The American Academy of Family Physicians has issued a list of the Top Five tests and procedures that may be overused and physicians and patients should question.

AAFP is a participant in the new Choosing Wisely campaign of the ABIM Foundation, which includes eight other medical societies and Consumer Reports. Each medical society has issued its own Top Five list. The AAFP list is:

1. Imaging for low back pain--Do not do imaging for low back pain within the first six weeks, unless red flags are present. (Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected.) Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs and involves unnecessary radiation exposure. Low back pain is the fifth most common reason for all physician visits.

2. Routine antibiotic prescriptions--Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial clinical improvement. (Symptoms must include discolored nasal secretions and facial or dental tenderness when pressure is applied.) Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis, resulting in risk of side effects without benefit. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.

3. Dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis--Do not use DEXA in women younger than age 65 or men younger than 70 with no risk factors. DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients.

4. Annual electrocardiograms (EKGs) or any other cardiac screening--Do not order EKGs or other cardiac screening for low-risk patients without symptoms. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

5. Pap smears--Do not perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease), and there is little evidence for improved outcomes.

More information on Choosing Wisely is available at

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