AUA issues recommendations on surveillance, opioids

Continuing its participation in the Choosing Wisely campaign, the AUA has added five new recommendations about tests and treatments that physicians and patients should question.

Released during the AUA annual meeting in Boston, the new directives are:

Don’t treat low-risk clinically localized prostate cancer (eg, Gleason score less than 7, PSA less than 10.0 ng/mL, and tumor stage T2 or less) without discussing active surveillance as part of the shared decision-making process.

Don’t treat uncomplicated cystitis in women with fluoroquinolones if other oral antibiotic treatment options exist.

Don’t continue opioid analgesia beyond the immediate postoperative period; prescribe the lowest effective dose and number of doses required to address the expected pain.

Don’t obtain urine cytology or urine markers as a part of the routine evaluation of the asymptomatic patient with microhematuria.

Don’t routinely use computed tomography to screen pediatric patients with suspected nephrolithiasis.

J. Stuart Wolf Jr., MD, of Dell Medical School, The University of Texas at Austin, is chair of the AUA Science & Quality Division that oversees the AUA’s Choosing Wisely effort. Speaking to Urology Times, he said, “Choosing Wisely is an incredibly useful program that has forced the AUA and other contributing organizations to really distill down pithy nuggets of information that are critical for and define good practice.”

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“The statements are highly vetted, evidence-based, and devoid of any caveats, which means they give straightforward guidance to physicians about things they should not do. They also have value for educating urology residents as well as our primary care colleagues in addition to their utility for helping to inform patients.”

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation developed around the theme of value in health care, with the aim of reducing overuse and inappropriate delivery of services. The AUA has participated in the program since 2012. It released a first set of five recommendations in 2013 and five more in 2015.

Christopher Tessier, MD, of Oregon Health & Science University in Portland, OR, served as chair for the latest AUA’s Choosing Wisely work force group. He told Urology Times, “The Choosing Wisely program is important to urologists not only for assuring patient safety, but also because we need to be at the forefront of suggesting ways to embark on this mission of value. Regardless of how individual urologists may feel that they are using resources judiciously, payers and regulators are watching. Because our payment structure is moving more towards a value-based formula that will consider costs and overuse, it is important for urologists to be part of the process.”

“We at the AUA feel we have a lot to offer in this space of value-based care based on a wealth of evidence to determine whether specific practices should or should not be done. Through Choosing Wisely, we can highlight our guideline statements that resonate with this emphasis towards reducing overuse and cost in medicine.”

Next: How the recommendations were chosen

To develop its latest list of statements, the AUA’s Choosing Wisely work force group first solicited topics from AUA members. The suggestions were reviewed for consistency with the objectives of the Choosing Wisely program and for scientific support from the AUA’s evidence-based clinical practice guidelines and other resources.

“It is interesting that two of our five statements reflect topics not covered in AUA guidelines, but instead are rooted in other guidance impacting urologic patient care,” said Dr. Tessier.

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He explained that support for the statement on antibiotic use for uncomplicated cystitis comes from an FDA Drug Safety Communication issued in July 2016 and the 2010 International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women from the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. The statement on opioid analgesia is backed by the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

AUA members were presented with a list of 12 candidate statements and asked to vote for their top five choices. The five new statements represent those that received the highest number of votes. Prior to release, the recommendations were reviewed and approved by the AUA Board of Directors in March 2017.

“The American Board of Internal Medicine Foundation, partnering with Consumer Reports, have done a good job publicizing the Choosing Wisely program directly to consumers. Feedback from AUA members for the Choosing Wisely campaign has increased since the first iteration, and I believe that reflects increased awareness among urologists,” Dr. Tessier said.