No siempre mas es mejor/Lista Top 5 para la Atención Primaria

The Top 5 list in primary care/The Good Stewardship Working Group , Agosto 2011.

Grupos de trabajo de las 3 especialidades de la atención primaria acordaron que una actividad ideal sería aquella que siendo común para la atención primaria esté fuertemente sustentada por la evidencia, conduzca a significativos beneficios en la salud, reduzca riesgos daños y costos.

La metodología utilizada fue una modificación de la técnica llamada Proceso de Grupo Nominal (Nominal group process).

Conclusiones: recomendamos que esta lista de las “5 actividades principales” (“Top 5”) sean implementadas in los servicios de atención primaria del territorio de los Estados Unidos.

Vea las Top five...a continuación / el editor

PD:Salvando las distancias culturales y de organización de sistema, mucho para meditar.

1. No realizar estudios de imágenes para el estudio del dolor lumbar en las primeras 6 semanas a menos que estén presentes señales de alerta.
2. No prescribir antibióticos de forma rutinaria en presencia de síntomas de sinusitis leve o moderada (que incluyen secreción nasal purulento y dolor maxilar o molestia facial o dental) a menos que duren 7 días o mas o evoluciones a empeoramiento de las molestias luego de una mejoría inicial.
3. No ordenar ECG u otras métodos de cribado cardiovascular en pacientes de bajo riesgo.
4. No realizar citología de cuello uterino , PAP, en mujeres menores de 21 años o en mujeres histerectomizadas por patologías benignas.
5. No realizar cribado para osteoporosis (DEXA screening) en mujeres menores de 65 años u hombres menores de 70 años, sin factores de riesgo.

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For family medicine:

• Avoid imaging for lower back pain for six weeks unless red flags are present.
• Cut back on prescribing antibiotics for sinus infections, since most are viral.
• Avoid cardiac screening in patients who are low risk and have no symptoms.
• Do not do Pap tests for cervical cancer in women under 21 or those who have had a hysterectomy for benign disease.
• Confine bone density scans known as dual-energy X-ray absorptiometry (DEXA) for osteoporosis to women aged 65 and over and for men 70 and older who also have risk factors, such as those who have already had fractures .

For internal medicine:

• Defer imaging for lower back pain.
• Do not order blood chemistry panels (a set of 8 blood tests to assess kidney function, blood sugar and other health indicators) or urinalysis in healthy adults with no symptoms, since blood lipids (fats) tests alone yield most positive results.
• Forego cardiac screening in healthy patients.
• Prescribe generic statins (cholesterol-lowering drugs) before brand-name ones
• Limit bone-density screening to older, at-risk patients .

In pediatrics:

• Avoid giving antibiotics for sore throats unless a test definitely turns up the bacteriaStreptococcus (strep throat)
• Avoid imaging for minor head injuries without risk factors such as loss of consciousness.
• Take a wait-and-see attitude towards middle-ear infections before referring the patient to a specialist.
• Recommend that parents not give their children over-the-counter cough-and-cold medicines.
• Make sure patients with asthma are using corticosteroid medicines properly, as this will cut down on episodes.

The report was funded by a grant from the American Board of Internal Medicine Foundation.

Several of the items -- those involving cardiac screening, overuse of antibiotics, bone-density scans and lower-back imaging -- appeared in more than one category.

But one item -- not doing blood chemistry panels and urinalysis among healthy adults without symptoms -- enjoyed only weak support from the practicing physicians who field-tested the suggestions.

The Top 5 lists will now be distributed to all NPA members. The researchers are also hoping to get funding to set up demonstration sites, creating training videos to help physicians hone their communication skills and finding ways to get patients on board, Smith said.

"These are certainly important issues," said Dr. Lawrence C. Kleinman, a primary care physician and associate professor of pediatrics at Mount Sinai School of Medicine in New York City.

But he also pointed out that "the lists were done with some nuance, which [is] valuable and important to incorporate in the understanding of this."