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An Official American Thoracic Society/American College of Chest Physicians Policy StatementChoosing Wisely Adult Pulmonary Top Five List: The Choosing Wisely Top Five List in Adult Pulmonary Medicine FREE TO VIEW

Renda Soylemez Wiener, MD, MPH; Daniel R. Ouellette, MD, FCCP; Edward Diamond, MD, MBA, FCCP; Vincent S. Fan, MD, MPH; Janet R. Maurer, MD, FCCP; Richard A. Mularski, MD, MSHS, MCR, FCCP; Jay I. Peters, MD, FCCP; Scott D. Halpern, MD, PhD
Author and Funding Information

From The Pulmonary Center (Dr Wiener), Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research (Dr Wiener), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; The Dartmouth Institute for Health Policy & Clinical Practice (Dr Wiener), Hanover, NH; Pulmonary and Critical Care Medicine (Dr Ouellette), Henry Ford Health System, Detroit, MI; Suburban Lung Associates (Dr Diamond), Elk Grove Village, IL; Health Services Research and Development (Dr Fan), VA Puget Sound Health Care System, Seattle, WA; Department of Medicine (Dr Fan), University of Washington, Seattle, WA; Department of Medicine (Dr Maurer), College of Medicine, The University of Arizona, Phoenix, AZ; Quality Improvement and Compliance (Dr Maurer), National Imaging Associates/Magellan Health Services, Inc, Phoenix, AZ; The Center for Health Research (Dr Mularski), Kaiser Permanente Northwest, Portland, OR; Department of Pulmonary/Critical Care Medicine (Dr Mularski), Northwest Permanente PC, Portland, OR; Department of Medicine (Dr Mularski), Oregon Health & Science University, Portland, OR; UT Health Science Center (Dr Peters), San Antonio, TX; South Texas Veterans Health Care System (Dr Peters), San Antonio, TX; and Departments of Medicine, Biostatistics and Epidemiology, and Medical Ethics and Health Policy (Dr Halpern), and the Leonard Davis Institute Center for Health Incentives and Behavioral Economics, The University of Pennsylvania, Philadelphia, PA.

Correspondence to: Renda Soylemez Wiener, MD, MPH, The Pulmonary Center, 72 E Concord St, R-304, Boston, MA 02118; e-mail: rwiener@bu.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(6):1383-1391. doi:10.1378/chest.14-0670
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The American Board of Internal Medicine Foundation’s Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated—and when they are not.

The United States spends more per capita on health care than any other developed nation.1 Although spending more money yields health benefits in some contexts, the United States has crossed onto the “flat of the curve,” in which spending more does not improve health.2 Research on geographic variations in health-care spending has shown that spending more money, doing more testing, and providing more expensive treatments does not consistently yield better outcomes.3 In fact, in many cases, overtesting and overtreatment can cause harm, as patients are exposed to radiation from extraneous imaging, physical complications from invasive procedures that are not clearly indicated, and adverse effects from unwarranted medications.4

Physicians have professional obligations to both their individual patients and to society.5 As such, it is incumbent upon physicians to help rein in the use of tests and treatments that offer little benefit, may cause harm, and add considerable expense. The question is, where to begin? It can be difficult for busy clinicians to stay up-to-date on the latest evidence on the benefits and harms of all tests and treatments in their field, and very few clinicians are fully cognizant of the costs associated with the care they provide.6,7 For these reasons, in 2010, Howard Brody,8 MD, PhD, challenged medical societies to compile evidence-based lists of the top five tests or treatments in their specialty that are commonly used at great expense, but that provide little benefit.

The American Board of Internal Medicine Foundation (ABIM) took the next step to make Dr Brody’s vision a reality, initiating the Choosing Wisely campaign.9 Choosing Wisely strives “to reduce overuse of tests and procedures and support physician efforts to help patients make smart and effective choices.”10 To date, > 50 societies have partnered with Choosing Wisely to create top five lists. The American College of Chest Physicians and American Thoracic Society (ATS) joined forces to produce the top five list for adult pulmonary medicine.

To promote consistency with other Choosing Wisely lists, the ATS and American College of Chest Physicians agreed prospectively that this document would not be developed in accordance with the methodologic standards of the Institute of Medicine, ATS, or American College of Chest Physicians for clinical practice guidelines, but would reflect a consensus from a joint ATS/American College of Chest Physicians task force.

In September 2012, the leaderships of the ATS and American College of Chest Physicians each nominated up to five members to join the task force. The final task force included eight pulmonologists (this statement’s authors). Task force members were selected to provide expertise in a broad range of areas within adult pulmonary medicine and included representatives from geographically diverse areas with experience in university hospitals, Veterans Health Administration medical centers, community-based integrated health-care systems, private practice, specialty services benefits management, and health-care administration.

During an initial meeting, we established the goals and ground rules guiding our task force. We agreed upon the following criteria for assessing potential items for inclusion in the top five list: (1) strength of evidence (how sure are we that our suggestion is correct?); (2) prevalence (how commonly do we think this issue arises?); (3) aggregate cost (how large are the anticipated cost savings if this suggestion is adhered to?); (4) relevance (to what extent is this a “core” or “unique” part of our profession, as opposed to an ancillary activity or part of good practice more generally?); (5) innovation (how much does this suggestion “move the needle” rather than recapitulate known best practices?).

Task force members then submitted suggested items to the task force lead (R. S. W.). Members derived items from multiple sources, including the literature, review of existing Choosing Wisely top five lists, feedback from community pulmonologists, and personal experience. The task force lead collated items, removed duplicates, and circulated the initial list of 30 unique items to the task force.

During the next meeting, we discussed each of these 30 items, debated the impact of each based on the five assessment criteria, and reached consensus on 10 items to explore in greater depth (Table 1). Working together with the task force lead, each task force member refined the wording of one to two items and an accompanying paragraph explaining the rationale for its inclusion. In doing so, the member synthesized the published literature relevant to the recommendation(s) and consulted with one to two content experts external to the task force (see the Acknowledgments section) to ensure the recommendation’s appropriateness. Task force members then returned their refined item(s) to the task force lead with a list of supporting references. The lead compiled and distributed the list of 10 items and accompanying materials to the entire task force.

Table Graphic Jump Location
Table 1 —Ten Proposed Items Explored in Further Detail, Including In-depth Literature Review and Feedback From External Content Experts

PE = pulmonary embolism; PH = pulmonary hypertension.

At our next meeting, we carefully reviewed all 10 proposed items. For each item, the designated member presented information relevant to the five assessment criteria, while others raised questions to clarify the intent, supporting evidence, impact, or relevance of the recommendation. After all views were heard, members independently rated each item on its overall impact as well as on each criterion. We agreed that the overall rating need not be an average of the criteria ratings, thereby enabling members to weigh certain criteria more heavily.

Task force members submitted their scores to the lead, who averaged members’ scores and ranked the items based on their mean overall score. The five items with the best overall scores were retained in a “penultimate” list. The task force jointly edited the five recommendations and accompanying paragraphs to ensure clarity prior to submitting the list to the ATS and American College of Chest Physicians executive committees.

The executive committees sought feedback from additional content experts, discussed the items internally, and provided written comments on each item to the task force. The task force incorporated these suggestions; when nuances were disputed, we held discussions with the societies’ leaderships to resolve disagreements, resulting in mutually agreeable wording changes.

The final list was then submitted to both societies’ executive committees. Both the ATS and American College of Chest Physicians elected to endorse the final top five list. The joint ATS/American College of Chest Physicians top five list in adult pulmonary medicine was released by the Choosing Wisely campaign in October 2013.10

Table 2 shows our final top five list. Following the Choosing Wisely format, each item includes the recommendation and a brief supporting paragraph. Here, we elaborate on why we selected these recommendations, including the rationale for doing less, the potential harms of doing more, and the prevalence and cost of overuse.

Table Graphic Jump Location
Table 2 —Final Top Five List Approved by Societies’ Leadership and Included in Choosing Wisely Campaign

ELISA = enzyme-linked immunosorbent assay. See Table 1 legend for expansion of other abbreviations.

1. Do Not Perform CT Scan Surveillance for Evaluation of Indeterminate Pulmonary Nodules at More Frequent Intervals or for a Longer Period of Time Than Recommended by Established Guidelines
Rationale:

Based on observational data of the natural history of pulmonary nodules,11 the American College of Chest Physicians and Fleischner Society have established algorithms to evaluate pulmonary nodules (parenchymal lesions ≤ 3 cm) that are indeterminate (not yet known to be malignant or benign).12,13 The algorithms take into account both the patient’s cancer risk factors and the nodule size in the recommended frequency and duration of CT scan surveillance. There is no evidence that monitoring nodules more often or for a longer duration than recommended improves outcomes such as resectability or mortality of lung cancer. Meanwhile, more intensive surveillance than recommended exposes patients to potential harms including unnecessary radiation (with the attendant risk of radiation-induced cancer),14 prolonged uncertainty with attendant anxiety and distress,15,16 increased likelihood of finding other incidentalomas that spur further workup, and the inconvenience of traveling to the medical center for unnecessary tests.

Scope of the Problem:

Pulmonary nodules are detected in hundreds of thousands of Americans each year.17 These numbers will only rise with the increasing use of CT scans for a variety of indications, including lung cancer screening.18 A cohort study in the Veterans Health Administration system showed that nonconcordance with guidelines for nodule evaluation is common (45%): Approximately 20% of patients received more intensive nodule evaluation, with several cases of surveillance extended well beyond the recommended 2-year duration (up to 16 CT scans over 8.5 years).19 Although the per unit cost of an extra CT scan may be small (roughly $1,400-$1,800),20 the aggregate costs of excessive radiographic surveillance are high.21

2. Do Not Routinely Offer Pharmacologic Treatment With Advanced Vasoactive Agents Approved Only for the Management of Pulmonary Arterial Hypertension to Patients With Pulmonary Hypertension Resulting From Left Heart Disease or Hypoxemic Lung Diseases (Group II or III Pulmonary Hypertension)
Rationale:

The evidence supporting the use of advanced vasoactive agents (eg, prostanoids, phosphodiesterase inhibitors, endothelin antagonists) for pulmonary hypertension arises primarily from studies of patients with pulmonary arterial hypertension.22 There is no consistent evidence that these agents confer clinical benefits in other types of pulmonary hypertension. Although small studies of sildenafil for pulmonary hypertension due to left heart disease have suggested mild improvements in a variety of hemodynamic, exercise capacity, and quality-of-life end points,2325 a subsequent trial of 216 patients with heart failure and preserved ejection fraction showed no benefits and a trend toward harm.26

Meanwhile, several other studies in which advanced vasoactive agents were administered to patients with group II or III pulmonary hypertension have confirmed the potential for harm. A trial of 471 patients with pulmonary hypertension due to severe left ventricular dysfunction was stopped early because of a trend toward increased mortality related to worsened pulmonary edema among patients randomized to epoprostenol.27 Advanced vasoactive agents can worsen hypoxemia among patients with group III pulmonary hypertension, as shown in a study of epoprostenol for idiopathic pulmonary fibrosis28 and in studies of sildenafil and bosentan for COPD.29,30

Although some experts believe that certain carefully selected patients with group II or III pulmonary hypertension behave more like pulmonary arterial hypertension (eg, patients with mitral stenosis whose pulmonary pressures have not improved despite valve replacement; patients whose pulmonary arterial pressures are elevated “out of proportion” to the underlying lung disease),31,32 these cases are unusual. For example, in one study of 998 patients with COPD, 11 (1.1%) had disproportionately elevated pulmonary arterial pressures.33 Because of the potential for harm with inappropriate use of advanced vasoactive agents, guidelines suggest these selected cases should be handled on a case-by-case basis in a pulmonary hypertension referral center.31,32 To avoid inappropriate use, patients should undergo evaluation with right-sided heart catheterization, echocardiography, chest imaging, 6-min walk test, and pulmonary function testing to determine the presence, severity, and etiology of pulmonary hypertension prior to considering advanced vasoactive therapy.31,32,34,35

Scope of the Problem:

With rising use of echocardiography, the detection of pulmonary hypertension has increased substantially in recent years.36 However, most cases are due to left heart disease or hypoxemic lung disease rather than pulmonary arterial hypertension.35,37 Although data on the frequency of inappropriate use of advanced vasoactive agents are sparse, one case series found that 57% of patients (24 of 42) started on advanced vasoactive medications prior to referral to a pulmonary hypertension center did not meet guideline criteria for their use.38 The economic burden of overuse is considerable, with annual per-patient costs estimated at $10,000 to $60,000 for oral regimens and $70,000 to $100,000 for prostanoids.32,3942

3. For Patients Recently Discharged on Supplemental Home Oxygen Following Hospitalization for an Acute Illness, Do Not Renew the Prescription Without Assessing the Patient for Ongoing Hypoxemia
Rationale:

Hypoxemia associated with an acute illness often resolves within days to weeks. Between 30% and 50% of patients prescribed home oxygen during an acute illness no longer meet criteria when reassessed 2 months to 3 months later.43,44 Although there is no known benefit to supplemental oxygen for individuals with an oxygen saturation > 88%, there are potential harms. In addition to the possible harms of oxygen toxicity, patients face decreased mobility, social stigma, irritation of the nasal mucosa, and inconvenience, and are at heightened risk of falls (due to entanglement in tubing) and fires (particularly if a smoker is in the home).45 Moreover, patients who had their home oxygen discontinued after a 2-month assessment showing they no longer met criteria had no significant decrement in health-related quality of life compared with those who continued oxygen without reassessment.43 The need for continued home oxygen should, therefore, be reassessed no later than 90 days after the initial prescription, during a time of clinical stability.46

Scope of the Problem:

In 2009, Medicare spent $2.15 billion on home oxygen.47 The use of home oxygen has almost doubled over the past decade, and by 2008, 5% of Medicare Part B beneficiaries were receiving home oxygen.47 Although it is unknown what percentage of these patients met criteria for supplemental oxygen, 35% to 65% of patients prescribed home oxygen during an acute hypoxemic event do not have the need for oxygen reassessed in a timely fashion.48

4. Do Not Perform Chest CT Angiography to Evaluate for Possible Pulmonary Embolism in Patients With a Low Clinical Probability and Negative Results of a Highly Sensitive D-Dimer Assay
Rationale:

The pretest probability of pulmonary embolism (PE) can be calculated using simple clinical prediction tools such as the Wells or Geneva scores (free calculators at www.mdcalc.com). Multiple studies have shown that among patients with a low clinical probability of PE and a negative D-dimer (by highly sensitive assay), clinically important PE is essentially excluded.49,50 For example, in the Christopher study,51 1,057 patients with a Wells score consistent with “PE unlikely” (ie, Wells score ≤ 4) and a negative D-dimer (≤ 500 ng/mL) were observed without anticoagulation for 3 months. Only five patients (0.5%) presented clinically in the next 3 months with a VTE, none of which was fatal. Thus, guidelines conclude CT pulmonary angiography is unnecessary among patients with a low probability of PE and a negative D-dimer.5254

There are harms associated with overuse of CT pulmonary angiography. Patients are exposed to needless radiation, with the attendant risks of radiation-induced cancers,14 and to contrast administration, with the attendant risks of kidney injury and anaphylactoid reactions.5557 Patients with a low clinical probability of PE, a negative D-dimer test or both who nonetheless undergo CT pulmonary angiography are more likely to have either an incidental finding necessitating further testing58 or an isolated subsegmental PE of unclear significance59 identified than a more central PE. Although isolated subsegmental emboli may be clinically insignificant, they are typically treated with anticoagulation, exposing patients to the risks of bleeding.60 At the population level, there is evidence that overuse of CT pulmonary angiography has led to overdiagnosis and overtreatment of clinically insignificant PE, with rising harms associated with anticoagulation of these patients.61

Scope of the Problem:

Data from multiple health maintenance organizations show CT pulmonary angiography use rose 14-fold from 0.3 to 4.0 per 1,000 beneficiaries between 2000 and 2008.62 These CT scans are often performed in patients who do not meet criteria for testing. For example, in one multicenter study, 55% of CT pulmonary angiograms were performed on patients with a low likelihood of PE based on Geneva scores, D-dimer testing, or both.63 Another multicenter study found the mean number of CT pulmonary angiograms performed per confirmed PE in the United States was 7.6 (vs 1.5 in Europe where CT scanning was reserved for patients with a higher likelihood of PE).64 Costs associated with CT pulmonary angiography are high (on average, $5,400 per scan, as compared with $1,400-$1,800 for other chest CT scans and $370 for chest radiograph).20

5. Do Not Perform CT Scan Screening for Lung Cancer Among Patients at Low Risk for Lung Cancer
Rationale:

The strongest evidence supporting low-dose CT scanning for lung cancer screening comes from the National Lung Screening Trial (NLST), which showed a 20% reduction in lung cancer death among individuals randomized to annual CT scan screening.18 The NLST enrolled individuals aged 55 to 74 years with at least 30 pack-years of tobacco use, who were either current smokers or had quit smoking within the past 15 years. Subsequent modeling studies suggest that the greatest benefit was derived among the highest-risk patients within the NLST population.65 By contrast, there is no evidence that individuals at low risk of lung cancer derive any benefit from CT scan screening. Although clinical practice guidelines differ in the recommended high-risk population for screening, no guideline recommends screening individuals with a smoking history of < 20 pack-years.6669

CT scan screening for lung cancer can cause harm.70 In the NLST, after three annual screening CT scans, 39% of patients had an abnormal finding (mostly pulmonary nodules) that led to further evaluation and 8% had extrapulmonary incidentalomas.18 Although 96% of these findings turned out to be false positives, evaluating these findings exposes patients to anxiety and distress,15,16 radiation for those who undergo surveillance,14 and possible physical complications among those who undergo biopsy.71,72 Even when screening identifies a cancer, overdiagnosis of a clinically insignificant tumor is possible; it has been estimated that 13% to 27% of screen-detected lung cancers are so indolent that they may be clinically unimportant.7375

Scope of the Problem:

The prevalence of CT scan screening for low-risk individuals is unknown. Since the US Preventative Services Task Force only recently recommended low-dose CT scan screening for lung cancer,69 most insurance agencies did not previously cover screening CT scans. Regardless, many hospitals market CT scan screening directly to consumers and do not consistently target only individuals at high risk of lung cancer.76 One rationale for our recommendation against screening low-risk individuals is to help prevent this practice from becoming prevalent.

The problem of excessive use of tests and treatments with low value to improve health in the United States has long been recognized.2 Many solutions have been proposed; few have succeeded at reining in rising costs. The Choosing Wisely campaign differs from past efforts in that physicians themselves are leading the way by identifying overused tests and treatments that may be doing more harm than good for patients at great expense to the health-care system.

Rather than dictating how clinicians care for all patients, Choosing Wisely aims to improve dialogue between clinicians and patients, with a goal of shifting routine care away from aggressive, expensive choices that are not supported by evidence. Although the recommendations in our top five list will not apply to every patient in the circumstances we have described, we carefully selected five scenarios in which the evidence supports the conclusion that “less is more” for most patients. When confronted with the scenarios we have described, clinicians should carefully consider and discuss our recommendations with patients rather than simply proceeding with testing or treating. Although some clinicians may worry that not ordering a test (eg, to look for cancer or PE) may lead to a lawsuit if the patient is later diagnosed with the condition, studies show that physicians who have communicated clearly and openly with patients are less likely to be sued.7779

A key issue is how to conduct these potentially challenging conversations. Some clinicians are concerned that patients will resist the Choosing Wisely recommendations, seeing them as a form of rationing. Modern patients, who have access to medical information from the plethora of Internet health sites and the barrage of direct-to-consumer pharmaceutical advertising, may come to appointments with particular tests or treatments in mind. Rather than taking the easier route of simply acquiescing to the patient’s request,80 we hope that pulmonologists and other affected clinicians will use our recommendations to engage patients in a frank discussion about the merits of more conservative approaches. To further this goal, the ABIM and Drexel University developed physician communication modules with examples of how to discuss Choosing Wisely recommendations, and Consumer Reports created patient education pages explaining why the tests and treatments on Choosing Wisely top five lists may not be right for them.10

Of course our recommendations will have little impact if word is not spread. Of note, the top five lists for adult pulmonary medicine and critical care medicine were the only two lists produced through multisociety collaborations; the adult pulmonary top five list should reach a particularly broad audience with the help of both the ATS and American College of Chest Physicians in disseminating our recommendations. We have begun to disseminate our top five list through a variety of forums: open sessions at the ATS and CHEST 2013 conferences to garner feedback on our recommendations; press releases to both the lay and medical communities; links to the top five list from the ATS and American College of Chest Physicians websites; and publication of this manuscript, with companion pieces planned in the American Journal of Respiratory and Critical Care Medicine and the Annals of the American Thoracic Society. We encourage ATS and American College of Chest Physicians members to spread the word to patients and colleagues alike.

The process used to create our top five list has limitations. First, because Choosing Wisely is designed as an effort led by physicians for physicians, our task force did not include a patient representative and thus may not represent their views. Second, a task force composed of different members with different areas of expertise may have produced a different list. However, our top five recommendations performed well on prespecified scoring criteria and were deemed appropriate by external content experts and the ATS and American College of Chest Physicians leaderships. Thus, while we believe each included item is meritorious, we acknowledge that other items not on this list could also represent important opportunities for improving the value of pulmonary medicine. Third, weak evidence bases regarding the benefits, harms, and cost-effectiveness of many tests and treatments commonly used in pulmonary medicine (eg, steroids for a variety of conditions) limited the range of topics we could consider. We have begun discussions with the American College of Chest Physicians leadership to create guidelines on how to conduct rigorous cost-effectiveness research, which we hope will strengthen the evidence base and help guide future efforts to identify low-value care in adult pulmonary medicine.

Moving forward, it will be important to examine whether implementation of our recommendations achieves their intended purpose: to reduce wasteful spending in adult pulmonary medicine without adversely affecting patient outcomes. An analysis of the first three top five lists released (all related to primary care) showed that if those recommendations were uniformly implemented in the United States, > $6 billion could be saved.81 We hope that future research will explore the potential or actual impact of the recommendations we have made for adult pulmonary medicine.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Maurer is an employee of a utilization management company reviewing appropriate evidence-based use of CT scans to screen for lung cancer. The remaining authors have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We acknowledge the contributions of our external content experts, who graciously provided timely and highly relevant feedback that helped us narrow our list of proposed items. These content experts included: Peter Bach, MD, PhD; Michael Gould, MD; James Jett, MD; Steven Kawut, MD; Elizabeth Klings, MD; Jerry Krishnan, MD, PhD; Paul Kvale, MD; Peter Lindenauer, MD; Lisa Moores, MD; Victor Tapson, MD; Alexander White, MD; Leo Wittnebel, MD; and Rex Yung, MD. We also acknowledge the hard work and tremendous support provided by Jessica Wisk and Judy Corn, MSEd, of the ATS and Jenny Nemkovich of the American College of Chest Physicians. The views expressed herein do not necessarily represent those of the Department of Veterans Affairs or the United States government.

ATS

American Thoracic Society

NLST

National Lung Screening Trial

PE

pulmonary embolism

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Stolz D, Rasch H, Linka A, et al. A randomised, controlled trial of bosentan in severe COPD. Eur Respir J. 2008;32(3):619-628.
 
Galiè N, Hoeper MM, Humbert M, et al; ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT) [published correction appears inEur Heart J. 201;32(8):926]. Eur Heart J. 2009;30(20):2493-2537.
 
McLaughlin VV, Archer SL, Badesch DB, et al; American College of Cardiology Foundation Task Force on Expert Consensus Documents; American Heart Association; American College of Chest Physicians; American Thoracic Society, Inc; Pulmonary Hypertension Association. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic ociety, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol. 2009;53(17):1573-1619.
 
Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-194.
 
Badesch DB, Champion HC, Sanchez MA, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S55-S66.
 
Hoeper MM, Barberà JA, Channick RN, et al. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S85-S96.
 
Hyduk A, Croft JB, Ayala C, Zheng K, Zheng ZJ, Mensah GA. Pulmonary hypertension surveillance—United States, 1980-2002. MMWR Surveill Summ. 2005;54(5):1-28.
 
Guazzi M, Galiè N. Pulmonary hypertension in left heart disease. Eur Respir Rev. 2012;21(126):338-346.
 
Deaño RC, Glassner-Kolmin C, Rubenfire M, et al. Referral of patients with pulmonary hypertension diagnoses to tertiary pulmonary hypertension centers: the multicenter RePHerral study. JAMA Intern Med. 2013;173(10):887-893.
 
Angalakuditi M, Edgell E, Beardsworth A, Buysman E, Bancroft T. Treatment patterns and resource utilization and costs among patients with pulmonary arterial hypertension in the United States. J Media Econ. 2010;13(3):393-402.
 
Berger A, Edelsberg J, Teal S, Mychaskiw MA, Oster G. Changes in healthcare utilization and costs associated with sildenafil therapy for pulmonary arterial hypertension: a retrospective cohort study. BMC Pulm Med. 2012;12:75.
 
Garin MC, Clark L, Chumney EC, Simpson KN, Highland KB. Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model. Clin Drug Investig. 2009;29(10):635-646.
 
Highland KB, Strange C, Mazur J, Simpson KN. Treatment of pulmonary arterial hypertension: a preliminary decision analysis. Chest. 2003;124(6):2087-2092.
 
Guyatt GH, Nonoyama M, Lacchetti C, et al. A randomized trial of strategies for assessing eligibility for long-term domiciliary oxygen therapy. Am J Respir Crit Care Med. 2005;172(5):573-580.
 
Chaney JC, Jones K, Grathwohl K, Olivier KN. Implementation of an oxygen therapy clinic to manage users of long-term oxygen therapy. Chest. 2002;122(5):1661-1667.
 
Croxton TL, Bailey WC. Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Respir Crit Care Med. 2006;174(4):373-378.
 
O’Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(suppl 6):vi1-vi68.
 
US Government Accountability Office. Medicare home oxygen: refining payment methodology has potential to lower program and beneficiary spending. Report No. GAO-11-56. GAO website. http://www.gao.gov/products/GAO-11-56. Published 2011. Accessed January 5, 2014.
 
Macnee W. Prescription of oxygen: still problems after all these years. Am J Respir Crit Care Med. 2005;172(5):517-518.
 
Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331(7511):259.
 
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):589-602.
 
van Belle A, Büller HR, Huisman MV, et al; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179.
 
Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57:628-652.e675.
 
Qaseem A, Snow V, Barry P, et al; Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2007;146(6):454-458.
 
Torbicki A, Perrier A, Konstantinides S, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-2315.
 
Brockow K, Ring J. Anaphylaxis to radiographic contrast media. Curr Opin Allergy Clin Immunol. 2011;11(4):326-331.
 
Kooiman J, Pasha SM, Zondag W, et al. Meta-analysis: serum creatinine changes following contrast enhanced CT imaging. Eur J Radiol. 2012;81(10):2554-2561.
 
Mitchell AM, Kline JA. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost. 2007;5(1):50-54.
 
Hall WB, Truitt SG, Scheunemann LP, et al. The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism. Arch Intern Med. 2009;169(21):1961-1965.
 
Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F. Diagnosis and management of subsegmental pulmonary embolism. J Thromb Haemost. 2006;4(4):724-731.
 
Donato AA, Khoche S, Santora J, Wagner B. Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography. Thromb Res. 2010;126(4):e266-e270.
 
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-837.
 
Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013;347:f3368.
 
Adams DM, Stevens SM, Woller SC, et al. Adherence to PIOPED II investigators’ recommendations for computed tomography pulmonary angiography. Am J Med. 2013;126(1):36-42.
 
Penaloza A, Kline J, Verschuren F, et al. European and American suspected and confirmed pulmonary embolism populations: comparison and analysis. J Thromb Haemost. 2012;10(3):375-381.
 
Kovalchik SA, Tammemagi M, Berg CD, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med. 2013;369(3):245-254.
 
Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for 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):e78S-e92S.
 
Jaklitsch MT, Jacobson FL, Austin JH, et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg. 2012;144(1):33-38.
 
NCCN clinical practice guidelines in oncology (NCCN guidelines) - lung cancer screening, version 1.2013. National Comprehensive Cancer Network website. http://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf. Published 2012. Accessed January 5, 2014.
 
Moyer VA. Screening for lung cancer: US Preventive Services Task Force recommendation statement [published online ahead of print December 31, 2013]. Ann Intern Med. doi:10.7326/M13-2771.
 
Humphrey LL, Deffebach M, Pappas M, et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013;159(6):411-420.
 
Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137-144.
 
Tukey MH, Wiener RS. Population-based estimates of transbronchial lung biopsy utilization and complications. Respir Med. 2012;106(11):1559-1565.
 
Veronesi G, Maisonneuve P, Bellomi M, et al. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Ann Intern Med. 2012;157(11):776-784.
 
Sone S, Nakayama T, Honda T, et al. Long-term follow-up study of a population-based 1996-1998 mass screening programme for lung cancer using mobile low-dose spiral computed tomography. Lung Cancer. 2007;58(3):329-341.
 
Patz EF Jr, Pinsky P, Gatsonis C, et al; NLST Overdiagnosis Manuscript Writing Team. Overdiagnosis in low-dose computed tomography screening for lung cancer. JAMA Intern Med. 2014;174(2):269-274.
 
Bach P. CT scam: don’t believe the hype about lung-cancer screenings. Slate website. http://www.slate.com/articles/health_and_science/medical_examiner/2010/11/ct_scam.html. Published 2010. Accessed January 5, 2014.
 
Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA. 1994;272(20):1619-1620.
 
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553-559.
 
Shapiro RS, Simpson DE, Lawrence SL, Talsky AM, Sobocinski KA, Schiedermayer DL. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149(10):2190-2196.
 
Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802.
 
Kale MS, Bishop TF, Federman AD, Keyhani S. “Top five” lists top $5 billion. Arch Intern Med. 2011;171(20):1856-1858.
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Ten Proposed Items Explored in Further Detail, Including In-depth Literature Review and Feedback From External Content Experts

PE = pulmonary embolism; PH = pulmonary hypertension.

Table Graphic Jump Location
Table 2 —Final Top Five List Approved by Societies’ Leadership and Included in Choosing Wisely Campaign

ELISA = enzyme-linked immunosorbent assay. See Table 1 legend for expansion of other abbreviations.

References

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Wiener RS, Gould MK, Slatore C, Fincke BG, Schwartz LM, Woloshin S. Resource use and guideline concordance in evaluation of pulmonary nodules for cancer: too much and too little care. [published online ahead of print April 7, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.561.
 
Covey AM, Gandhi R, Brody LA, Getrajdman G, Thaler HT, Brown KT. Factors associated with pneumothorax and pneumothorax requiring treatment after percutaneous lung biopsy in 443 consecutive patients. J Vasc Interv Radiol. 2004;15(5):479-483.
 
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Galiè N, Manes A, Negro L, Palazzini M, Bacchi-Reggiani ML, Branzi A. A meta-analysis of randomized controlled trials in pulmonary arterial hypertension. Eur Heart J. 2009;30(4):394-403.
 
Lewis GD, Lachmann J, Camuso J, et al. Sildenafil improves exercise hemodynamics and oxygen uptake in patients with systolic heart failure. Circulation. 2007;115(1):59-66.
 
Lewis GD, Shah R, Shahzad K, et al. Sildenafil improves exercise capacity and quality of life in patients with systolic heart failure and secondary pulmonary hypertension. Circulation. 2007;116(14):1555-1562.
 
Guazzi M, Vicenzi M, Arena R, Guazzi MD. PDE5 inhibition with sildenafil improves left ventricular diastolic function, cardiac geometry, and clinical status in patients with stable systolic heart failure: results of a 1-year, prospective, randomized, placebo-controlled study. Circ Heart Fail. 2011;4(1):8-17.
 
Redfield MM, Chen HH, Borlaug BA, et al; RELAX Trial. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. JAMA. 2013;309(12):1268-1277.
 
Califf RM, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure: The Flolan International Randomized Survival Trial (FIRST). Am Heart J. 1997;134(1):44-54.
 
Ghofrani HA, Wiedemann R, Rose F, et al. Sildenafil for treatment of lung fibrosis and pulmonary hypertension: a randomised controlled trial. Lancet. 2002;360(9337):895-900.
 
Blanco I, Gimeno E, Munoz PA, et al. Hemodynamic and gas exchange effects of sildenafil in patients with chronic obstructive pulmonary disease and pulmonary hypertension. Am J Respir Crit Care Med. 2010;181(3):270-278.
 
Stolz D, Rasch H, Linka A, et al. A randomised, controlled trial of bosentan in severe COPD. Eur Respir J. 2008;32(3):619-628.
 
Galiè N, Hoeper MM, Humbert M, et al; ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT) [published correction appears inEur Heart J. 201;32(8):926]. Eur Heart J. 2009;30(20):2493-2537.
 
McLaughlin VV, Archer SL, Badesch DB, et al; American College of Cardiology Foundation Task Force on Expert Consensus Documents; American Heart Association; American College of Chest Physicians; American Thoracic Society, Inc; Pulmonary Hypertension Association. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic ociety, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol. 2009;53(17):1573-1619.
 
Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189-194.
 
Badesch DB, Champion HC, Sanchez MA, et al. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S55-S66.
 
Hoeper MM, Barberà JA, Channick RN, et al. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S85-S96.
 
Hyduk A, Croft JB, Ayala C, Zheng K, Zheng ZJ, Mensah GA. Pulmonary hypertension surveillance—United States, 1980-2002. MMWR Surveill Summ. 2005;54(5):1-28.
 
Guazzi M, Galiè N. Pulmonary hypertension in left heart disease. Eur Respir Rev. 2012;21(126):338-346.
 
Deaño RC, Glassner-Kolmin C, Rubenfire M, et al. Referral of patients with pulmonary hypertension diagnoses to tertiary pulmonary hypertension centers: the multicenter RePHerral study. JAMA Intern Med. 2013;173(10):887-893.
 
Angalakuditi M, Edgell E, Beardsworth A, Buysman E, Bancroft T. Treatment patterns and resource utilization and costs among patients with pulmonary arterial hypertension in the United States. J Media Econ. 2010;13(3):393-402.
 
Berger A, Edelsberg J, Teal S, Mychaskiw MA, Oster G. Changes in healthcare utilization and costs associated with sildenafil therapy for pulmonary arterial hypertension: a retrospective cohort study. BMC Pulm Med. 2012;12:75.
 
Garin MC, Clark L, Chumney EC, Simpson KN, Highland KB. Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model. Clin Drug Investig. 2009;29(10):635-646.
 
Highland KB, Strange C, Mazur J, Simpson KN. Treatment of pulmonary arterial hypertension: a preliminary decision analysis. Chest. 2003;124(6):2087-2092.
 
Guyatt GH, Nonoyama M, Lacchetti C, et al. A randomized trial of strategies for assessing eligibility for long-term domiciliary oxygen therapy. Am J Respir Crit Care Med. 2005;172(5):573-580.
 
Chaney JC, Jones K, Grathwohl K, Olivier KN. Implementation of an oxygen therapy clinic to manage users of long-term oxygen therapy. Chest. 2002;122(5):1661-1667.
 
Croxton TL, Bailey WC. Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Respir Crit Care Med. 2006;174(4):373-378.
 
O’Driscoll BR, Howard LS, Davison AG; British Thoracic Society. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008;63(suppl 6):vi1-vi68.
 
US Government Accountability Office. Medicare home oxygen: refining payment methodology has potential to lower program and beneficiary spending. Report No. GAO-11-56. GAO website. http://www.gao.gov/products/GAO-11-56. Published 2011. Accessed January 5, 2014.
 
Macnee W. Prescription of oxygen: still problems after all these years. Am J Respir Crit Care Med. 2005;172(5):517-518.
 
Roy PM, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism. BMJ. 2005;331(7511):259.
 
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):589-602.
 
van Belle A, Büller HR, Huisman MV, et al; Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179.
 
Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57:628-652.e675.
 
Qaseem A, Snow V, Barry P, et al; Joint American Academy of Family Physicians/American College of Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2007;146(6):454-458.
 
Torbicki A, Perrier A, Konstantinides S, et al; ESC Committee for Practice Guidelines (CPG). Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-2315.
 
Brockow K, Ring J. Anaphylaxis to radiographic contrast media. Curr Opin Allergy Clin Immunol. 2011;11(4):326-331.
 
Kooiman J, Pasha SM, Zondag W, et al. Meta-analysis: serum creatinine changes following contrast enhanced CT imaging. Eur J Radiol. 2012;81(10):2554-2561.
 
Mitchell AM, Kline JA. Contrast nephropathy following computed tomography angiography of the chest for pulmonary embolism in the emergency department. J Thromb Haemost. 2007;5(1):50-54.
 
Hall WB, Truitt SG, Scheunemann LP, et al. The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism. Arch Intern Med. 2009;169(21):1961-1965.
 
Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F. Diagnosis and management of subsegmental pulmonary embolism. J Thromb Haemost. 2006;4(4):724-731.
 
Donato AA, Khoche S, Santora J, Wagner B. Clinical outcomes in patients with isolated subsegmental pulmonary emboli diagnosed by multidetector CT pulmonary angiography. Thromb Res. 2010;126(4):e266-e270.
 
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-837.
 
Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013;347:f3368.
 
Adams DM, Stevens SM, Woller SC, et al. Adherence to PIOPED II investigators’ recommendations for computed tomography pulmonary angiography. Am J Med. 2013;126(1):36-42.
 
Penaloza A, Kline J, Verschuren F, et al. European and American suspected and confirmed pulmonary embolism populations: comparison and analysis. J Thromb Haemost. 2012;10(3):375-381.
 
Kovalchik SA, Tammemagi M, Berg CD, et al. Targeting of low-dose CT screening according to the risk of lung-cancer death. N Engl J Med. 2013;369(3):245-254.
 
Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for 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):e78S-e92S.
 
Jaklitsch MT, Jacobson FL, Austin JH, et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg. 2012;144(1):33-38.
 
NCCN clinical practice guidelines in oncology (NCCN guidelines) - lung cancer screening, version 1.2013. National Comprehensive Cancer Network website. http://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf. Published 2012. Accessed January 5, 2014.
 
Moyer VA. Screening for lung cancer: US Preventive Services Task Force recommendation statement [published online ahead of print December 31, 2013]. Ann Intern Med. doi:10.7326/M13-2771.
 
Humphrey LL, Deffebach M, Pappas M, et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013;159(6):411-420.
 
Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137-144.
 
Tukey MH, Wiener RS. Population-based estimates of transbronchial lung biopsy utilization and complications. Respir Med. 2012;106(11):1559-1565.
 
Veronesi G, Maisonneuve P, Bellomi M, et al. Estimating overdiagnosis in low-dose computed tomography screening for lung cancer: a cohort study. Ann Intern Med. 2012;157(11):776-784.
 
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