The American Academy of Neurology's Top Five Choosing Wisely recommendations

Abstract

Methods: A Choosing Wisely Working Group of 10 AAN members was formed to oversee the process and craft the evidence-based recommendations. AAN members were solicited for recommendations, the recommendations were sent out for external review, and the Working Group members (article authors) used a modified Delphi process to select their Top Five Recommendations. Results and recommendations:The Working Group submitted 5 neurologic recommendations to the AAN Practice Committee and Board of Directors; all 5 were approved by both entities in September 2012. Recommendation 1: Don't perform EEGs for headaches. Recommendation 2: Don't perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Recommendation 3: Don't use opioids or butalbital for treatment of migraine, except as a last resort. Recommendation 4: Don't prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of multiple sclerosis. Recommendation 5: Don't recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (,3%). Alzheimer disease, Parkinson disease, stroke, and multiple sclerosis affect approximately 15 million people and account for more than $290 billion in health care spending annually in the United States.

Trends in the Ambulatory Management of Headache: Analysis of NAMCS and NHAMCS Data 1999–2010

“…[8][9][10] The Choosing Wisely campaign of the American Board of Internal Medicine has recently identified reducing the use of advanced imaging and prescriptions for opioids and barbiturates for headache as important opportunities to improve value in our healthcare system. [11][12][13] Despite broad agreement on these issues over the past decade, preliminary evidence suggests persistent overuse of these low-value services. 14,15 In this context, we used nationally representative data on ambulatory visits to clinicians to evaluate trends over the past decade in headache management in the office setting.…”

Expenditures in the elderly with peripheral neuropathy

“…1,2 Such efforts need to be informed regarding aggregate expenditures associated with individual tests so that the focus can be on high-impact tests. 3 Identifying these high-impact tests in the evaluation of peripheral neuropathy is particularly important because it is a highly prevalent disease encountered by many provider types.…”

The American Academy of Neurology's Top Five Choosing Wisely recommendations

“…Editor's Note: Subsequent to the online publication of "The American Academy of Neurology's Top Five Choosing Wisely Recommendations," 1 WriteClick submissions were received expressing concern about the fourth recommendation: "do not prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of MS." The American Academy of Neurology (AAN) responded that, due to an administrative error, they had not originally contacted the AAN Multiple Sclerosis (MS) Section Executive Committee about this recommendation but had contacted them when they learned of the error. An "Expression of Concern" was published online (http:// neurology.org/lookup/doi/10.1212/WNL.0b013e318296f79b) attached to the article.…”

“…John R. Corboy, Aurora, CO: Recommendation 4 in the Choosing Wisely article by Langer-Gould et al 1 suggests that interferons and glatiramer acetate (GA) should not be used in patients with progressive, nonrelapsing forms of MS. This recommendation fails to recognize clear benefits in subsets of both secondary progressive 2 and primary progressive 4 patients, especially in those with history of recent relapse, enhancing lesions on scans, and perhaps mostly, younger progressive patients.…”

“…It is important to note that these concerns were not new and had already been brought to the Working Group's attention during the development process by other groups from whom feedback was solicited. 1 The Working Group reconvened and found no reason to change this recommendation. Recommendation 4 is based on strong evidence.…”