In 2012, multiple medical societies and consumer groups launched the “Choose Wisely Campaign” challenging medical specialties to identify five common tests or procedures within their field that were often overused and should be questioned by both physicians and patients. These lists were based on evidence and clinical guidelines. Since then, leaders at PALTmed have developed and just released “20 Things Prescribers and Patients Should Question in Post-Acute and Long-Term Care.

Over the years, I’ve shared many of these evidence-based “Pearls” with colleagues and nursing home staff as a great teaching tool for reducing low-value care interventions that also may increase the risk of adverse events or result in the wrong intervention(s) or delay attaining the right diagnosis.

Recently, I was asked to assess a colleague’s older patient who had developed a sudden paranoid psychosis that was so severe, her roommate was moved out of her room, and the patient refused food, fluids, meds, and collection of urine for a “possible UTI”. I assessed her and found she had recently begun a low dose of an antidepressant, but could not detect any other reason for this new behavior. With the approval of her DPOA, I stopped the new med, ordered a brief trial of Seroquel 12.5 mg daily, and requested a Fem-Cath UA since UTI history could not be elicited. Fortunately, her paranoid psychosis resolved within 24 hrs. and did not recur off Seroquel. Unfortunately, the UA returned + for pyuria and > 100K E.coli. Without subsequent UTI symptoms, she had asymptomatic bacteriuria and should not be treated with antibiotics. At this facility, a nurse questioned the decision not to treat with antibiotics, which is addressed in #3 of Choose Wisely: “Don’t obtain urine tests until clinical UTI criteria are met”.

I also recall an older patient I admitted for rehab after cardiac bypass surgery for acute coronary syndrome. He had type 2 diabetes managed preoperatively with metformin with an A1C of 7.0. He was transferred to us off metformin on Humalog SSI (Sliding Scale Insulin) a.c. and h.s. I was concerned about the necessity and safety of the latter order since the patient complained bitterly of insomnia, loss of appetite, reduced short term memory, and felt like his life was over. Instead, I chose Lantus initially six units daily and quickly advanced to ten units daily to obtain safe levels of glycemia with lower risk of hypoglycemia. In addition, I resumed his metformin and began empagliflozin. By the end of the week, I was able to stop Lantus. Choose Wisely #2 recommends avoiding SSI in long-stay residents and gives cogent reasons for doing so. Those same reasons apply to this patient.

I hope you will share the “Top Twenty” with your providers, licensed staff, and even post them for patients and families to see. In a time of scarce resources, we must do more to avoid low value care.

References Documents
Click here for PALTmed’s Choosing Wisely Guide Webpage: https://paltmed.org/choosing-wisely-guide