Elderly Adults Not Chosen for Society for General Internal Medicine Choosing Wisely Recommendation.

Abstract

To the Editor: The American Board of Internal Medicine (ABIM) foundation created the Choosing Wisely campaign to help guide physicians and patients away from unnecessary or harmful tests and procedures. Many of the medical subspecialty societies have released their recommendations for “Five Things Physicians and Patients Should Question.” These recommendations have served as a guide to assist physicians through multiple common dilemmas in healthcare delivery.1, 2 It is important to note the intention and limitations of these guidelines. The recommendation from the Society for General Internal Medicine (SGIM) regarding annual physical examinations in older adults was reviewed. In 2013, the SGIM published their “Five Things Physician and Patients Should Question.”1 One of the recommendations was “Don't perform routine general health checks for asymptomatic adults.” This recommendation stated that “general health checks without a specific cause including the “health maintenance” annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing,”1 but there was not an explicit discussion as to how this recommendation applies to older adults, so the data have been reviewed. Review of the data upon which this recommendation is based revealed significant limitations in application to older adults. The Cochrane review upon which this recommendation is largely based included 14 studies, 13 of which had participants younger than 65.3 The authors note in their methods that “although we originally planned to include trials of geriatric screening, we found that they included many interventions in addition to screening, such as falls prevention and specialist medication review. Thus, we excluded trials described as specifically targeting older people only, or which only enrolled people aged >65.”3 Specifically, 15 studies were excluded because they were conducted in older adults. Eleven studies were excluded because the cohort was aged 65 and older, and four studies were excluded because they were based on a geriatric syndrome of falls or frailty.3 Another review also cites four studies focused on cohorts aged 65 and older, all of which showed a positive effect of their intervention.4 Ultimately, it concluded that the “evidence suggests that the [periodic health evaluation] (PHE) improves delivery of some recommended preventive services and may lessen patient worry. Although additional research is needed to clarify the long-term benefits, harms, and costs of receiving the PHE, evidence of benefits in this study justifies implementation of the PHE in clinical practice.”4 The evidence behind the SGIM choosing wisely recommendation not to perform general health checks for asymptomatic adults is strong for the population aged 18–64, but this recommendation has not been shown to be appropriate for individuals aged 65 and older. A Cochrane editorial asks, “How should practitioners use the findings of [the previous study]3?… When contemplating screening, practitioners should focus on tests that are targeted to the patient's age, sex, and specific risk factors, and that are supported by high-quality evidence.”5 In the effort to provide high-value care, it is imperative to focus recommendations on the proper cohort and not to assume that this information applies to older adults. Conflict of Interest: All authors report no relevant financial or personal conflicts of interest. Author Contributions: Archbald-Pannone, Nadkarni: study concept and design, data acquisition and interpretation, manuscript preparation. Sponsor's Role: None.