Top Five Recommendations to Reduce Unnecessary Medical Expenses

To reduce wasteful practices in medicine, the American Board of Internal Medicine and Consumer Reports developed the “Choosing Wisely” campaign. As a participant in the campaign, The American Academy of Neurology (AAN) selected a diverse panel with experience in evidence-based guidelines and practice parameters. The AAN sought from its members recommendations of practices that are common in neurology yet have strong evidence of lacking benefit (or causing harm) and are costly. From 178 submissions, the AAN selected 5 as having strong supporting rationales and obtained input from relevant subspecialty experts and patient advocacy groups. These practices are as follows:

• Don't perform electroencephalography (EEG) for headache disorders. Rationale: Clinical features have better diagnostic accuracy for primary headaches. Neuroimaging has higher sensitivity than EEG to evaluate for a mass lesion, if clinically suspected.

• Don't perform carotid ultrasound for syncope without other neurological symptoms. Rationale: Syncope is common, carotid disease causes focal neurological symptoms, and indiscriminate use of ultrasound results in unnecessary procedures.

• For migraine, reserve opioids and butalbital as a last resort. Rationale: Nonopioid analgesics often work, and migraine-specific treatments are available. Opioids and butalbital increase the risk for analgesia-overuse headaches and chronic headaches. Opioids can be considered for ≤9 days per month when other treatments fail or medical comorbidity prevents use of first-line treatments.

• Don't prescribe disease-modifying therapies (DMTs) for those with progressive, nonrelapsing multiple sclerosis (MS). Rationale: DMTs have not shown efficacy in reducing disability in progressive MS and have potential adverse effects.

• Don't recommend carotid endarterectomy (CEA) for asymptomatic carotid stenosis unless the complication rate is <3%. Rationale: A benefit for asymptomatic carotid disease requires very low angiographic and surgical complication rates.