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Editorial

The ASPS Choosing Wisely List for Plastic Surgery

Gutowski, Karol M.D.; Gray, Diedra M.P.H.

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Plastic and Reconstructive Surgery: October 2014 - Volume 134 - Issue 4 - p 853-855
doi: 10.1097/PRS.0000000000000686
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The American Society of Plastic Surgeons (ASPS) is participating in the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine Foundation. This initiative helps physicians and patients engage in conversations about the appropriate use of tests and procedures, and supports physician efforts to help patients make smart and effective care choices. The Choosing Wisely initiative was initially reviewed by the ASPS Quality and Performance Measurement Committee and the Executive Committee. Once the ASPS signed on to participate in the initiative, ASPS Quality staff solicited potential topic suggestions from the ASPS Health Policy, Patient Safety, and Quality and Performance Measurement committees. All topic suggestions were collected and collated with topics that were suggested by multiple committees or committee members being prioritized. A final list of prioritized topics was developed and compared with those currently included on lists that have been published by other specialty societies, to minimize any overlap. ASPS Quality staff then conducted a review of supporting evidence, including evidence-based clinical practice guidelines and systematic reviews. The draft topics/statements for the ASPS list were then narrowed down further, based on supporting evidence and a final review by the Quality and Performance Measurement Committee. The final suggested list was then shared with the active ASPS membership and approved by the ASPS Executive Committee. The ASPS list is primarily supported by high-quality evidence and several additional individual studies. The resulting list, included below, is intended to stimulate discussion about the appropriateness of many frequently ordered tests or treatments.

The Choosing Wisely campaign dovetails with the ASPS commitment to providing quality care to plastic surgery patients and helping them make the most informed decisions about procedures. The Society continuously works to improve evidence-based clinical guidelines, performance measures, and quality initiatives, to better serve patients and to ensure their surgical goals are met. Participation in the campaign supports the ASPS Evidence-Based Medicine initiative, which incorporates the ASPS critical appraisal process, to assign appropriate levels of evidence and include the highest quality literature available in all literature reviews and analyses used in the development of quality products.

Since the launch of the campaign in 2012, more than 60 medical specialty societies have signed on, creating lists that pertain specifically to their physician members or specialists. However, the impact of the campaign has come into question on several occasions. Although the intent is for each specialty society to identify unnecessary services that are relevant to their area of medicine, several organizations have expressed difficulty identifying such services based on the available evidence. Another observation has been that some of the suggested unnecessary services identified have little impact on improving quality and lowering costs (such as simple laboratory tests) instead of targeting more meaningful services (such as major procedures and operations).

Despite these questions, overall the campaign has been successful thus far, garnering a lot of media attention and even inspiring the launch of the Choosing Wisely campaign in other countries. The campaign has succeeded in raising awareness about shared decision-making and appropriate use of resources. This is a great start but, for the campaign to truly reach its potential, it is imperative that medical specialty societies continue to review existing and new evidence, to identify treatments, tests, and procedures that have an even greater impact on relevant specialties. With this in mind, participating societies should continuously review the lists they have developed and make an effort to update the lists as needed. This ongoing review will allow the campaign to have the greatest possible impact on shared decision-making and appropriate use.

ASPS LIST OF FIVE THINGS PHYSICIANS AND PATIENTS SHOULD QUESTION

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

1. Avoid Performing Routine Mammography before Breast Surgery

Mammograms should be ordered based on existing clinical practice guideline recommendations, for patients undergoing breast surgery, including noncomplicated breast augmentation, mastopexy, and breast reduction. Existing clinical practice guidelines recommend annual screening mammograms for patients of specific age groups. There are no recommendations for patients undergoing elective breast surgery to undergo additional screening unless there are concerning aspects of the patient’s history or findings during a physical examination that would suggest the need for further investigation.1–5

2. Avoid Using Drains in Breast Reduction Mammaplasty

Although wound drains can minimize the amount of fluid at the surgical site, there is no evidence to support the use of drains. Evidence also indicates that the use of drains neither increases nor decreases postoperative complications, causes greater patient discomfort, and possibly increases the length of hospital stay. In patients that have liposuction as an adjunctive technique to breast reduction, the decision to use drains is left to the surgeon’s discretion.6–8

3. Avoid Performing Routine and Follow-Up Mammography of Reconstructed Breasts after Mastectomies

Evidence indicates that clinical examination is sufficient to detect local cancer recurrence in patients undergoing breast reconstruction after complete mastectomy. Current clinical practice guidelines recommend regular clinical examinations for detection of breast cancer, and imaging studies are not recommended as a part of routine surveillance. However, diagnostic imaging is indicated if there are clinical findings and/or clinical concern for recurrence. In cases of breast reconstruction after partial mastectomy or lumpectomy, mammography is still recommended. It is also important to continue mammography of the opposite breast in women who have undergone a unilateral mastectomy.9–11

4. Avoid Performing Plain Radiography in Instances of Facial Trauma

Evidence currently indicates that maxillofacial computed tomography is available in most trauma centers and is the most sensitive method for detecting fractures in instances of facial trauma. Evidence also indicates that the use of plain radiography does not improve quality of care, causes unnecessary radiation exposure, and leads to a substantial increase in costs. Use of plain radiography for diagnosis and treatment is helpful in instances of dental and/or isolated mandibular injury or trauma.12,13

5. Avoid Continuing Prophylactic Antibiotics for Greater Than 24 Hours after a Surgical Procedure

Current evidence suggests that discontinuing antibiotic prophylaxis within 24 hours or less after surgery is sufficient for preventing surgical-site infection compared with continuing antibiotic prophylaxis beyond 24 hours after surgery. Prolonged use of antibiotics may increase the occurrence of antibiotic-resistant bacteria and increase the risk of other infections. This recommendation is also supported by the Surgical Care Improvement Project, which is a national quality partnership of organizations interested in improving surgical care by significantly improving surgical complications. In cases where a surgical drain is placed next to a prosthetic device (e.g., breast implant or tissue expander), there is not enough evidence to recommend discontinuing antibiotics and therefore the decision is left to the surgeon’s discretion. This recommendation does not apply to cardiothoracic surgical procedures.14,15

ACKNOWLEDGMENT

Large portions of this text were originally published on the American Board of Internal Medicine Foundation Web site (http://www.choosingwisely.org/doctor-patient-lists/american-society-of-plastic-surgeons/?utm_source=focus&utm_medium=email&utm_content=062114&utm_campaign=asps-focus). The ASPS created the content for its list and retains ownership. This text has been reproduced for publication in Plastic and Reconstructive Surgery with permission from the ASPS.16

REFERENCES

1. American College of Radiology. ACR Practice Guideline for the performance of screening and diagnostic mammography. 2013 Reston, Va American College of Radiology Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Screening_Mammography.pdf. Accessed September 20, 2013
2. American Society of Breast Surgeons. Position statement on screening mammography. 2011 Columbia, Md American Society of Breast Surgeons
3. American College of Obstetricians and Gynecologists. Breast cancer screening. 2011 Washington, DC American College of Obstetricians and Gynecologists
4. U.S. Preventive Services Task Force. . Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716–726, W–236
5. American Cancer Society. Breast cancer: Early detection. 2013 Atlanta, Ga American Cancer Society Available at: http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-toc. Accessed November 4, 2013.
6. American Society of Plastic Surgeons. Evidence-based clinical practice guideline: Reduction mammaplasty. 2011. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction%20Mammaplasty_%20Evidence%20Based%20Guidelines_v5.pdf. Accessed September 20, 2013
7. Stojkovic CA, Smeulders MJC, Van der Horst CM, Khan SM. Wound drainage after plastic and reconstructive surgery of the breast. Cochrane Database Syst Rev. 2013;3:CD007258
8. Kosins AM, Scholz T, Cetinkaya M, Evans GRD. Evidence-based value of subcutaneous surgical wound drainage: The largest systematic review and meta-analysis. Plast Reconstr Surg. 2013;132:443–450
9. American Society of Plastic Surgeons. Evidence-based clinical practice guideline: Breast reconstruction with expanders and implants 2013. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/breast-reconstruction-expanders-with-implants-guidelines.pdf. Accessed September 20, 2013
10. American College of Radiology. ACR Practice Guideline for the performance of screening and diagnostic mammography. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Screening_Mammography.pdf. Accessed September 20, 2013
11. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: Breast cancer screening and diagnosis. Version 2; 2013. Available at: http://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf. Accessed September 20, 2013
12. Sitzman TJ, Hanson SE, Alsheik NH, Gentry LR, Doyle JF, Gutowski KA. Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients. Plast Reconstr Surg. 2011;127:1270–1278
13. Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA. Management of mandible fractures. Plast Reconstr Surg. 2006;117:48e–60e
14. Bratzler DW, Dellinger EP, Olsen KM, et al.American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283
15. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38:1706–1715
16. ABIM Foundation. Choosing Wisely: An initiative of the ABIM Foundation. Available at: http://www.choosingwisely.org/doctor-patient-lists/american-society-of-plastic-surgeons/?utm_source=focus&utm_medium=email&utm_content=062114&utm_campaign=asps-focus. Accessed July 1, 2014
©2014American Society of Plastic Surgeons