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Special Article |

The “Top 5” Lists in Primary Care:  Meeting the Responsibility of Professionalism

Arch Intern Med. 2011;171(15):1385-1390. doi:10.1001/archinternmed.2011.231.
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Background Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled “Promoting Good Stewardship in Clinical Practice” that aimed to develop a list of the top 5 activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved.

Methods Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities. A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians.

Results The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities that could improve clinical care.

Conclusions Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities that could lead to higher quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the activities, the potential positive impact on medical care quality and cost, and the ease with which the activities could be performed. We recommend that these “Top 5” lists of activities be implemented in primary care practice across the United States.

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Figure 1. “Top 5” activities in family medicine. AACE indicates American Association of Clinical Endocrinology4; ACOG, American College of Obstetrics and Gynecology5; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; Ann IM, Annals of Internal Medicine8; Cochrane, Cochrane Database of Systematic Reviews9; DEXA, dual energy x-ray absorptiometry; ECG, electrocardiogram; NOF, National Osteoporosis Foundation10; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.11

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Figure 2. “Top 5” activities in internal medicine. AACE indicates American Association of Clinical Endocrinology4; ACOG, American College of Obstetrics and Gynecology5; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; Ann IM, Annals of Internal Medicine8; Cochrane, Cochrane Database of Systematic Reviews9; DEXA, dual energy x-ray absorptiometry; ECG, electrocardiogram; LDL, low-density lipoprotein; NOF, National Osteoporosis Foundation10; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.11 Lipitor is manufactured by Pfizer, New York, New York; Crestor, by AstraZeneca, Wilmington, Delaware.

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Figure 3. “Top 5” activities in pediatrics. AAP/AAFP indicates the American Academy of Pediatrics/American Academy of Family Practice14; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; CT, computed tomography; ED, emergency department; EE, Essential Evidence15; FDA, US Food and Drug Administration16; NAEPP, National Asthma Education and Prevention Program17; NICE, National Institute for Health and Clinical Excellence18; and OME, otitis media with effusion.

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Submit a Comment
re map of medicine.
Posted on May 25, 2011
Nasir Hannan, MbChB
General Practitioner
Conflict of Interest: None Declared
Really interesting article. In the UK we have the map of medicine to guide us in our investigative and treatment decisions and I find this quite useful in my practice. We have been looking at what were the 5 most expensive treatment options at my centre and then applied our map of medicine protocols to this to generate more efficient prescribing.

Conflict of Interest: None declared
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