Imaging’s don’t do list: 17 societies make picks

Seventeen medical specialty societies, including the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and Society of Cardiovascular Computed Tomography (SCCT), have released lists of tests, procedures or treatments that are commonly ordered, but which are not always necessary. More than 130 tests and procedures comprise the American Board of Internal Medicine’s Choosing Wisely campaign.

Each specialty society identified five tests or procedures that are commonly performed, but whose use should be questioned.

SNMMI’s recommendations are:

1. Don’t use PET/CT for cancer screening in healthy individuals.
2. Don't perform routine annual stress testing after coronary artery revascularization.
3. Don’t use nuclear medicine thyroid scans to evaluate thyroid nodules in patients with normal thyroid gland function.
4. Avoid using a CT angiogram to diagnose pulmonary embolism in young women with a normal chest x-ray; consider a radionuclide lung study instead.
5. Don't use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in this field.

SCCT’s recommendations are:

1. Don’t use coronary artery calcium scoring for patients with known coronary artery disease (including stents and bypass grafts).
2. Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk.
3. Don’t order coronary artery calcium scoring for screening purposes on low-risk asymptomatic individuals except for those with a family history of premature coronary artery disease.
4. Don’t routinely order coronary CT angiography for screening asymptomatic individuals.
5. Don’t use coronary CT angiography in high-risk emergency department patients presenting with acute chest pain.

Other societies also issued recommendations aimed at curbing unnecessary imaging. These include:

• Don’t automatically use CT scans to evaluate children’s minor head injuries. (American Academy of Pediatrics)
• Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure. (American Academy of Pediatrics)
• CT scans are not necessary in the routine evaluation of abdominal pain. (American Academy of Pediatrics)
• Avoid doing stress tests using echocardiographic images to assess cardiovascular risk in persons who have no symptoms and a low risk of having coronary disease. (American Society of Echocardiography)
• Don’t screen for carotid artery stenosis in asymptomatic adult patients. (American Academy of Family Physicians)
• Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. (American Academy of Neurology)
• Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis. (American Academy of Hospice and Palliative Medicine)
• Don’t order a CT scan of the head/brain for sudden hearing loss. (American Academy of Otolaryngology—Head and Neck Surgery Foundation)
• Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis. (American Academy of Otolaryngology—Head and Neck Surgery Foundation)
• Don’t obtain CT or MRI in patients with a primary complaint of hoarseness prior to examining the larynx. (American Academy of Otolaryngology — Head and Neck Surgery Foundation)
• Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis. (American College of Rheumatology)
• Don’t routinely repeat DXA scans more often than once every two years. (American College of Rheumatology)
• Don’t order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram. (American Society of Echocardiography)
• Don’t repeat echocardiograms in stable, asymptomatic patients with a murmur/click, where a previous exam revealed no significant pathology. (American Society of Echocardiography)
• Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease. (American Society of Echocardiography)
• Avoid using stress echocardiograms on asymptomatic patients who meet “low-risk” scoring criteria for coronary disease. (American Society of Echocardiography)
• Avoid transesophageal echocardiography to detect cardiac sources of embolization if a source has been identified and patient management will not change. (American Society of Echocardiography)
• A routine bone scan is unnecessary in men with low-risk prostate cancer. (American Urological Association)
• Don’t perform ultrasound on boys with cryptorchidism. (American Urological Association)
• Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. (Society of Hospital Medicine—Pediatric Hospital Medicine)
• Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery. (Society of Thoracic Surgeons)
• Don’t perform a routine pre-discharge echocardiogram after cardiac valve replacement surgery. (Society of Thoracic Surgeons)
• Patients with suspected or biopsy proven Stage I nonsmall cell lung cancer do not require brain imaging prior to definitive care in the absence of neurologic symptoms. (Society of Thoracic Surgeons)
• Don’t reimage deep vein thrombosis in the absence of a clinical change. (Society for Vascular Medicine)

The current lists follow the first round of Choosing Wisely lists, which were released by nine medical specialty societies in April 2012.