Letters Figure. Trends of Radioactive Iodine (RAI) Therapy Misuse in Papillary Thyroid Microcarcinomas Over Time, by Facility Type Academic/Research Hospital Programs Comprehensive Community Hospital Programs Community Hospital Programs RAI P < .001 P < .001 P = .26 100 100 100 No Yes 80 80 80 71.6 72.5 71.2 72.2 75.0 74.3 74.8 75.0 72.3 74.6 77.6 76.6 77.6 60 77.5 78.4 60 82.2 60 78.5 77.3 78.3 80.2 81.5 83.6 86.4 81.4 40 40 40 RAI Misuse, % RAI Misuse, % RAI Misuse, % 20 20 20 25.0 25.7 25.2 25.0 28.4 27.5 28.8 27.7 27.8 22.5 25.4 22.4 22.7 23.4 21.6 21.5 21.7 22.4 18.6 19.8 18.5 16.4 13.6 17.8 0 0 0 2004 20052006 2007 2008 2009 2010 2011 2004 20052006 2007 2008 2009 2010 2011 2004 20052006 2007 2008 2009 2010 2011 Year of Diagnosis Year of Diagnosis Year of Diagnosis Misuse of RAI therapy in papillary thyroid microcarcinomas in academic/research programs, comprehensive community programs, and community programs. In conclusion, our study demonstrates that nearly one- Commission on Cancer have not verified and are not responsible for the analytic fourth of patients with thyroid cancer may receive unnec- or statistical methods used, or the conclusions drawn from these data by the investigators. esary RAI treatment. Ongoing efforts should be undertaken to Additional Contributions: Mohamed Abdelgadir Adam, MD, Section of educate health care professionals in the appropriate use of RAI Endocrine Surgery, Department of Surgery, Duke University Medical Center, therapy to optimize patient care. Durham, North Carolina, and Linda Youngwirth, MD, Duke Clinical Research Institute, and Section of Endocrine Surgery, Department of Surgery, Duke Paolo Goffredo, MD University Medical Center, Durham, North Carolina, assisted with data acquisition and statistical work. They were not compensated for their Samantha M. Thomas, MB contributions. Michaela A. Dinan, PhD 1. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Jennifer M. Perkins, MD Association management guidelines for patients with thyroid nodules and Sanziana A. Roman, MD differentiated thyroid cancer. Thyroid. 2009;19(11):1167-1214. Julie A. Sosa, MD 2. Smallridge RC, Ain KB, Asa SL, et al. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012;22 (11):1104-1139. Author Affiliations: Duke Clinical Research Institute, Durham, North Carolina (Goffredo, Dinan, Sosa); Department of Biostatistics, Duke University, Durham, 3. Kloos RT, Eng C, Evans DB, et al. Medullary thyroid cancer: management North Carolina (Thomas); Department of Medicine, Duke University, Durham, guidelines of the American Thyroid Association. Thyroid. 2009;19(6):565-612. North Carolina (Perkins); Section of Endocrine Surgery, Department of Surgery, 4. Lee SL. Complications of radioactive iodine treatment of thyroid carcinoma. Duke University Medical Center, Durham, North Carolina (Roman, Sosa). J Natl Compr Canc Netw. 2010;8(11):1277-1287. Corresponding Author: Sanziana A. Roman, MD, Section of Endocrine Surgery, 5. National Cancer Data Base. 2014. https://www.facs.org/quality%20programs Department of Surgery, Duke University School of Medicine, DUMC #2945, /cancer/ncdb/puf. Accessed May 1, 2014. Durham, NC 27710 ([email protected]). 6. National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Published Online: February 16, 2015. doi:10.1001/jamainternmed.2014.8020. Program. http://seer.cancer.gov/data/. Published 2014. Accessed June 1, 2014. Author Contributions: Dr Sosa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Creating a List of Low-Value Health Care Study concept and design: Goffredo, Dinan, Roman, Sosa. Activities in Swiss Primary Care Acquisition, analysis, or interpretation of data: Goffredo, Thomas, Dinan, In 2010, the idea emerged of creating lists of low-value health Perkins. Drafting of the manuscript: Goffredo, Dinan, Perkins, Roman. care activities as a way to confront rising medical costs and en- Critical revision of the manuscript for important intellectual content: All authors. courage cost-conscious care. The Good Stewardship Working Statistical analysis: Goffredo, Thomas, Dinan, Roman. Group1 and Brody2 pioneered the idea of “top 5” lists, leading Obtained funding: Goffredo. Administrative, technical, or material support: Dinan, Roman, Sosa. to the Choosing Wisely 3 Study supervision: Perkins, Roman, Sosa. Related article page 642 and campaign. Building on this Conflict of Interest Disclosures: None reported. Invited Commentary page 644 momentum, there has been Funding/Support: Dr Goffredo is supported by the Fondazione Italiana per la widespread interest in pro- Ricerca sul Cancro (Italian Foundation for Cancer Research). posing additional lists.4 In 2012, the Swiss Society of General Role of the Funder/Sponsor: The funding source had no role in the design and Internal Medicine committed to creating a list for Swiss am- conduct of the study; collection, management, analysis, and interpretation of bulatory internal medicine. the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: Some of the data used in the study are derived from a deidentified Methods | A review of publications was performed using the National Cancer Data Base file. The American College of Surgeons and the search terms low value, disinvestment, less is more, and avoidable 640 JAMA Internal Medicine April 2015 Volume 175, Number 4 (Reprinted) jamainternalmedicine.com Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Letters Figure. Flowchart of Recommendations Through the Delphi Process 50 Under consideration Chosen for next round 15 pass to Eliminated round 3 40 Final selection 3 recommendations 17 are 30 10 reranked 14 Agreement Agreement Frequency Committee 5 ranking ranking ranking selection international 20 38 13 Recommendations, No. Recommendations, 6 10 5 Swiss A total of 50 recommendations were novel 7 ranked during the Delphi process, 12 0 recommendations including 38 existing international recommendations and 12 novel From Review Round 1 Round 2 Round 3 Final recommendations from the experts. of Publications From the top 10 recommendations of Results the Delphi process, an expert panel chose the final top 5 list. Table. Top 10 Recommendations Based on Frequency Scorea Frequency Score Agreement Score Rank Recommendation (32-96)b (0-10)c 1 Do not obtain imaging studies in patients with nonspecific low 94 9.56 back pain 2 Do not prescribe antibiotics for uncomplicated URTIs 92 9.40 3 Do not perform the PSA test to screen for prostate cancer 90 9.59 without a discussion of the risks and benefits 4 Do not perform laboratory testing in patients with a clinical 87 9.03 diagnosis of an uncomplicated URTI 5 Do not continue pharmacological treatment of GERD with 82 9.50 long-term acid suppression therapy without titrating to the lowest effective dose Abbreviations: DEXA, dual-energy x-ray absorptiometry; GERD, 6 Do not routinely prescribe antibiotics for acute 81 9.50 mild-to-moderate sinusitis gastroesophageal reflux disease; PSA, prostate-specific antigen; 7 Do not use antimicrobials to treat bacteriuria in 80 9.16 URTI, upper respiratory tract immunocompetent older adults infection. 8 Do not routinely obtain radiographic imaging for patients who 78 9.91 meet diagnostic criteria for uncomplicated acute rhinosinusitis a Boldface indicates items retained 9 Do not obtain preoperative chest radiography in the absence of a 77 9.26 for top 5. clinical suspicion b Frequency scores are from round 3. 10 Do not use DEXA screening for osteoporosis in women younger 72 9.16 c Agreement scores are from rounds 1 than 65 or men younger than 70 and 2. care. Three sets of lists were identified (1103 recommenda- formed based on Swiss Society of General Internal Medicine tions)3,5,6 as of March 5, 2013. Two physicians excluded recom- members who expressed a specific interest in this subject. mendations that were not relevant to ambulatory internal medi- In round 1, experts gave their level of agreement with the cine (eg, specialized medicine, pediatrics), leading to an initial international recommendations using a 10-point Likert scale. list of 38 international recommendations. Experts could also propose additional recommendations. Af- An online Delphi process was then applied, using succes- ter a review of publications to ensure their validity based on sive electronic survey instruments placed on the Survey Mon- available evidence, 12 of 21 novel recommendations were re- key website (www.surveymonkey.com). All committee mem- tained. bers of the Swiss Society of General Internal Medicine and the In round 2, recommendations with intermediate scores in Swiss Society of Family Medicine, along with professors from round 1 (average scores, 7-9) were reranked based on experts’ the divisions of General Internal Medicine and Family Medi- level of agreement, along with the 12 novel recommendations. cine at the 5 Swiss university medical schools, were invited to For round 3, recommendations with scores greater than 9 participate as experts. A 7-member advisory committee was were graded based on a 3-point Likert scale in 3 areas: fre- jamainternalmedicine.com (Reprinted) JAMA Internal Medicine April 2015 Volume 175, Number 4 641 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Letters quency, costs, and patient harm. Frequency was defined as how Study concept and design: Selby, Gaspoz, Rodondi, Neuner-Jehle, Perrier, often the average general practitioner is faced with the deci- Cornuz. Acquisition, analysis, or interpretation of data: Selby, Rodondi, Neuner-Jehle, sion to perform the test or prescribe the treatment. Costs were Perrier, Zeller, Cornuz. direct costs and not those of unanticipated adverse effects or Drafting of the manuscript: Selby, Zeller, Cornuz.