SOURCE: American College of Chest Physicians

American College of Chest Physicians

October 28, 2013 14:45 ET

The American College of Chest Physicians Releases List of Common but Not Always Necessary Tests or Procedures in Pulmonary Medicine

Group Seeks to Encourage Physician and Patient Conversation

CHICAGO, IL--(Marketwired - October 28, 2013) - The American College of Chest Physicians (ACCP) today at its annual meeting, CHEST 2013, released a list of specific tests or procedures that are commonly ordered but not always necessary in pulmonary medical care. The list was identified by a collaborative task force assembled by the ACCP and the American Thoracic Society (ATS) as part of Choosing Wisely®, an initiative of the ABIM Foundation. Each Choosing Wisely list identifies five targeted, evidence-based recommendations for a given medical specialty that can support conversations between patients and physicians about what care is necessary.

The collaborative task force of the ACCP and ATS identified the following five recommendations in pulmonary care:

1. Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.

In patients with no prior history of cancer, solid nodules that have not grown over a 2-year period have an extremely low risk of malignancy (although longer follow-up is suggested for ground-glass nodules). Similarly, repeating CT scans every 3 months for 2 years or more has not been shown to improve outcomes such as lung cancer mortality. Meanwhile, extended or intensive surveillance exposes patients to increased radiation and prolonged uncertainty.

1. Do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension).

Evidence and clinical practice guidelines have not established benefits of vasoactive agents -- drugs that increase or decrease blood pressure and/or heart rate -- for patients with pulmonary hypertension resulting from left heart disease or hypoxemic -- low level of oxygen in the blood -- lung diseases. Moreover, the use of these agents may cause harm in certain situations and incurs substantial cost and resource utilization.

1. For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia.

Hypoxemia, or abnormally low levels of oxygen in the blood, often resolves after recovery from an acute illness, and continued prescription of supplemental oxygen therapy incurs unnecessary cost and resource use. At the time that supplemental oxygen is initially prescribed, a plan should be established to re-assess the patient no later than 90 days after discharge. Medicare and evidence-based criteria should be followed to determine whether the patient meets criteria for supplemental oxygen.

1. Do not perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.

Clinical practice guidelines for pulmonary embolism indicate that the cost and potential harms of CT angiography (including radiation exposure and the possibility of detecting and treating clinically insignificant pulmonary emboli with anticoagulation) outweigh the benefits for patients with a low pre-test probability of pulmonary embolism.

1. Do not perform CT screening for lung cancer among patients at low risk for lung cancer.

Low dose chest CT screening for lung cancer has the potential to reduce lung cancer death in patients at high risk (i.e., individuals aged 55-74 with at least a 30-pack year history of tobacco use, who are either still smoking or quit within the past 15 years). However, CT screening for lung cancer also has the potential to cause a number of adverse effects (e.g., radiation exposure, high false positive rate, harms related to downstream evaluation of pulmonary nodules, overdiagnosis of indolent tumors). Thus, screening should be reserved for patients at high risk of lung cancer and should not be offered to individuals at low risk of lung cancer.

The complete methodology behind the creation of this pulmonary care list and each recommendation will be published in the ACCP's journal CHEST in 2014. In addition, ACCP is participating on the creation of a similar list for critical care, to be released in early 2014, in collaboration with members of the Critical Care Societies Collaborative.

"The ACCP and ATS task force has shown tremendous leadership by releasing its list of tests and procedures they say are commonly done in pulmonology care, but aren't always necessary," said Richard J. Baron, MD, president and CEO of the ABIM Foundation. "The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what care they need, and what we can do to reduce waste and overuse in our health care system."

To date, over 80 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the conversations about appropriate care. With the release of this new list, the campaign will have covered more than 250 tests and procedures that the specialty society partners say are overused and inappropriate, and that physicians and patients should discuss.

The campaign also continues to reach millions of consumers nationwide through a stable of consumer and advocacy partners, led by Consumer Reports -- the world's largest independent product-testing organization-which has worked with the ABIM Foundation to distribute patient -- friendly resources for consumers and physicians to engage in these important conversations.

To learn more about Choosing Wisely and to view the complete lists and additional detail about the recommendations and evidence supporting them, visit

About ACCP

The ACCP is the global leader in clinical chest medicine, representing 18,700 members who provide patient care in the areas of pulmonary, critical care and sleep medicine in the United States and throughout the world. The mission of the ACCP is to promote the prevention, diagnosis, and treatment of chest diseases through education, communication and research. For information about the ACCP, visit the ACCP website at, or follow the ACCP on Facebook and Twitter and the meeting hashtag, #CHEST2013.

About Choosing Wisely®

First announced in December 2011, Choosing Wisely®is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. Participating specialty societies are working with the ABIM Foundation and Consumer Reports to share the lists widely with their members and convene discussions about the physician's role in helping patients make wise choices. Learn more at

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