TSANZ’s Top-5 ‘Do Not Do’ recommendations for practices that are not helpful and possibly harmful

Public health

By Michael Woodhead

17 May 2021

The Thoracic Society of Australia and New Zealand (TSANZ) has drawn up its list of low-value tests, treatments and procedures that should be phased out because they are ineffective, wasteful and harmful.

The top five ‘do not do’ respiratory practices have been developed by the TSANZ in conjunction with the RACP’s Evolve program that aligns with the Choosing Wisely campaign to promote high-value evidence-based care.

The Top 5 recommendations are:

1. Do not perform a D-Dimer in patients at high risk of pulmonary embolism.

Rationale: While a negative D-dimer result can rule out pulmonary embolism (PE) in a person with a low or moderate clinical probability for PE , it is not helpful in patients with a high probability it does not exclude PE in more than 15%.

2. Do not use long term systemic corticosteroids for management of chronic obstructive pulmonary disease (COPD).

Rationale: There is insufficient evidence regarding efficacy of systemic corticosteroids in the treatment of COPD without exacerbations. Given their well-known adverse effects, especially COPD patients who tend to be older, less active and have histories of smoking, their long term use cannot be recommended. 

3. Do not initiate maintenance inhalers in minimally symptomatic COPD patients with a low risk of exacerbation.

Rationale: Inhalers only have evidence for reducing COPD exacerbations and do not modify disease. For COPD patients who are asymptomatic or minimally symptomatic, quitting smoking is often the only required therapy. The use of short- or long-acting bronchodilators on a regular basis is not generally recommended.

4. Do not routinely follow-up solid pulmonary nodules smaller than 6 mm detected in low-risk patients.

Rationale: Smaller size pulmonary nodules are associated with low risk of cancer in people with low clinical risk such as younger age groups and less smoking exposure. While the National Lung Screening Trial showed that CT lung screening reduced lung cancer mortality in high-risk patients with a threshold of 4 mm for nodule size, more than half of the examinations were positive for 4-6mm nodules. Raising the threshold for a positive result to 6 mm would almost double the positive predictive value (PPV)  – 7.2% at 6 mm vs 3.8% at 4 mm – without affecting the sensitivity to detect cancer.

5. Do not perform a serum ACE for the diagnosis or monitoring of sarcoidosis.

Rationale: There are no reliable biomarkers or gold standard tests for sarcoidosis. While high serum ACE is present in up to 75% of untreated patients, testing has a poor sensitivity, insufficient specificity (a false positive rate of around 10%) and inconsistent correlation with disease severity.

According to Evolve, the lists aim “to reduce low-value care by supporting physicians to be leaders in changing clinical behaviour for better patient care, make better decisions, and make better use of resources.”

They encourage physicians to help implement the ‘Do Not Do’ recommendations by making them a routine part of clinical handovers, including the recommendations in education sessions and undertaking a clinical audit and feedback project on a recommendation.

They also suggest discussing the Evolve recommendations with referring doctors and multidisciplinary care teams, and also to engage with hospital management in implementing the recommendations across the health service.

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