February 13th, 2016

“Choosing Wisely” in HIV Medicine — Sensible (But Safe) Suggestions

doctor and patientThe American Board of Internal Medicine has a noble program called Choosing Wisely®, which is both trademarked (look, I even included the “®”), and pretty darn sensible — it has the goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures.”

If you clicked on the above link, you’ll be taken to the web site, which, in addition to having the obligatory stock photos of earnest doctor-looking people talking to earnest patient-looking people (hey, I have access to some of these too!), also has the specific “Choosing Wisely®” suggestions drawn from various professional societies.

Not surprisingly, all are logical, evidence-driven, and wise. Searching for the term “back pain” brings up 11 recommendations to avoid unnecessary tests and treatments. These range from the simple “Don’t obtain imaging studies in patients with non-specific low back pain” to “Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).”

You get the idea. There’s a ton of back pain out there, and we get way too many spine imaging tests. There are so many unnecessary spine MRIs done in the United States that it’s surprising our population doesn’t have its own magnetic force, pulling nearby metallic objects toward our lower backs. So we should be “Choosing [more] Wisely®” when to do them.

The HIV Medical Association just weighed in, and came up with 5 overused tests, all quite logical.

  1. Avoid unnecessary CD4 cell counts.
  2. Don’t order complex lymphocyte panels when ordering CD4 counts.
  3. Avoid quarterly viral load testing of patients who have durable viral suppression, unless clinically indicated.
  4. Don’t routinely test for CMV IgG in HIV-infected patients who have a high likelihood of being infected with CMV.
  5. Don’t routinely order testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency for patients who are not predisposed due to race/ethnicity.

Good choices, all.

But you might also find that the recommendations are kind of safe, low hanging fruit on the tree of wasteful tests. Furthermore, items #4 and #5, while certainly wasteful (ok, practically useless), are hardly budget-busting diagnostic or therapeutic black holes (to start a new metaphor). These blood tests cost around $50 each; an MRI $2000-3000. And the blood tests are only done once, at the time of a new HIV diagnosis.

In other words, when the policy wonks start talking about rising costs and waste in our healthcare system, they will not be citing G6PD testing in HIV patients.

I shared this opinion with my friend Joel Gallant — because this list sounded just like him — and he confessed that he had a role in its creation “as part of a committee”. (I bet he wrote the whole thing).

I also offered up a few bolder suggestions for avoiding wasteful tests or treatments in HIV care, and he wrote back the following:

We had to be careful not to go against any guidelines.

But if we didn’t have that limitation, anything that you would list? Guidelines- concordant or not?

I’ve got a few ideas, would love to hear yours.

[youtube http://www.youtube.com/watch?v=AotDqbCXJes&w=560&h=315]
(H/T to the other Joel — Joel M — for the video.)

3 Responses to ““Choosing Wisely” in HIV Medicine — Sensible (But Safe) Suggestions”

  1. Cathal O Broin says:

    Those who get 3 monthly lipid checks just because they’re in a HIV clinic! We most certainly go against the lipid guidelines in terms of surveillance of those on statins.

    In contrast, we could order more…
    1. Annual Hep C Ab in MSMs – often forgotten int the ‘birthday bloods’ bundle.
    2. DXA scans for the cirrhotic/>50s/early menopause etc

  2. Jody says:

    I will forward this to our Ryan White funders, who still require ridiculous amounts of unnecessary labs and metrics, in order to meet their guidelines for funding.
    It takes years before they catch-up with HIV treatment guidelines- frustrating and a waste of resources.

  3. Jeff Kirchner says:

    “Our” HIV guidelines need to be updated and can then re-address some of the things noted above by you (and Joel) — I would also encouraged some Primary Care representation by IDSA – if the IDSA guidelines are continued to be called “Primary Care Guidelines” as the first 2 versions have been titled.
    Nov 2013 was the last (Aberg, Gallant et al).
    Many Family Medicine / Internal Medicine physicians who work in HIV care are indeed members of both clubs – AAFP / ACP and IDSA.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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