The American Geriatrics Society CW list says that physicians should not use benzodiazepines or other sedative-hypnotic drugs in older adults as a first-line insomnia treatment. They note high risks for motor vehicle accidents, as well as falls and hip fractures in these patients. Again, while it may not directly affect the practice of rheumatologists, there is a subset of patients for whom they need to keep this suggestion in mind.
“Sleep disorders are very common in patients with rheumatic disease,” notes Dr. Yazdany. “They will often bring this problem to our attention and ask for a medication to relieve the situation.”
There is a wealth of evidence in older patients showing that these kinds of medications can cause significant harm. Other options should be explored first.
A similar concern was brought up by the ACOEM’s suggestion that opioids should not be prescribed for either chronic or acute pain in those with safety-sensitive jobs, such as operating vehicles or heavy equipment. As with the benzodiazepine measure, this is an indirect concern that many rheumatologists may not have in the forefront of their decision-making process.
“Certainly in our practices we see people in pain from rheumatic diseases who operate heavy machinery or do similar work,” notes Dr. King. “Most rheumatologists know that we should use the lowest doses of these medications that are consistent with pain relief. I don’t think it is always on our radar to think about the special concerns with opioids in this particular population.”
From Under- to Overutilization
The overarching message from CW campaigns is that the focus of what constitutes quality has changed over the last decade or so.
“It is not really surprising that Choosing Wisely came along when it did,” says Dr. Saag. “There has been a traditional focus on underuse of medical modalities as a quality concern. What we are seeing now is an era of cost containment and a shift toward overutilization as a quality measure.”
Rheumatologists can mine the lists from other societies and find practice gems, especially in areas not usually thought of as part of rheumatology practice.
CW seeks out the top interventions and tests within different specialties that are of high cost and doubtful or little value. Dr. Saag notes that value is not just about cost, but has to do with how cost relates to value. There are very costly tests that still give important information. The key is finding those with high cost but little value and rooting them out.
