Internal Medicine Essentials
American College of Physicians

HVC Recommendations

About High Value Care

The High Value Care initiative of the American College of Physicians is an effort to improve health care outcomes by encouraging physicians to provide care with proven benefit and to reduce harms and costs by avoiding unnecessary interventions. The initiative integrates the important concept of health care value (balancing clinical benefit with costs and harms) for a given intervention into various educational materials to address the needs of medical students, trainees, practicing physicians, and patients.

To incorporate high value care principles into IM Essentials, we have highlighted high value care recommendations throughout this program that meet the definition below. In addition, we have aggregated each section’s recommendations at the beginning of the section so that they can be reviewed in one location.

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations in IM Essentials.

Cardiovascular Medicine Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Cardiovascular Medicine section of IM Essentials.

  • Use of antioxidant vitamins or hormone replacement therapy in postmenopausal women is not recommended for coronary artery disease (CAD) risk reduction.
  • Testing homocysteine levels should not be performed as part of routine cardiovascular risk assessment.
  • The American Heart Association and Centers for Disease Control and Prevention do not recommend routine measurement of highly-sensitive C-reactive protein (hs-CRP), but measurement may be useful in patients with a moderate (10%-20%) 10-year risk of a first CAD event.
  • Asymptomatic patients without cardiovascular risk factors should not undergo routine screening for CAD, either with electrocardiography or stress testing.
  • Computed tomography (CT)-based coronary artery calcium scoring is an evolving technology with unclear benefit in predicting cardiovascular risk relative to traditional risk-prediction tools; it should therefore not be used routinely.
  • Patients with a low probability of CAD do not require stress testing, and patients with a high probability of CAD should be started immediately on medical management, with consideration of coronary angiography if there is no response to therapy or if severe disease is suspected.
  • Positron emission tomography (PET) with CT is a complex and expensive diagnostic modality and its appropriate role in evaluating chronic stable angina remains to be established.
  • Patients with an abnormal stress test who do not have factors suggestive of severe CAD may benefit from initial medical management.
  • Percutaneous coronary intervention (PCI; angioplasty and stent placement) has not been shown to reduce mortality or cardiovascular events in patients with stable CAD, but it has been shown to reduce angina and to improve quality of life. PCI is most appropriately used in patients who do not respond to medical therapy.
  • Routine resting electrocardiograms (ECGs) are not recommended if there have been no changes in symptoms, examination findings, or medications. A repeat stress test is indicated if there is a change in symptoms but should not be performed routinely.
  • Although newer oral anticoagulant medications do not require routine monitoring of their anticoagulation effect and may have several other potential advantages, they are significantly more expensive than warfarin.
  • Echocardiography should not be used to screen for heart failure in asymptomatic patients without murmurs.
  • Do not routinely measure B-type natriuretic peptide (BNP) in patients with typical signs and symptoms of heart failure.
  • Once heart failure is diagnosed, serial chest radiographs are not sensitive to small changes in pulmonary vascular congestion and are not recommended.
  • Combined treatment with an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin receptor blocker (ARB) is not recommended as additional benefit of using these two medications together is not well established.
  • Spironolactone is usually first-line therapy due to clinical experience and cost considerations; however, the more receptor-specific eplerenone may be useful in individuals developing gynecomastia with spironolactone.
  • Echocardiographic reassessment of ejection fraction is most useful when there is a notable change in clinical status rather than at regular or arbitrary intervals.
  • Not all systolic murmurs are pathologic. Short, soft systolic murmurs (grade <3) that are asymptomatic often do not require further investigation.
  • Routine serial echocardiography is not needed in asymptomatic patients with prosthetic heart valves.
  • For most patients, imaging studies are not needed for routine monitoring of peripheral artery disease (PAD), but may be indicated if intervention is felt to be needed.
  • In patients with a low likelihood of disease, D-dimer testing may be useful in excluding the diagnosis of dissection.
  • Screening for carotid stenosis is not recommended in the general population.
  • Carotid artery stenting is usually associated with a higher risk of stroke than surgery and is not routinely performed in patients with carotid stenosis.
  • Patients with a low clinical likelihood of deep vein thombosis (DVT) should undergo testing with D-dimer as the combination of a low clinical probability, and negative D-dimer rules out DVT.
  • There is no indication for routine screening for DVT in asymptomatic patients at risk for venous thromboembolism (VTE).
  • Newer oral anticoagulation medications tend to be very expensive and their long-term safety remains to be established.

Endocrinology and Metabolism Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Endocrinology and Metabolism section of IM Essentials.

  • In the absence of clinical findings, testing only for serum prolactin may be appropriate for microadenomas.
  • Screening for hyperthyroidism is not recommended for the general population.
  • Thyroid-stimulating hormone (TSH) receptor antibody tests lack sensitivity and specificity in Graves disease and are minimally useful for initial diagnosis.
  • Patients with subclinical hypothyroidism may not require treatment if they are asymptomatic or are women not desiring pregnancy or currently pregnant.
  • An annual evaluation of serum TSH levels is recommended in patients receiving levothyroxine therapy; studies have demonstrated that up to 30% of such patients may be unintentionally under- or overtreated.
  • For patients with a history of hypoglycemia, a limited life expectancy, and advanced macrovascular complications, a target hemoglobin A1c (HbA1c) goal of 8.0% may be reasonable.
  • There is no advantage of newer bisphosphonates compared to older forms available as generics (ie, oral alendronate).
  • Teriparatide is 10 times more expensive than other therapies for osteoporosis and cannot be continued beyond 24 months because of concern about a potential risk for osteosarcoma.
  • Because of potential side effects and expense, denosumab is considered second-line therapy for patients unable to take or tolerate bisphosphonate therapy.
  • For patients with a normal or low normal bone mineral density (BMD), repeat dual-energy x-ray absorptiometry (DEXA) scans need not occur for 10 to 15 years.

Gastroenterology and Hepatology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Gastroenterology and Hepatology section of IM Essentials.

  • The diagnosis of gastroesophageal reflux disease is usually based on the clinical picture.
  • Proton pump inhibitor (PPI) therapy is the treatment of choice for patients presenting with gastroesophageal reflux disease.
  • Younger patients with mild to moderate epigastric pain consistent with peptic ulcer disease and no other associated symptoms can be treated empirically with a PPI and forgo endoscopy.
  • Repeat liver chemistry studies are indicated in asymptomatic patients to confirm any abnormal test results.
  • The duration of liver test abnormalities can often be determined through the history and laboratory records, and this is important information in interpreting abnormal liver studies.
  • Asymptomatic patients with mild liver enzyme abnormalities require only follow-up with repeated laboratory studies.
  • Liver biopsy is often not required to make the diagnosis of nonalcoholic fatty liver disease in a consistent clinical setting.
  • Screening for gallstones in asymptomatic, average-risk individuals is not indicated.
  • Measuring serum lipase alone is sufficient to confirm the diagnosis of acute pancreatitis in the appropriate clinical setting.
  • Imaging of the pancreas in acute pancreatitis is not indicated in all patients but should be considered in those with moderate or severe pancreatitis or persistent fever and in those who do not improve clinically within 48 to 72 hours to confirm the diagnosis, exclude other intraabdominal processes, grade the severity of pancreatitis, and diagnose local complications (pancreatic necrosis, pseudocyst, abscess).
  • Because most episodes of diarrhea are self-limited, diagnostic testing generally is reserved for patients with severe diarrheal illness characterized by fever, blood in the stool, or signs of dehydration (weakness, thirst, decreased urine output, orthostasis) or patients with diarrhea lasting >7 days.

General Internal Medicine Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the General Internal Medicine section of IM Essentials.

  • Muscle relaxants and opioid analgesics have not been shown to be more effective than NSAIDs for treatment of low back pain, and both may have central nervous system side effects and addiction potential.
  • Antiviral therapy for influenza is indicated only for hospitalized patients and those with severe, complicated, or progressive illness.
  • There is little evidence to support the use of most over-the-counter and prescription antitussive medications for treatment of cough, with the effectiveness of most agents being similar to placebo.
  • The history and physical examination identify a cause of syncope in 45% of cases.
  • Patients with a history suggestive of neurocardiogenic syncope who are deemed at low risk may require no further evaluation.
  • As many as two-thirds of patients with lymphadenopathy have an obvious self-limited cause, such as a recent upper respiratory tract infection, that does not require further evaluation.
  • Because of the many potential causes of lymphadenopathy, the clinician must rely heavily on the patient's history and physical examination to focus the subsequent laboratory or imaging evaluation on the most likely diagnoses.
  • Before pursuing additional testing in patients with unexplained weight loss, review prior medical studies such as age-appropriate cancer screening to help identify areas that may need further investigation.
  • Cellulitis is a clinical diagnosis; cultures usually are not necessary, and results are seldom positive.
  • Folliculitis often resolves spontaneously; therefore, systemic antibiotics should not be used routinely.
  • Incision and drainage may be adequate therapy for skin abscesses, and systemic antibiotics are not routinely required.
  • Attempted elimination of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage (decolonization) using intranasal mupirocin or from body surfaces using topical antiseptic cleansers is not recommended as a routine part of managing MRSA infections, although it may have a role in outbreaks, patients in intensive care units, and selected patients with recurrent S. aureus infections.
  • Combination antifungal and glucocorticoid products should be avoided in treating fungal skin infections.
  • Systemic glucocorticoids have not been shown to reduce the incidence of postherpetic neuralgia.
  • In most cases, the history and physical examination are sufficient to diagnose acne.

Hematology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Hematology section of IM Essentials.

  • Universal screening of unselected populations for inherited thrombophilias should be avoided.
  • Routinely screening for inherited thrombophilias in patients undergoing high-risk surgical procedures (such as certain orthopedic surgeries) is not recommended.
  • Testing for inherited causes of thrombophilia in the setting of an acute venous thromboembolism (VTE) may not be reliable since the acute phase reactants of the VTE may interfere with factor measurements.
  • Most experts do not recommend testing for the congenital thrombophilias to determine the method, intensity or duration of treatment for patients presenting with their first venous thromboembolism unless there is a suggestive or known history of familial thrombophilia.
  • Except to monitor the effectiveness of anticoagulant therapy, routinely checking laboratory studies once the diagnosis of thrombophilia has been established is not recommended.
  • A more restrictive approach to transfusion in non-cardiac patients with a hemoglobin goal of 7 to 8 g/dL (70-80 g/L) is favored in most patients.

Infectious Disease Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Infectious Disease section of IM Essentials.

  • Fever, as a symptom, does not always require treatment.
  • Frequent hand washing has been proven to prevent transmission of common respiratory infections.
  • Vaccination for influenza can reduce the risk of influenza-like illnesses by 36%.
  • The use of vitamin C or echinacea to prevent common respiratory infections is not supported by strong evidence.
  • Laboratory testing and imaging studies are unnecessary for diagnosis of common respiratory infections.
  • Codeine and over-the-counter antitussive agents have not been proven to be effective for acute cough in patients with upper respiratory infections (URIs).
  • Antibiotics are not indicated for uncomplicated URIs, even when purulent sputum or nasal discharge is present.
  • Do not use prophylactic antibiotics in asymptomatic individuals with pharyngitis to prevent the spread of infection.
  • Patients with 0 or 1 Centor criteria are at sufficiently low risk <3%) that they should neither be tested for group A streptococcal pharyngitis nor treated with antibiotics.
  • Avoid sinus imaging in uncomplicated acute sinusitis; patients with ophthalmic or neurologic symptoms or signs may need diagnostic imaging.
  • Antibiotics have been found to have little if any role in the treatment of patients with acute sinusitis in the primary care setting, and in most cases, symptomatic treatment is first-line therapy.
  • Sputum Gram stain and culture are not indicated in hospitalized patients with less severe pneumonia, but they should be obtained for any patient at risk for infection with drug-resistant or unusual pathogens or those with severe pneumonia.
  • In hospitalized patients on intravenous antibiotics, switch to oral antibiotic therapy once symptoms improve and when patients have no fever on two occasions 8 hours apart and are able to take medications by mouth.
  • Only obtain a chest radiograph after initial therapy for community-acquired pneumonia if the patient does not respond to treatment, or to document resolution of pneumonia with risk factors and suspicion of an underlying disease, such as malignancy.
  • Screening is not needed for individuals at low risk of tuberculosis.
  • Antibiotic prophylaxis for endocarditis is not indicated for patients with low- or moderate-risk cardiac conditions undergoing any type of procedure.
  • Pathogen-directed therapy for endocarditis should be instituted once the microbiologic cause has been identified.
  • Urinalysis should not be ordered as part of a routine well care examination in men and nonpregnant women.
  • Urinalysis can be omitted for healthy women with acute cystitis if there are no complicating factors.
  • A follow-up urinalysis or culture is not indicated after treatment for an uncomplicated upper respiratory tract infection (URI) with symptom resolution.

Nephrology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Nephrology section of IM Essentials.

  • Because of its long half-life, measurement of serum 25(OH)D2 is the best indicator of total body vitamin D stores.
  • Except for stone composition, additional studies for nephrolithiasis (such as 24-hour urine collections) are not done routinely and should be reserved for patients with recurrent stones in which they may be used to prescribe specific pharmacologic and dietary interventions.

Neurology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Neurology section of IM Essentials.

  • Most primary headaches are benign and do not require routine laboratory evaluation or imaging studies.
  • No one triptan for migraine headache has been shown to be superior to others, so treatment decisions should be made on prior experience and cost.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and hormone replacement therapy have not been shown to prevent cognitive decline or dementia.
  • Medications should be carefully reviewed at each visit to avoid unnecessary treatment that can cause delirium or exacerbate preexisting dementia.
  • High-dose vitamin E, aspirin, and NSAIDs have not been found to slow the progression of symptoms in Alzheimer disease and should not be recommended.
  • Brain imaging is usually unhelpful in the diagnosis of delirium unless there is a history of a fall or headache or evidence of focal neurologic impairment.
  • Electromyography and nerve conduction studies may not be necessary when the history and examination point to a clear etiology of peripheral neuropathy (eg, classic carpal tunnel syndrome) or when an underlying condition exits that can explain the clinical presentation (eg, long-standing diabetes in a patient with a mild distal symmetric polyneuropathy).
  • The benefit of antiviral therapy in treating Bell palsy has not been established.
  • Opioids should generally be avoided in treating peripheral neuropathy but may be considered for acute, severe pain or when other treatments have been unsuccessful.
  • The diagnosis of essential tremor is based on clinical features and the elimination of secondary causes.
  • Patients who have had only a single seizure may not require treatment.

Oncology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Oncology section of IM Essentials.

  • In patients with incidentally discovered pulmonary nodules, obtain prior chest radiographs or imaging scans if possible to determine stability over time. No follow-up is recommended for nodules that are ≤4 mm in patients who have never smoked and who have no other known risk factors for malignancy (history of a first-degree relative with lung cancer or significant radon or asbestos exposure).
  • Routine screening for BRCA1 and BRCA2 mutations is not recommended in women who are at low risk for developing breast cancer.
  • Screening for cervical cancer may be discontinued at age 65 years if the patient has been adequately screened, has had normal Pap smears, and has no other risk factors.
  • Screening for cervical cancer is not indicated or necessary in patients who have had a total hysterectomy (with removal of the cervix) for benign disease.
  • Serum carcinoembryonic antigen (CEA) should not be used as a screening test for colorectal cancer due to its poor sensitivity and specificity.

Pulmonary and Critical Care Medicine Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Pulmonary and Critical Care Medicine section of IM Essentials.

  • A serum B-type natriuretic peptide (BNP) level <100 pg/mL helps exclude heart failure in the setting of acute dyspnea.
  • The key to the workup of chronic dyspnea is a detailed history, approached in a systematic way to guide the search for the underlying cause in an efficient manner.
  • Thoracentesis can be deferred in those patients with a small amount of pleural fluid and associated heart failure, pneumonia, or heart surgery (<1 cm thick on decubitus radiography or ultrasonography).
  • Pleural fluid amylase should be measured only when pancreatic disease, esophageal rupture, or malignancy is considered.
  • Omalizumab is a monoclonal antibody that binds to IgE and is useful for reducing exacerbations in patients with severe persistent asthma who have evidence of allergies. Because severe anaphylaxis has been reported with the drug use and it is extremely expensive, it is used only in selected patients who remain symptomatic despite other therapies.
  • Smoking cessation is the most clinically effective and cost-effective way to prevent and slow the progression of chronic obstructive pulmonary disease (COPD) as well as improve disease-related survival.
  • Screening for airway obstruction in asymptomatic patients is not recommended as there is little evidence that making the diagnosis in this setting is beneficial.
  • A metered-dose inhaler (MDI), with proper instruction and good technique, is as effective as a nebulizer.
  • The use of alternative home respiratory tests for the diagnosis of sleep apnea, even when interpreted by a certified sleep specialist, may provide inaccurate results.
  • Inferior vena cava filters should not be used routinely for perioperative prophylaxis for pulmonary embolism.
  • Screening for either deep vein thrombosis (DVT) or pulmonary embolism (PE) in asymptomatic patients at risk for venous thromboembolism (VTE) is not indicated as noninvasive diagnostic tests are insensitive and not associated with improved clinical outcomes.
  • In clinically stable patients (eg, outpatients without hemodynamic compromise) with a low probability of PE, a normal D-dimer value effectively rules out PE and is correlated with an excellent outcome without further workup or treatment.

Rheumatology Recommendations

High Value Care Recommendations

High Value Care Recommendation: A recommendation to choose diagnostic and management strategies for patients in specific clinical situations that balance clinical benefit with cost and harms with the goal of improving patient outcomes.

Below are the High Value Care Recommendations for the Rheumatology section of IM Essentials.

  • Nonspecific rheumatologic tests (eg, rheumatoid factor, antinuclear antibodies, erythrocyte sedimentation rate) should be ordered only to confirm a diagnosis suggested by the history and physical examination and not for general evaluation of nonspecific joint pain.
  • Obtain radiographs in patients with acute knee pain only in those who fulfill ≥1 of the Ottawa knee rules.
  • In chronic knee pain syndromes, radiographs are often unlikely to alter management. Advanced imaging (such as magnetic resonance imaging [MRI]) should be used only in selected patients with knee pain, often in consultation with a specialist.
  • Arthroscopic surgery has not been shown to improve outcomes as compared with pharmacologic and physical therapy for non-osteoarthritis-related knee pain.
  • Imaging of the shoulder for acute pain should be based on the clinical presentation; except for specific indications (such as a rotator cuff tear), radiography has a limited role in the diagnosis and management of chronic shoulder pain.
  • In clinical practice, the diagnosis of osteoarthritis should be based primarily on history and physical examination findings. Laboratory tests are not helpful for diagnosis.
  • Due to low sensitivity, the absence of findings on plain radiography does not rule out symptomatic disease in any joint.
  • Therapy for osteoarthritis should begin with and always include nonpharmacologic measures.
  • Acetaminophen is first-line pharmacologic therapy for osteoarthritis because it is safe, effective, and inexpensive.
  • Although cylcooxygenase-2-selective nonsteroidal anti-inflammatory drugs (NSAIDs) are somewhat less likely to cause gastrointestinal ulcers, they are not more effective than nonselective NSAIDs, are significantly more expensive, and are associated with an increased risk for adverse cardiovascular events.
  • Opiate analgesics may play an additional role in the treatment of patients whose pain is refractory to other treatments but should not be used routinely due to potential side effects and dependency.
  • Asymptomatic hyperuricemia itself is not an indication for uric acid-lowering therapy.
  • Uric acid levels alone are inadequate to confirm or exclude a diagnosis of gout.
  • Allopurinol is typically safe and effective and is considered first-line therapy for most patients with an indication for uric acid lowering treatment.
  • There is no evidence to support the use of antibiotic prophylaxis to prevent infectious arthritis in patients with prosthetic joints undergoing procedures.
  • No adequate screening test for rheumatoid arthritis (RA) currently exists and there are no screening recommendations, including testing for rheumatoid factor (RF), for otherwise healthy individuals.
  • Antinuclear antibodies (ANA) may be positive in 40% of patients with RA and is a nonspecific finding.
  • Magnetic resonance imaging and ultrasonography are more sensitive imaging modalities for early erosive disease compared with radiography. However, their roles in diagnosis have not been established and they are not obtained routinely.
  • Testing for HLA-B27 positivity generally is not helpful diagnostically in patients suspected of having spondyloarthritis because most HLA-B27–positive persons do not develop disease.
  • Routine testing for ANA or rheumatoid factor in patients with suspected fibromyalgia is not indicated and may be confusing as these tests often are abnormal in normal individuals.
  • Opioid analgesics and glucocorticoids have no demonstrated efficacy in fibromyalgia and should be avoided.