The American Academy of Neurology provides evidence-based guidelines for practitioners and patients with the aim of reducing costs.
To reduce wasteful practices in medicine, the American Board of Internal Medicine and Consumer Reports developed the “Choosing Wisely” campaign. As a participant in the campaign, The American Academy of Neurology (AAN) selected a diverse panel with experience in evidence-based guidelines and practice parameters. The AAN sought from its members recommendations of practices that are common in neurology yet have strong evidence of lacking benefit (or causing harm) and are costly. From 178 submissions, the AAN selected 5 as having strong supporting rationales and obtained input from relevant subspecialty experts and patient advocacy groups. These practices are as follows:
- Don’t perform electroencephalography (EEG) for headache disorders. Rationale: Clinical features have better diagnostic accuracy for primary headaches. Neuroimaging has higher sensitivity than EEG to evaluate for a mass lesion, if clinically suspected.
- Don’t perform carotid ultrasound for syncope without other neurological symptoms. Rationale: Syncope is common, carotid disease causes focal neurological symptoms, and indiscriminate use of ultrasound results in unnecessary procedures.
- For migraine, reserve opioids and butalbital as a last resort. Rationale: Nonopioid analgesics often work, and migraine-specific treatments are available. Opioids and butalbital increase the risk for analgesia-overuse headaches and chronic headaches. Opioids can be considered for 9 days per month when other treatments fail or medical comorbidity prevents use of first-line treatments.
- Don’t prescribe disease-modifying therapies (DMTs) for those with progressive, nonrelapsing multiple sclerosis (MS). Rationale: DMTs have not shown efficacy in reducing disability in progressive MS and have potential adverse effects.
- Don’t recommend carotid endarterectomy (CEA) for asymptomatic carotid stenosis unless the complication rate is <3%. Rationale: A benefit for asymptomatic carotid disease requires very low angiographic and surgical complication rates.
Comment: Patients have expectations for testing and treatment, and clinicians can feel obliged to reassure patients and reduce legal risk. The Choosing Wisely campaign seeks to inform patients and lend credence to clinicians to act more conservatively. Insurance providers are increasingly creating such guidelines, but guidelines created through the AAN may be more valid and accepted.
These recommendation are useful, especially the limitations on opioids for migraine. DMTs should not be started for primary or nonrelapsing, secondary progressive MS. However, some patients on a DMT long-term may have transitioned to secondary progressive MS with no relapses for 3 years, but may still relapse or worsen upon DMT withdrawal. Knowing the CEA complication rate for each surgeon in your center is a good idea, but these data are not always available, despite the long-standing recommendation that they should be.
Source: Journal Watch Neurology