measuring or treating any of these risk factors when managing lipid levels (see Question 66).
  • The benefits of statin therapy are generally class specific, and there is no compelling evidence that newer agents are more effective than established statin medications, which may be more cost effective.
  • Because the risk of significant liver or muscle damage is very low in patients on statin therapy, routine follow-up testing is not indicated and should be performed based on the development of symptoms or other clinical findings while on therapy (see Question 158).
  • Cardiovascular primary prevention with statin therapy in older patients (ages 65-80 years) is controversial.
  • Because many episodes of erectile dysfunction are transient, an extensive laboratory evaluation is not mandatory at presentation without symptoms or findings suggestive of an underlying systemic disorder or before implementing lifestyle modification or counseling therapy.
  • In adult men, asymptomatic hydroceles and varicoceles can usually be diagnosed clinically and generally do not require advanced imaging or treatment.
  • Intrauterine devices (IUDs) combine the highest contraceptive efficacy (typical failure rate <1%) with the lowest cost.
  • Initial evaluation of women with dysmenorrhea includes a thorough history, with particular attention to sexual activity and risks for abuse or infection; unless pelvic pathology is suspected (previous radiation, trauma, infection, foreign body), treatment may be initiated without further evaluation (see Question 131).
  • There is no role for antibiotic eye drops in the treatment of viral conjunctivitis (see Question 11).
  • Treatment of allergic conjunctivitis includes oral antihistamines, topical antihistamines, and artificial tears; antibiotic treatment is not indicated.
  • Imaging of the central nervous system is not considered part of a routine evaluation for bilateral hearing loss.
  • For the diagnosis of sinusitis, imaging is rarely necessary in an average-risk patient; however, it should be considered in immunocompromised patients at risk for unusual organisms, such as fungal or pseudomonal sinusitis (see Question 107).
  • Empiric antibiotic treatment for acute pharyngitis not based on a clinical decision tool (such as the Centor criteria) should be discouraged (see Question 161).
  • In the management of epistaxis, unless the patient has severe bleeding or has an associated systemic disease, laboratory studies and imaging are usually not necessary (see Question 4).
  • In patients with dental infections without cellulitis or systemic symptoms, antibiotic therapy is not necessary if dental intervention can be performed within several days.
  • Visualizing a hemorrhoid or other source of rectal bleeding in a low-risk patient younger than 40 years without other symptoms to suggest inflammatory bowel disease or colon cancer may spare the patient further endoscopic evaluation (see Question 48).
  • When a somatoform disorder is suspected, laboratory and other testing should be ordered logically to evaluate plausible medical diagnoses; extensive and elaborate testing to explore unsupported or very unlikely diagnoses should be avoided (see Question 85).
  • Frequent, routine review to verify need for medication and appropriate dosing is an important aspect of optimal geriatric care (see Question 46).
  • Interventions to prevent pressure ulcers are much more cost effective than the prolonged and intensive efforts required for treatment of existing ulcers (see Question 24).
  • Comprehensive batteries of laboratory testing, chest radiographs, and electrocardiograms should not be routinely performed in the preoperative setting without specific indication as they may result in further testing, delay surgery, and add expense, and such testing rarely influences perioperative care (see Question 8).
  • Preoperative tests should be based on known or suspected comorbidities and should only be ordered when a result will alter management (see Question 8).
  • Comprehensive preoperative testing has not been shown to be helpful in cataract surgery and is not endorsed by any major specialty society or payor.
  • Preoperative pulmonary function testing should be reserved for patients with unexplained dyspnea (see Question 47).
  • Laboratory testing for underlying bleeding disorders and anemia should be reserved for patients in whom there is a reasonable probability of an abnormal test and is not required as a routine component of preoperative evaluation (see Question 8).
  • Blood transfusion is reserved for patients with symptomatic anemia, a preoperative hemoglobin concentration below 6 g/dL (60 g/L), postoperative hemoglobin concentration below 7 g/dL (70 g/L), or patients with symptomatic cardiovascular disease and hemoglobin concentrations between 6 and 10 g/dL (60 and 100 g/L).

Hematology and Oncology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Hematology and Oncology section of MKSAP 16.

  • Do not institute therapy in patients with asymptomatic multiple myeloma.
  • Perform an abdominal fat pad aspirate or bone marrow biopsy as a less invasive method for diagnosing AL amyloidosis (see Question 40).
  • Do not treat asymptomatic paroxysmal nocturnal hemoglobinuria in the absence of hemolysis.
  • Use ferrous sulfate, 325 mg three times daily, as the least expensive preparation for treating iron deficiency (see Question 61).
  • Do not add ascorbic acid to facilitate absorption of oral iron salts in the treatment of iron deficiency.
  • Do not perform intrinsic factor antibody testing in diagnosing pernicious anemia.
  • Treat cobalamin deficiency with oral cobalamin, 1000 to 2000 µg/d orally, instead of parenteral therapy (see Question 28).
  • To establish a diagnosis of folate deficiency, institute a therapeutic trial of folate after cobalamin deficiency is excluded.
  • Do not initiate iron replacement therapy in patients with inflammatory anemia (see Question 26).
  • Do not screen for hereditary hemochromatosis in the general population.
  • Most patients with immune thrombocytopenic purpura do not require a bone marrow biopsy to establish the diagnosis; reserve bone marrow biopsy for patients with atypical findings including anemia or leukopenia (see Question 23).
  • In adults with immune thrombocytopenic purpura, reserve therapy for patients with platelet counts lower than 30,000 to 40,000/µL (30-40 × 109/L) or with bleeding (see Question 23).
  • The likelihood of heparin-induced thrombocytopenia should be calculated using the “4T score” prior to diagnostic testing or treatment.
  • Do not routinely perform thrombophilia testing in patients with venous thromboembolism; in most instances, the results will not influence treatment duration.
  • Use pretest probability models to determine the diagnostic likelihood of deep venous thrombosis and pulmonary embolism in outpatients; patients with low pretest probability scores and a normal D-dimer assay do not require imaging studies.
  • Low-molecular-weight heparin (LMWH) rather than unfractionated heparin should be used whenever possible for the initial inpatient treatment of deep venous thrombosis; unfractionated heparin or LMWH is appropriate for the initial treatment of pulmonary embolism (see Question 29).
  • Outpatient treatment of deep venous thrombosis, and possibly pulmonary embolism, with low-molecular-weight heparin is safe and cost-effective for carefully selected patients and should be considered if the required support services are in place.
  • Preoperative coagulation screening is recommended only in patients with a personal or family history of mucocutaneous or postsurgical bleeding; there is no indication for routine coagulation screening of most surgical patients.
  • Hematologic evaluation for anemia in pregnant women is necessary only in patients with marked anemia, additional cytopenias, abnormal reticulocyte counts, or abnormal cellular indices.
  • In pregnant women with microcytic anemia and no obvious blood loss, empiric oral iron supplementation is appropriate, and additional evaluation is not necessary.
  • There is no benefit to routine erythrocyte transfusion during pregnancy in patients with sickle cell anemia.
  • No data support superiority of cesarean or vaginal delivery in pregnant patients with sickle cell anemia.
  • Do not use screening blood tests (including tumor markers) and imaging (except for mammography) in the routine follow-up of otherwise asymptomatic patients with a history of treated breast cancer and no specific findings on clinical examination (see Question 123).
  • Perform BRCA1/BRCA2 testing only in high-risk patients and only when the results will be likely to change management of the patient or family members (see Question 83).
  • Manage patients with low-risk prostate cancer and a life expectancy of less than 10 years with observation and palliation if necessary (see Question 84).
  • Do not routinely use transrectal ultrasonography to diagnose prostate cancer in a patient with an abnormal prostate-specific antigen value or an abnormal digital rectal examination, because it is associated with a high-false negative rate, and patients with a normal ultrasound will still require a biopsy.
  • Testicular cancer staging should include a CT scan of the abdomen and pelvis, chest CT (if pulmonary symptoms or with abnormal chest radiograph), and serum tumor markers (α-fetoprotein, β-human chorionic gonadotropin, and lactate dehydrogenase levels); PET scanning is associated with frequent false-negative results and is not recommended.
  • Do not use PET scanning in routine postoperative colorectal cancer surveillance (see Question 143).
  • Follow-up imaging is not necessary in low-risk individuals (never-smokers, no history of a first-degree relative with lung cancer or significant radon or asbestos exposure) with incidentally found pulmonary nodules (see Question 81).
  • Young, otherwise asymptomatic patients with lymphadenopathy and benign clinical features (small mobile lymph nodes, present for a short duration, in the cervical and inguinal regions) only need reassurance and clinical follow up, not additional laboratory or imaging studies.
  • To attempt induction of remission of gastric mucosa-associated lymphoid tissue lymphoma, use antimicrobial agents and proton pump inhibitors as initial treatment instead of surgery or chemotherapy (see Question 80).
  • Do not treat asymptomatic patients with chronic lymphocytic leukemia and good-risk prognostic findings, regardless of the leukocyte count.
  • The presence of tumor markers in patients with cancer of unknown primary (CUP) site is rarely diagnostic, and an undirected initial screening for carcinoembryonic antigen, CA-19-9, CA-15-3, CA-125, and other markers is unwarranted.
  • PET scanning has not been shown to improve outcomes in patients with cancer of unknown primary site and is not recommended as part of the standard evaluation.
  • Patients with cancer of unknown primary site and disseminated adenocarcinoma have an unfavorable prognosis, regardless of the degree of differentiation, and should not receive aggressive platinum-based chemotherapy regimens.
  • Observation alone is an acceptable standard management option for asymptomatic patients with resected melanoma versus routine surveillance imaging studies (CT, MRI, and PET), which have low yield and a fairly high false-positive rate (see Question 102).

Infectious Disease Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Infectious Disease section of MKSAP 16.

  • Do not use latex agglutination tests to identify the cause of bacterial meningitis because results of these tests rarely change treatment.
  • Pre-lumbar puncture CT scans are only recommended in patients with a suspected mass lesion; who are immunocompromised; who have a history of central nervous system disease; or who present with new-onset seizures, decreased level of consciousness, focal neurologic deficits, or papilledema.
  • The diagnosis of skin infections is typically based on clinical findings, not blood, skin, or biopsy cultures.
  • Incision and drainage is the primary therapy for a cutaneous abscess, and possibly, antibiotic treatment, depending on extent and severity of infection.
  • Ulcers that are clinically uninfected (that is, without purulence or inflammation) should not be treated with antibiotics.
  • Blood cultures, sputum Gram stain and culture, and pneumococcal and Legionella urine antigen testing are optional in outpatients with community-acquired pneumonia (see Question 79).
  • Once patients with pneumonia are ready to switch to oral therapy, most can be safely discharged without observation (see Question 46).
  • Follow-up chest imaging is not indicated in most patients with pneumonia who improve with treatment but should be considered in those who are older than 40 years of age and smokers.
  • Serologic testing is not recommended for patients with early Lyme disease because a measurable antibody response may not have had time to develop (see Question 23).
  • Serologic testing for Lyme disease should be restricted to patients with clinically suggestive signs or symptoms who either reside in or have traveled to an endemic area.
  • Urine culture is usually not needed for patients with an uncomplicated urinary tract infection because results rarely change management.
  • Urologic investigation, including CT and/or ultrasonography, should be restricted to those with pyelonephritis who have persistent flank pain or fever after 72 hours of antimicrobial therapy.
  • Screening for and treatment of asymptomatic bacteriuria is indicated only in pregnant women and patients undergoing invasive urologic procedures (see Question 85).
  • Do not obtain MRIs to follow treatment response of patients with osteomyelitis because results are not very specific and can lead to additional unwarranted therapy.
  • Do obtain blood cultures in patients with suspected vertebral osteomyelitis because such culture results are positive in more than 50% of patients and can minimize the extent of the evaluation.
  • Do not obtain stool cultures in otherwise healthy patients with diarrhea unless they have had symptoms for longer than 3 days, associated fever, or bloody or mucoid stools because results rarely change management (see Question 48).
  • Do not obtain stool cultures in hospitalized patients with diarrhea after they have been in the hospital longer than 3 days.
  • Do not send formed stool for Clostridium difficile toxin testing because positive results are more likely to reflect colonization than active infection.
  • Do not send stool for ova and parasites testing in patients with diarrhea lasting fewer than 7 days.
  • HIV viral load testing should only be used to diagnose patients with suspected acute-phase HIV and to monitor the efficacy of antiretroviral treatment.
  • When influenza virus infection has been documented in the community, a diagnosis can be established clinically and rapid influenza diagnostic tests are unnecessary.
  • Prophylactic or therapeutic antiviral therapy should be avoided in persons at low risk for or with equivocal clinical findings of influenza virus infection (see Question 43).
  • Use newer antimicrobial agents only when clearly indicated and when appropriate treatment options are unavailable because they are expensive and need to be reserved for the most serious infections.

Nephrology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Nephrology section of MKSAP 16.

  • Kidney ultrasonography is safe, not dependent upon kidney function, noninvasive, and relatively inexpensive and may be used to diagnose urinary tract obstruction, cysts, and mass lesions as well as to assess kidney size and cortical thickness (see Question 90).
  • Although home blood pressure monitors are usually not reimbursed by insurers, their relatively low cost (usually less than $100) and reasonable accuracy have made them attractive components to the management of hypertension.
  • There is wide variability in the cost of antihypertensive medications; newer and more expensive agents have not been shown to be significantly safer or more effective than many older, well-established medications that are available in generic form.
  • Fixed combinations of antihypertensive medications offer less dosing flexibility and are often substantially more expensive than prescribing the component medications independently.
  • Lifestyle modifications, including weight loss, reduction of dietary sodium intake, aerobic physical activity of at least 30 minutes a day at least three times a week, and a reduction in alcohol consumption, are a relatively cost-effective way to reduce high blood pressure (see Question 6 and Question 102).
  • Only consider evaluating for secondary causes of hypertension when there is onset at a young age, no family history, no risk factors, rapid onset of significant hypertension, abrupt change in blood pressure in a patient with previously good control, or a concomitant endocrine abnormality (see Question 43, Question 58, Question 62, Question 91, and Question 107).
  • The benefit of ultrafiltration for fluid removal over adequately dosed diuretics is unproved, especially when the risk of the procedure (central line placement) and increased hypotension are considered.
  • Rasburicase is considerably more expensive than allopurinol and is therefore used primarily in patients with high risk for tumor lysis syndrome or if excessively high uric acid levels occur in the context of chemotherapy (see Question 3).
  • Plain abdominal radiography has no role in the acute diagnosis of kidney stones (see Question 21 and Question 75).
  • Cinacalcet is currently the only calcimimetic agent available; this agent is very expensive, and its role in patients with chronic kidney disease has not yet been defined (see Question 42).
  • There is no role for the routine measurement of erythropoietin levels in patients with chronic kidney disease (see Question 105).
  • Hospice services are infrequently utilized for patients with end-stage kidney disease who choose to avoid or withdraw from dialysis but would be a potential benefit.

Neurology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Neurology section of MKSAP 16.

  • Do not routinely order neuroimaging or other diagnostic tests (electroencephalography, lumbar puncture, or blood testing) in patients with primary headaches; the diagnostic yield of a brain MRI or a head CT scan in patients with a chronic headache and no other concerning signs or symptoms is less than 1% (see Question 58).
  • Do not use the combination of aspirin and clopidogrel for secondary prevention of stroke because this combination has no additional benefit over a single antiplatelet agent alone and has a higher risk of bleeding (see Question 34).
  • Order CT of the head rather than MRI of the brain to rule out an intracerebral hemorrhage, subarachnoid bleeding, or hydrocephalus in a patient with an acute stroke because CT is more cost-effective, less time consuming, and more readily available than MRI (see Question 7 (Revised)).
  • Treat neuropathic pain with generic tricyclic antidepressants (amitriptyline and nortriptyline) because they are generally better tolerated and much less expensive than pregabalin, although their use may be limited by the development of anticholinergic adverse effects.
  • After brain death has been established with apnea testing, do not perform confirmatory testing with electroencephalography or transcranial Doppler ultrasonography because it is unnecessary (see Question 8 (Revised)).

Pulmonary and Critical Care Medicine Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Pulmonary and Critical Care Medicine section of MKSAP 16.

  • Omalizumab is recommended only for patients with severe asthma who have allergies, an elevated IgE level, and persistent symptoms despite optimizing therapy with combination therapy of high-dose inhaled corticosteroids and a long-acting β2-agonist (see Question 73).
  • Smoking cessation is the single most clinically effective and cost-effective way to prevent COPD, slow progression of established disease, and improve survival.
  • Spirometry is essential for the diagnosis of COPD, although testing for airflow limitation should not be performed in asymptomatic individuals as a screening intervention (see Question 81).
  • Roflumilast is a very expensive medication with significant side effects (diarrhea, weight loss, nausea, headache, anxiety, insomnia, and depression), and it should be reserved for patients with severe disease not adequately controlled on other COPD medications (see Question 85).
  • In multiple randomized trials, noninvasive positive pressure ventilation reduced the need for intubation, shortened hospital stays, and decreased mortality in patients with moderate to severe COPD exacerbations (see Question 61).
  • In the intensive care unit, daily interruption of sedation and spontaneous breathing trials lead to sooner extubation and lower rate of mechanical ventilation.
  • Ventilator-associated pneumonia can be prevented by the routine use of protocols that require elevating the head of the bed by 30 degrees and hastening time to extubation.
  • In patients with septic shock, the efficacy of crystalloid or colloid is likely equivalent; however, colloid is far more expensive (see Question 26).
  • High-dose corticosteroids are of no benefit in sepsis and have been shown to harm patients in earlier studies; intravenous hydrocortisone is appropriate in septic shock only if blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy (see Question 26).
  • The combination of history, physical examination, serology, and characteristic radiographic studies can often lead to a firm diagnosis and obviate the need for an open lung biopsy in up to 60% or more of patients with diffuse parenchymal lung disease.
  • Examination of previous chest imaging is critical in pulmonary nodule evaluation and may show that a nodule is stable, growing, or shrinking over time.
  • Solid pulmonary nodules that remain stable in size for 2 years on chest radiograph or CT scan are considered benign, and no further follow-up is indicated; this is known as the 2-year stability rule.
  • Calcification in a benign pattern (central, diffuse, lamellar) indicates that a pulmonary nodule is a granuloma and requires no further investigation (see Question 6).
  • In order to limit unnecessary invasive testing, the diagnosis and staging of lung cancer is best done simultaneously.
  • PET scanning and integrated PET-CT are valuable tools in the evaluation of non–small cell lung cancer; they have been shown to be cost effective owing to avoidance of unnecessary surgery in one out of five patients whose disease was previously considered resectable.
  • Thoracentesis is not necessary in patients who develop small pleural effusions associated with heart failure, pneumonia, or heart surgery.
  • Chest CT exposes patients to doses of radiation that are forty times higher than chest radiography; therefore, the benefit of CT in clinical evaluation should be weighed against the radiation exposure, especially in younger patients who are more vulnerable to radiation-induced malignancy (see Question 34).
  • The use of well-validated scoring systems to generate pretest clinical probability of pulmonary embolism is essential to guide diagnostic test selection (see Question 79, Question 89, and Question 94).
  • In clinically stable patients with a low pretest probability of pulmonary embolism, a normal D-dimer assay effectively excludes pulmonary embolism and eliminates the need for further testing (see Question 79).

Rheumatology Recommendations

High-Value Care Recommendations

The American College of Physicians, in collaboration with multiple other organizations, is embarking on a national initiative to promote awareness about the importance of stewardship of health care resources. The goals are to improve health care outcomes by providing care of proven benefit and reducing costs by avoiding unnecessary and even harmful interventions. The initiative comprises several programs that integrate the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of trainees, practicing physicians, and patients.

To integrate discussion of high-value, cost-conscious care into MKSAP 16, we have created recommendations based on the medical knowledge content that we feel meet the below definition of high-value care and bring us closer to our goal of improving patient outcomes while conserving finite resources.

What is a High-Value Care Recommendation? A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High-Value Care Recommendations for the Rheumatology section of MKSAP 16.

  • Do not obtain an antinuclear antibody test in patients with nonspecific symptoms such as fatigue and myalgia or in patients with fibromyalgia.
  • The diagnosis of periarthritis (bursitis, tendinitis) is based upon the history and physical examination; laboratory testing and imaging are unnecessary (see Question 59 and Question 76).
  • Do not perform an MRI in patients with suspected carpal tunnel syndrome, because the diagnostic utility of MRI in this setting is unclear (see Question 81).
  • Methotrexate may be used as the initial disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis treatment; this agent is usually better tolerated than other DMARDs and also has good efficacy, long-term compliance rates, and a relatively low cost (see Question 28 and Question 67).
  • When sacroiliitis is suspected, begin with plain radiography and only proceed to MRI of the sacroiliac joints in patients with high clinical suspicion and negative plain radiographs (see Question 41).
  • Patients with ankylosing spondylitis are monitored clinically; do not use periodic CT or MRI to monitor disease activity and response to treatment.
  • Treat patients with podagra (inflammation of the first metatarsophalangeal joint) empirically for gout and do not perform joint aspiration, because gout is common and infection uncommon in this location.
  • Do not use uric acid–lowering drugs for gout prophylaxis in patients who have had single or very rare (<2 per year) attacks; these patients can be managed expectantly, because next attacks may be quite delayed.
  • Do not treat patients with asymptomatic hyperuricemia (see Question 52).
  • A kidney or lung biopsy is unnecessary in patients with a classic presentation of granulomatosis with polyangiitis (also known as Wegener granulomatosis) and positive c-ANCA (antiproteinase-3 antibodies); reserve biopsy for patients with atypical presentations.