Thoracic Society of Australia and New Zealand

The Thoracic Society of Australia and New Zealand (TSANZ) is the only health peak body representing a range of professions (medical specialists, scientists, researchers, academics, nurses, physiotherapists, students and others) across various disciplines within the respiratory/sleep medicine field in Australia and Aotearoa New Zealand. The TSANZ is a Health Promotion Charity.

TSANZ is committed to serving the professional needs of its members by improving knowledge and understanding of lung disease, with the ultimate goals being to prevent respiratory illness through research and health promotion and to improve health care for people with respiratory illness.

Download the Thoracic Society of Australia and New Zealand's Evolve Top-5 recommendations (PDF) on adult thoracic medicine and watch the recommendations video.

Top-5 recommendations on low-value practices | Adult

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

Rationale and evidence

Rationale

The sequence for diagnostic testing in patients with suspected pulmonary embolism (PE) depends on the clinical circumstances. The certainty of a negative diagnosis for PE via an algorithm including a negative D-dimer result is enhanced when the algorithm follows a multi-branch diagnostic pathway. While combining a negative D-dimer result with a low or moderate clinical probability for PE rules out these diagnoses, the use of D-dimer is not helpful in patients with a high probability clinical assessment since a negative D-dimer does not exclude PE in more than 15% of such patients.

According to Wells’ criteria for deep vein thrombosis, a score of less than 2 indicates low risk, and above 2 indicates intermediate/high risk. The high score is ≥4.5 in the 2-tier model and >6 in the 3-tier model (2-6 indicates moderate risk in this model).

Evidence

Kearon C, Ginsberg JS, Douketis J, et al. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial. Ann Intern Med. 2006;144(11): 812-21.

Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004;140(8): 589.

Crawford F, Andras A, Welch K, et al. D-dimer test for excluding the diagnosis of pulmonary embolism.  Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD010864.

Righini M, Le Gal G, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: A randomised non-inferiority trial. Lancet. 2008 Apr;371(9621):1343-52.

'Pulmonary embolism diagnosis study'. (CANPEDS) Group Ann Intern Med. 2006;144(11): 812.

Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006;119(12): 1048.

Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep 25;349(13): 1227-35.


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

Rationale and evidence

Rationale

Despite their ongoing and frequent use, there is insufficient evidence regarding efficacy of systemic corticosteroids in the treatment of COPD without exacerbations. Well- known side-effects of this drug group are obesity, respiratory and peripheral muscle weakness, hypertension, psychiatric disorders, diabetes mellitus, osteoporosis, skin thinning and bruising. The burden of cardiovascular disease has a significant impact on all-cause mortality in COPD patients. The combination of limited efficacy and potential toxicity of the drugs, especially in the at-risk patients who tend to be older, less active and have histories of smoking, means that long term use of systemic corticosteroids in COPD is not recommended.

In the cases of the exacerbations of COPD, a 2018 systematic review from Cochrane suggests that a 5-day course of oral corticosteroids is likely to be sufficient and that the likelihood that shorter courses of systemic corticosteroids (of around 5 days) lead to worse outcomes compared with longer courses (10 to 14 days) is low.

Evidence

M Decramer, L M Lacquet, R Fagard, and P Rogiers. Corticosteroids contribute to muscle weakness in chronic airflow obstruction.  American Journal of Respiratory and Critical Care Medicine Volume 150, Issue 1.

Falk JA, Minai OA, Mosenifar Z. Inhaled and systemic corticosteroids in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4): 506-512.

McEvoy CE1, Niewoehner DE. Adverse effects of corticosteroid therapy for COPD. A critical review.  Chest. 1997 Mar;111(3): 732-43.

McGarvey LP, John M, Anderson JA, et al. Ascertainment of cause-specific mortality in COPD: operations of the TORCH Clinical Endpoint CommitteeThorax 2007;62:411 - 415.

Olof Selroos. (2004) 'The place of inhaled corticosteroids in chronic obstructive pulmonary disease'. Current Medical Research and Opinion. 20:10, 1579-1593.

N.M. Siafakas, P. Vermeire, N.B. Pride, et al. 'Optimal assessment and management of chronic obstructive pulmonary disease (COPD)'. Eur Respir J. 1995, 8, 1398–1420.

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2019.

Walters JAE, Tan DJ, White CJ & Wood‐Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD006897.


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

Rationale and evidence

Rationale

Most patients with COPD present with mild disease and few complaints but tend to live a very sedentary lifestyle. The cornerstone of management of mild COPD is smoking cessation, the only proven intervention to relieve symptoms, modify the natural history of disease and lower mortality rates. For asymptomatic or minimally symptomatic patients, quitting smoking is often the only required therapy. Other effective behavioural interventions include maintaining or increasing physical activity, ensuring adequate sleep and a healthy diet and the use of effective stress management strategies.

Inhalers have evidence for only reducing exacerbations and do not modify disease. The use of short- or long-acting bronchodilators on a regular basis is not generally recommended for minimally symptomatic COPD patients with a low risk of exacerbation.

Evidence

 Achilleos KM, Powrie JD. 'Diagnosis and management of stable COPD'. BJMP 2011;4(3): a427.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD.

Chee A & Sin DD. 'Treatment of mild chronic obstructive pulmonary disease'. Int J Chron Obstruct Pulmon Dis. 2008, Dec; 3(4): 563–573.


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

Rationale and evidence

Rationale

There is a lack of direct evidence related to cancer probability in small nodules in low-risk patients. The National Lung Screening Trial, the largest randomised study of lung cancer screening in a high-risk population to date, showed that that CT lung screening reduces lung cancer mortality in high-risk patients when the minimum size of a positive pulmonary nodule is set at 4 mm. As more than half of baseline examinations in the study were positive for nodules 4 to 6 mm in size, raising the threshold for a positive result to 6 mm would decrease the baseline positive rate from 27.3% to around 13.4%.

Since the positive predictive value (PPV) of an examination deemed positive for a nodule of 4 to 6 mm stands at 0.5%, increasing the threshold to 6 mm might act to increase the PPV by a factor of 1.8 (7.2% at 6 mm vs 3.8% at 4 mm) without significantly affecting the sensitivity to detect cancer. Given that the average risk of cancer in solid nodules smaller than 6 mm in patients at high risk is less than 1%, it is reasonable to assume an even lower risk in a patient with low clinical risk.

According to the risk categories proposed by the American College of Chest Physicians (ACCP), low risk, which corresponds to an estimated risk of cancer of less than 5%, is associated with young age, less smoking, smaller nodule size, regular margins, and location in an area other than the upper lobe.

Evidence

Yip R1, Henschke CI, Yankelevitz DF, Smith JP. CT screening for lung cancer: Alternative definitions of positive test result based on the national lung screening trial and international early lung cancer action program databases. Radiology. 2014, Nov;273(2): 591-6. 2014 Jun 19.

Gould MK, Donington J, Lynch WR, et al. 'Evaluation of individuals with pulmonary nodules: when is it lung cancer?' Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl): e93S-e120S.

Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. 

National Lung Screening Trial Research Team Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011; 365:395-409.

McKee, Brady J. et al.'  Performance of ACR Lung-RADS in a Clinical CT lung screening program'. Journal of the American College of Radiology'. 2015, 12 (3): 273 - 276.


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

Rationale and evidence

Rationale

Sarcoidosis is a multisystemic disease with heterogenous clinical presentations. Diagnosis of sarcoidosis is often challenging because of the lack of reliable biomarkers and other gold standard tests. Unusually high serum angiotensin converting enzyme (ACE) is present in up to 75% of untreated patients.

However, testing for high serum ACE level has been repeatedly demonstrated to have a poor sensitivity, insufficient specificity (including a false positive rate of around 10%) and inconsistent correlation with disease severity. As such, its general clinical utility is limited.

Evidence

Gomez NS, Peters Jl, MD, Nambiar AM, University of Texas Health Science Center, San Antonio. Diagnosis and management of sarcoidosis. Texas Am Fam Physician. 2016, 15;93(10): 840 - 850.

Ungprasert P, Carmona EM, Crowson CS, Matteson. 'Diagnostic utility of angiotensin-converting enzyme in sarcoidosis: A population-based study'. EL Lung. 2016;194(1): 91-5.

Studdy PR & Bird R. Serum angiotensin converting enzyme in sarcoidosis - its value in present clinical practice. Ann Clin Biochem. 1989;26 (Pt 1):13.

 Baughman RP. Pulmonary sarcoidosis. Clin Chest Med. 2004;25 (3): 521





How this list was developed

The TSANZ worked with RACP’s Policy & Advocacy team as part of the Evolve program to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting under the guidance of the TSANZ Central Office and members of the TSANZ Board, the list was condensed to the top 5 recommendations for reducing low-value practices in adult thoracic medicine. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest in or professional engagement with thoracic medicine.

Per usual processes, the recommendations were then consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further work and refinements by Policy & Advocacy and TSANZ, which approved these Top-5 recommendations.

 

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