Five Things Patients and Providers Should Question Do not perform a laparotomy for the management of non-malignant disease when surgical management is indicated and a vaginal, 1 laparoscopic or robotic-assisted approach is feasible and appropriate. Selection of an endoscopic approach should be tailored to patient selection, surgeon ability, and equipment ability. The surgeon should take into consideration how the procedure may be performed cost-effectively with the fewest complications. Do not perform routine oophorectomy in premenopausal women undergoing hysterectomy for non-malignant indications who are at 2 low risk for ovarian cancer. Outside of high-risk populations, the association of oophorectomy with increased mortality in the general population has substantial implications, particularly as it relates to higher rates of coronary heart disease and cardiovascular death. The long-term risks associated with salpingo-oophorectomy are most pronounced in women who are younger than 45–50 years who were not treated with estrogen. Do not routinely administer prophylactic antibiotics in low-risk laparoscopic procedures. 3 The use of prophylactic antibiotics in women undergoing gynecologic surgery is often inconsistent with published guidelines. Although the appropriate use of antibiotic prophylaxis for hysterectomy is high, antibiotics are increasingly being administered to women who are less likely to receive benefit. The potential results are significant resource use and facilitation of antimicrobial resistance. Avoid the unaided removal of endometrial polyps without direct visualization when hysteroscopic guidance is available and can be safely performed. 4 Endometrial polyps are a common gynecologic disease. Though conservative management may be appropriate in some patients, hysteroscopic polypectomy is the mainstay of treatment. Removal without the aid of direct visualization should be avoided due to its low sensitivity and negative predictive value of successful removal compared to hysteroscopy and guided biopsy. Avoid opioid misuse in the chronic pelvic pain patient without compromising care through education, responsible opioid prescribing and advocacy. 5 Patients have a right to appropriate assessment and management of pain; however, opioid misuse has become a public health crisis. It is essential that providers become familiar with published FDA and CDC plans and guidelines. Providers must also educate and screen for risk factors for opioid misuse and follow patients on chronic opioid therapy for any signs of misuse. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physicians. Released November 15, 2017 How This List Was Created As an international leader in the advancement of minimally invasive surgery, AAGL relies on its society members and board to determine the various needs and best practices to promote safe, higher quality care to patients. The list of things to question provided to the Choosing Widely campaign was submitted to the AAGL Board, who developed a subcommittee dedicated to analyzing the recommended interventions. The subcommittee of expert surgeons in the field of minimally invasive surgery recommended and developed a more effective use of health care resources, along with safe techniques to practice. The submitted list was reviewed and approved by the AAGL Board. Sources Gala R et al. Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared with Laparoscopy and Laparotomy, J Minim Invasive Gynecol. 1 2014 May-Jun;21(3):353-61. ACOG Committee Opinion: Choosing the Route of Hysterectomy for Benign Disease, Number 701, June 2017 Evans EC et al. Salpingo-oophorectomy at the time of Benign Hysterectomy. Obstet Gynecol 2016;128:476-485. 2 Parker WH et al. Long-term Mortality Associated with Oophorectomy versus Ovarian Conservation in the Nurses’ Health Study, Obstet Gynecol 2013;121(4):709-716. Wright J et al. Use of Guideline Based Antibiotic Prophylaxis in Women Undergoing Gynecologic Surgery, Obstet Gynecol 2013; 122:1145-1153. 3 ACOG Practice Bulletin: Antibiotic Prophylaxis for Gynecologic Procedures, Number 104 May 2009 (Reaffirmed 2016) AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps. Journal of Minimally Invasive Gynecology, Vol 19, No 1, January/ February 2012. 4 Bettocchi et al. Diagnostic Inadequacy of Dilatation & Curettage, Fertil Steril 2001;75:803-805. Svirsky R et al. Can We Rely on Blind Endometrial Biopsy for Detection of Focal Intrauterine Pathology?, Am J Obstet Gynecol 2008;199:115.e1-115.e3 Phillips DM. JCAHO pain management standards are unveiled. JAMA 2000;284:428-429. 5 Dowell, T.M. Haegerich, R. Chou, CDC guideline for prescribing opioids for chronic pain - United States, 2016, MMWR Recomm. Rep. 65 (1) (2016) About the ABIM Foundation About the AAGL The mission of the ABIM Foundation is to advance Established in 1971, AAGL was the first medical professionalism to improve the health organization of its kind dedicated to care system. We achieve this by collaborating with gynecologic endoscopic surgery. Still today, physicians and physician leaders, medical trainees, AAGL remains the largest international, health care delivery systems, payers, policymakers, professional society in minimally invasive consumer organizations and patients to foster a shared ® gynecology. With over 7,000 members, understanding of professionalism and how they can AAGL is recognized worldwide for leading adopt the tenets of professionalism in practice. the field through education, communication and research. AAGL works with some of the world’s finest gynecologic surgeons to promote quality health care To learn more about the ABIM Foundation, visit www.abimfoundation.org. for women by advancing minimally invasive gynecologic practices through clinical practice, research, innovation and dialogue. For more information or to see other lists of Five Things Patients and Providers Should Question, visit www.choosingwisely.org. AMDA – The Society for Post-Acute and Long-Term Care Medicine™ Ten Things Physicians and Patients Should Question Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings. Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional 1 decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems. Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home. 2 SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regiments, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic. Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract. Chronic asymptomatic bacteriuria is frequent in the LTC setting, with prevalence as high as 50%. A positive urine culture in the absence of localized urinary tract infection (UTI) symptoms (i.e., dysuria, frequency, urgency) is of limited value in identifying whether a patient’s symptoms are caused by a UTI. Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in LTC facilities that contributes 3 to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea or other adverse drug events, resistant organisms, and infection due to Clostridium difficile. An additional concern is that the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the more timely detection of the patient’s more serious underlying problem. A patient with advanced dementia may be unable to report urinary symptoms. In this situation, it is reasonable to obtain a urine culture if there are objective signs of systemic infection such as fever (increase in temperature of equal to or greater than 2°F [1.1°C] from baseline) leukocytosis, or a left shift or chills in the absence of additional symptoms (e.g., new cough) to suggest an alternative source of infection. Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals