The AAN has an assortment of patient engagement resources that includes Shared Decision-making Tools and the AAN's Choosing Wisely recommendations. Review five things you can do to improve patient engagement at your practice.
SHARED DECISION-MAKING TOOLS FOR PATIENTS AND PHYSICIANS
The AAN has developed ten shared decision-making tools for you and your patients. For more information, listen to this mini webinar on shared decision-making. If you have ideas for future tools, or how to improve current tools please let AAN Quality Staff know your thoughts.
- Multiple Sclerosis Disease-modifying Therapy
- Dementia Medication
- Epilepsy Surgery
- Vascular Malformations
- Anticoagulants After Stroke
- Imaging for Headache
- Severe Migraine Relief
- Carotid Artery Stenosis
- Initiation of Treatment for Parkinson's Disease
Choosing Wisely: AAN Cites Five Things to Question
The AAN released its first list of Five Things Physicians and Patients Should Question in 2013. As the momentum for the Choosing Wisely initiative continues, the AAN will be supporting the campaign for a second time. Check back here often for updates and opportunities to comment on the draft recommendations that will tentatively be available in early 2015.
In 2012, the AAN joined the Choosing Wisely campaign, a project initiated by the American Board of Internal Medicine (ABIM) Foundation to promote appropriate medical decision-making and the stewardship of health care resources. The campaign is designed to help consumers and physicians engage in conversations about the overuse of particular tests, procedures, and treatments, and to help patients make smart and effective care choices. In February 2013, the AAN participated in a news conference with the ABIM Foundation and Consumer Reports, where medical specialties announced their lists of the top five questionable tests and procedures each selected for patients and physicians to consider.
The AAN's complete recommendations and methods were published online ahead of print in the February 21, 2013, issue of Neurology®.
The AAN and Consumer Reports collaborated to create two patient-oriented messages on carotid artery surgery and treating migraine headache. The patient-oriented tool for migraine is also available in Spanish.
The following topics contain Choosing Wisely recommendations that pertain to neurology but were created by other organizations. Visit choosingwisely.org for more information. An article on all Choosing Wisely recommendations pertinent to neurology was published in the September 2015 issue of Neurology® Clinical Practice.
- Imaging for Low Back Pain
- Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
- Don’t obtain imaging (plain radiographs, magnetic resonance imaging, computed tomography [CT], or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags.
- Don’t obtain imaging studies in patients with non-specific low back pain.
- Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags.
- Avoid imaging studies (MRI, CT or X-rays) for acute low back pain without specific indications.
- Don’t initially obtain X-rays for injured workers with acute non-specific low back pain.
- Don’t order an imaging study for back pain without performing a thorough physical examination.
- Avoid lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equine syndrome, or cancer with bony metastasis).
- CT Scans For Minor Head Injury/Syncope
- Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.
- Don't routinely obtain CT scanning of children with mild head injuries.
- Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
- Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
- In the evaluation of simple syncope and a normal neurological examination, don't obtain brain imaging studies (CT or MRI).
- Medications For Insomnia
- Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
- Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary.
- Don't prescribe medication to treat childhood insomnia, which usually arises from parent-child interactions and responds to behavioral intervention.
- Don't routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.
- Antipsychotics For Behavioral Symptoms
- Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
- Don't prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.
- Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
- Feeding Tubes In Dementia
- Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
- Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
- Don't insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.
- Imaging For Headache
- Opioids For Chronic Non-Cancer Pain
- Carotid Imaging For Asymptomatic Patients
- EMG For Spine Pain
- Polysomnogram For Insomnia
- Bedrest For Low Back Pain
- Autoantibody Panels Without Positive ANA
- Laboratory Tests
- Don't repeat a confirmed positive ANA in patients with established JRA or systemic lupus erythematosus (SLE).
- Don't test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.
- Don't test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma or prolonged immobility.
- Don't routinely screen for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage (SAH) or genetic disorders that may predispose to aneurysm formation.
- Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.
- Don't routinely order imaging for all patients with double vision.
- Avoid ordering a brain CT or brain MRI to evaluate an acute concussion unless there are progressive neurological symptoms, focal neurological findings on exam or there is concern for a skull fracture.
- Don't order computed tomography (CT) scan of the head/brain for sudden hearing loss.
- Don't perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.
- Don't order low back X-rays as part of a routine preplacement medical examination.
- Don't use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in this field.
- Avoid transesophageal echocardiography (TEE) to detect cardiac sources of embolization if a source has been identified and patient management will not change.
- Don't initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.
- Don't administer steroids after severe traumatic brain injury.
- Don't routinely use seizure prophylaxis in patients following ischemic stroke.
- Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
- Don't prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.
- Don't recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.
- Don't routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.
- Don't prescribe opiates in acute disabling low back pain before evaluation and a trial of other alternatives is considered.
- Don't prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment.
- Don't delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
- Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
- Don't perform elective spinal injections without imaging guidance, unless contraindicated.
- Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
- Don't order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
- Don't routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- Don't use polysomnography to diagnose restless legs syndrome, except rarely when the clinical history is ambiguous and documentation of periodic leg movements is necessary.
- Don't perform positive airway pressure re-titration studies in asymptomatic, adherent sleep apnea patients with stable weight.
- Don't order repeat epidural steroid injections without evaluating the individual's response to previous injections.
- Don't recommend surgical deactivation of migraine trigger points outside of a clinical trial.
- Don't routinely order low- or iso-osmolar radiocontrast media or pretreat with corticosteroids and antihistamines for patients with a history of seafood allergy, who require radiocontrast media.
Additional Resources for Physicians and Patients
- View AAN's Five Things Physicians and Patients Should Question
- Neurology ® article: The American Academy of Neurology's Top Five Choosing Wisely recommendations
- AAN Press Release