Protection against the overuse and underuse of health care – methodological considerations for establishing prioritization criteria and recommendations in general practice

Muche-Borowski, Cathleen; Abiry, Dorit; Wagner, Hans-Otto; Barzel, Anne; Lühmann, Dagmar; Egidi, Günther; Kühlein, Thomas; Scherer, Martin

doi:10.1186/s12913-018-3569-9

Table 2 List of prioritized guideline recommendations for protection against the overuse and underuse of health care

From: Protection against the overuse and underuse of health care – methodological considerations for establishing prioritization criteria and recommendations in general practice

Clinical guideline		Recommendation (short)	Protection against…^a	Reference
Prevention/risk factor reduction
Cough	1	Recommendation for regular documentation of smoking status in smokers with cough	Underuse	[38]
Asthma	2	Recommendation for prevention of passive smoking	Underuse	[39]
Back pain	3	Recommendation for physical activity in the prevention of back pain and back pain related sick leave	Underuse	[40]
Screening
Skin cancer prevention	4	Recommendation against general skin cancer screening	Overuse	[42]
Alcohol-related disorders	5	Recommendation against general screening for at-risk drinking in primary care setting	Overuse	[43]
Prostate cancer	6	Recommendation against general PSA screening. Recommendation for a discussion of the pros and cons in patients asking for advice	Overuse	[44]
Diagnostics
Sore throat	7	Recommendation for Centor Score and McIsaac Score to determine when to perform a throat swab	Overuse	[45]
Fatigue	8	Recommendation for two-question depression screening in patients with unspecific fatigue	Underuse	[41]
	9	Recommendation for basic diagnostics in every patient with fatigue (anamnesis, physical examination, blood work)	Underuse	[41]
	10	Recommendation against cancer diagnostics in patients with fatigue and no further signs of cancer	Overuse	[41]
Chest pain	11	Recommendation for Marburg Heart Score for estimating the probability of ischemic heart disease in patients with chest pain in the primary care setting	Overuse and Underuse	[46]
Chest pain	12	Recommendation on coronary angiography only if defined diagnostic or therapeutic benefit is present	Overuse	[46]
Diabetic neuropathy	13	Recommendation on comprehensive diabetic foot examination	Underuse	[47]
Chronic congestive heart failure	14	Recommendation for echocardiography in every patient with congestive heart failure	Underuse	[48]
Chronic congestive heart failure	15	Recommendation for echocardiography reports including an interpretation of the result	Underuse	[48]
Dementia	16	Recommendation for limiting imaging in dementia patients to those with possibly treatable disease	Overuse	[49]
Back pain	17	Recommendation against imaging in uncomplicated acute back pain	Overuse	[40]
Therapy
Sore throat	18	Recommendation for patient-doctor discussion of the inappropriateness of antibiotics against viral infections	Overuse	[45]
Cough	19	Recommendation on rational antibiotic treatment of CAP	Overuse	[38]
	20	Recommendation against antibiotics in acute uncomplicated bronchitis	Overuse	[38]
	21	Recommendation against regular use of neuraminidase inhibitors in seasonal influenza	Overuse	[38]
	22	Recommendation against expectorants in acute infectious cough	Overuse	[38]
Diabetes – treatment	23	Recommendation for discontinuing diabetes medication when therapeutic goal is reached with minimal drug dose	Overuse	[50]
Diabetes – treatment	24	Recommendation for rational HbA1c targets in patients with type 2 diabetes	Overuse	[50]
Diabetic foot	25	Recommendation on correct management of diabetic foot ulcers	Underuse	[51]
Chronic congestive heart failure	26	Recommendation against inappropriate medicines in patients with chronic congestive heart failure	Overuse	[48]
	27	Recommendation for ACE inhibitors in patients with reduced ejection fraction	Underuse	[48]
	28	Recommendation for beta blockers in patients with congestive heart failure	Underuse	[48]
Dementia	29	Recommendation for stopping drug treatment for dementia if dementia is exacerbated	Overuse	[49]
Back pain	30	Recommendation against IV or IM medications in unspecific acute or chronic back pain	Overuse	[40]
Back pain	31	Recommendation against IV NSAIDs in back pain	Overuse	[40]
Chronic ischemic heart disease	32	Recommendation for statin therapy without dose adjustment	Overuse	[52]
Long-term care in primary care setting
Diabetes – treatment	33	Recommendation against regular monitoring of the lipid response to statin therapy	Overuse	[50]
Chronic congestive heart failure	34	Recommendation for appropriate management of elevated creatinine in patients with chronic congestive heart failure	Underuse	[48]
	35	Recommendation on content of regular control examinations	Underuse	[48]
	36	Recommendation for encouraging physical exercise in patients with stable congestive heart failure	Underuse	[48]
	37	Recommendation for weight monitoring in patients with congestive heart failure	Underuse	[48]
Dementia	38	Recommendation for additional focus on well-being of family members of a patient with dementia in primary care setting	Underuse	[49]

^aBased on the mean scores of the prioritization criteria “Relevance for overuse of health care” and “Relevance for underuse of health care” assigned by the clinically active authors of the guideline “Protection against the overuse and underuse of health care”. A difference larger than one point between the means of the two criteria determined the category (protection against overuse vs. underuse). If the difference was one point or smaller, the recommendation was regarded as relevant for both overuse and underuse

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ISSN: 1472-6963

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