To Reduce Waste in System, AAN Says ‘Choose Wisely’

The United States has the most expensive yet least effective health care system, as compared with those of other nations. ¹ According to the Institute of Medicine, some $750 billion was spent on “wasted medical services” in 2009 alone.² If these expenditures continue unchecked, health care spending is projected to constitute a quarter of the gross domestic product by 2025.³ Rising health care costs—caused in part by “wasteful practices”—render millions of citizens vulnerable and have a deleterious impact on the nation’s economy.¹

To address “wasteful practices,” the American Board of Internal Medicine Foundation (ABIMF) initiated the “Choosing Wisely” campaign, which encouraged medical specialty societies to develop lists of the five procedures or examinations in their specialty that may contribute to health care waste, and are not supported by evidence of benefit and non-evidence of harm.⁴

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The American Academy of Neurology (AAN) published its recommendations in February 2013, in an article titled “The American Academy of Neurology’s Top Five Choosing Wisely Recommendations.”⁵ They emphasize that these recommendations are “not intended to eliminate use of these procedures or tests entirely, but rather to give patients and physicians full information to engage in an honest discussion about when and in whom these medications, tests, or procedures may be more harmful than beneficial, or simply unnecessary.”⁵

Recommendation #1: Don’t perform EEGs for headaches.

Headache is the “most common pain disorder,” affecting 15 to 20 percent of people.⁵ According to a 1995 literature review,⁶ the electroencephalogram (EEG) has no advantage over clinical evaluation in diagnosing headaches. Moreover, patients with clinically diagnosed migraine have high-frequency photic driving responses (H responses) on EEG,⁶ but routine EEGs do not typically include the high frequencies necessary to identify an H response; and identifying an H response offers no advantage over clinical reference standards in diagnosing headache disorders. In cases in which structural abnormities are suspected, patients benefit more from higher-sensitive neuroimaging studies, such as CT or MRI.⁷

Recommendation #2: Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

The authors state that “occlusive carotid artery disease does not cause fainting, but rather causes focal neurologic deficits such as unilateral weakness.” ^{5, 8} They add that fainting is extremely common, with a lifetime prevalence of 40 percent.⁹ They conclude EEG in patients with syncope is “wasteful” and may yield incidental findings that are irrelevant and lead to unnecessary and potentially harmful further testing. Additional sources for their recommendations are the AHA/ACCF Scientific Statement on the Evaluation of Syncope,¹⁰ and the NICE Guideline on transient loss of consciousness in adults and young people.¹¹

Recommendation #3: Don’t use opioids or butalbital for the treatment of migraine, except as a last resort.

Effective “migraine-specific medications” or nonopioid, nonbarbiturate analgesics should be used for treatment of migraine.^{7,12,13,14,15,16} Opioids and butalbital “increase medication overuse headache and chronic migraine.”¹⁷ Opioids should be considered only as “rescue therapy” if migraine-specific treatments are infective or are contraindicated. In these circumstances, “use should be limited to nine days per month,” and providers should “focus on preventive and behavioral aspects of migraine care.”