2018 clinical revisions - interqual review manager · american medical association, 515 ... review...

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InterQual® Specialty Referral Criteria

2018 Clinical Revisions

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Organization and features

Although some revisions below apply to all criteria subsets, the revisions will only display in new criteria sets or in those that were updated

this cycle. Criteria subsets that were not updated this cycle will be updated in the next revision cycle.

Criteria-Specific Changes

Category: Cardiovascular Disorders

Subset Indication Revision Rationale

Congenital

Heart Disease

Changed indication "Congenital heart

disease by TTE/Hx with CXR results available"

to "Congenital heart disease by transthoracic

or transesophageal echocardiogram or by

history”

Congenital heart disease can be diagnosed by

transesophageal echocardiogram, in addition to

transthoracic echocardiogram.

Congenital

Heart Disease

Congenital heart

disease by

transthoracic or

transesophageal

Added "New symptoms or findings and CXR

results available"

Cardiology management may be needed when

the patient with congenital heart disease has

new symptoms or findings.




echocardiogram

or by history

Congenital

Heart Disease

Congenital heart

disease by

transthoracic or

transesophageal

echocardiogram

or by history

Added "Follow-up" Cardiology management is appropriate for an

adult with congenital heart disease.

Congenital

Heart Disease

Congenital heart

disease by

transthoracic or

transesophageal

echocardiogram

or by history

Added "Pregnancy" Cardiology management and consultation with

a high-risk obstetrician are appropriate for a

woman who is pregnant or contemplating

pregnancy who has congenital heart disease.




Hypertension

(HTN)

Hypertensive

emergency

Changed “Systolic BP > 160 mmHg” and

“Diastolic BP > 100 mmHg” to “Systolic BP ≥

160 mmHg” and “Diastolic BP ≥ 100 mmHg”

under “Elevated BP”

Referral to a specialist should include patients

with a systolic BP of 160 mmHg or a diastolic BP of

100 mmHg.

Hypertension

(HTN)

Hypertensive

urgency


“Diastolic BP > 100 mmHg” to “Systolic BP ≥

160 mmHg” and “Diastolic BP ≥ 100 mmHg”

under “Elevated BP”



100 mmHg.

Hypertension

(HTN)

Continued

hypertension

(HTN) after

treatment

Changed “Systolic BP > 140 mmHg” to

“Systolic BP ≥ 140 mmHg” under “Findings”


with a systolic BP of 140 mmHg.

Hypertension

(HTN)

Continued

hypertension

Changed “Diastolic BP > 90 mmHg” to

“Diastolic BP ≥ 90 mmHg” under “Findings”


with a diastolic BP of 90 mmHg.




(HTN) after

treatment

Hypertension

(HTN)

Continued

hypertension

(HTN) after

treatment

Changed “Systolic BP > 130 mmHg with

DM/chronic renal disease by Hx” to “Systolic

BP ≥ 130 mmHg and,” “Predicted 10-year risk

by atherosclerotic cardiovascular disease

(ASCVD) calculator ≥ 10%,” “Coronary artery

disease (CAD) by history,” “Heart failure (HF)

by physical examination or chest x-ray,”

“Stroke or transient ischemic attack (TIA) by

history,” “Diabetes mellitus (DM) by history,”

and “Chronic renal disease by history” under

“Findings”

Joint guidelines from the American Heart

Association and the American College of

Cardiology recommend pharmacological and

nonpharmacological interventions for patients

with a systolic BP of 130 mmHg or more when

there is a history of cardiovascular disease or an

estimated 10-year atherosclerotic cardiovascular

disease risk of 10% or more.

Hypertension

(HTN)

Continued

hypertension

Changed “Diastolic BP > 80 mmHg with

DM/chronic renal disease by Hx” to “Diastolic

BP ≥ 80 mmHg and,” “Predicted 10-year risk

Joint guidelines from the American Heart

Association and the American College of

Cardiology recommend pharmacological and




(HTN) after

treatment

by atherosclerotic cardiovascular disease

(ASCVD) calculator ≥ 10%,” “Coronary artery

disease (CAD) by history,” “Heart failure (HF)

by physical examination or chest x-ray,”

“Stroke or transient ischemic attack (TIA) by

history,” “Diabetes mellitus (DM) by history,”

and “Chronic renal disease by history” under

“Findings”

nonpharmacological interventions for patients

with a diastolic BP of 80 mmHg or more when

there is a history of cardiovascular disease or an

estimated 10-year atherosclerotic cardiovascular

disease risk of 10% or more.

Hypertension

(HTN)

Renovascular

hypertension

(HTN)


“Diastolic BP > 90 mmHg” to “Systolic BP ≥ 140

mmHg” and “Diastolic BP ≥ 90 mmHg” under

“Findings”



90 mmHg.

Myocarditis Changed indication "Acute myocarditis" to

"Suspected acute myocarditis"

Without doing an endomyocardial biopsy and

looking at the histology, a diagnosis of

myocarditis can only be suspected based on




history, examination, laboratory studies, and

imaging findings.

Myocarditis Suspected acute

myocarditis

Added "Symptoms," “Chest pain,” “New

onset or worsening heart failure or dyspnea,”

“Palpitations,” “Syncope,” “or Cardiogenic

shock”

Although not all patients with acute myocarditis

are symptomatic, the primary care provider

would not suspect acute myocarditis unless the

patient had the symptoms as listed.


myocarditis

Changed "Cardiac enzyme/C-reactive

protein/ESR elevation" to "Cardiac enzyme

results available"

C-reactive protein and ESR are nonspecific

markers of inflammation so they may not be

checked in all patients with suspected

myocarditis. Cardiac enzymes should be

checked, however, to exclude myocardial

ischemia as a cause of the patient's symptoms.


myocarditis

Added "Chest x-ray results available" Chest x-ray should be done in the evaluation of

suspected myocarditis to exclude other causes

of the patient's symptoms.



Category: Dermatologic Disorders


Acne, Rosacea,

and Perioral

Dermatitis

Acne Removed "Topical Abx ≥ 8 wks" under

"Continued findings after Rx" and changed

TWO "Medications" to ONE

Although combination therapy is likely more

effective, monotherapy can be tried first line in

the treatment of mild acne. Topical antibiotics

can be tried but should not be used alone.

Atopic Dermatitis

(Eczema)

Changed indication “Atopic dermatitis

(eczema)” to “Atopic dermatitis (eczema)

by physical examination”

This change was made to clarify that the

patient was being referred for current findings

and not a history of eczema.

Atopic Dermatitis

(Eczema)

Added indication "Atopic dermatitis by

history"

A dermatologist may follow a patient with

ongoing symptoms or findings of atopic

dermatitis.

Atopic Dermatitis

(Eczema)

Atopic dermatitis

(eczema) by

physical

examination

Added "Allergist" to the list of specialists

appropriate for referral

An allergist, as well as a dermatologist, may be

involved in the care of a patient with atopic

dermatitis.




Drug Eruptions and

Hypersensitivity

Syndromes

Drug eruption Changed "Erythematous macules/papules

by PE" to "Erythematous macules or

papules or bullae by physical examination"

Some drugs can cause a bullous reaction.

Drug Eruptions and

Hypersensitivity

Syndromes

Erythema

multiforme

Added "Oral mucosa" under "Involved

area"

In addition to the trunk or extremities, the oral

mucosa may be involved in erythema

multiforme.

Drug Eruptions and

Hypersensitivity

Syndromes

Stevens−Johnson

syndrome or

toxic epidermal

necrolysis (TEN)

Added "Ophthalmologist,” “Critical Care

Specialist,” and “Infectious Disease

Specialist" to the list of specialists


Referral to these specialists, in addition to a

dermatologist, may be appropriate for the

diagnosis or management of a patient with

Stevens-Johnson syndrome or toxic epidermal

necrolysis.

Drug Eruptions and

Hypersensitivity

Syndromes

Changed indications "Stevens-Johnson

syndrome" and "Toxic epidermal necrolysis

(TEN)" to "Stevens-Johnson syndrome or

toxic epidermal necrolysis (TEN)"

Stevens-Johnson syndrome and toxic

epidermal necrolysis are both severe

mucutaneous drug reactions, distinguished




only by severity and percent body surface

area involved.

Drug Eruptions and

Hypersensitivity

Syndromes

Stevens−Johnson

syndrome or

toxic epidermal

necrolysis (TEN)

Change the rule of BOTH "Erythema" and

"Exfoliation" to "Erythema or exfoliation"

under "Skin findings"

The patient may only have erythema if early in

the presentation.

Drug Eruptions and

Hypersensitivity

Syndromes

Stevens-Johnson

syndrome or

toxic epidermal

necrolysis (TEN)

Added "Involved area," "Trunk," "Palms or

soles," or Extremities" under "Skin findings"

These areas represent the usual distribution of

Stevens Johnson syndrome or toxic epidermal

necrolysis.

Drug Eruptions and

Hypersensitivity

Syndromes

Erythema

nodosum

Removed “Distribution” and “Bilateral” The primary distribution of erythema nodosum

is the extensor aspect of the extremities, which

is not always bilateral.




Drug Eruptions and

Hypersensitivity

Syndromes

Erythema

nodosum

Added "Tuberculin skin test (TST) or

interferon gamma release assay (IGRA)"

under "Tests nondiagnostic for etiology of

erythema nodosum"

The individual should be tested to exclude

tuberculosis as a cause of erythema nodosum.

Hair Disorders Androgenetic

alopecia in

female patient

Removed "Periodic Assessment" as a

reason for specialty involvement

The primary care provider can follow a woman

with androgenetic alopecia long-term.

Hidradenitis

Suppurativa

Hidradenitis

suppurativa

Added "Severe disease" under "Findings" Referral for evaluation of a patient with severe

disease at initial presentation, not only

recurrent nodules or abscesses, is appropriate.

Infections of the

Skin, Bacterial

Folliculitis Changed "Continued findings after

systemic Abx ≥ 10 days" to "Continued

findings after systemic antibiotics"

A full course of systemic antibiotics, not

necessarily 10 days or longer, should have

been tried.

Infections of the

Skin, Bacterial

Impetigo Added "Oral antibiotics ≥ 7 days" under

"Continued findings after treatment"

Oral antibiotics should be tried if there is no

resolution of findings after topical treatment.




Infections of the

Skin, Bacterial

Suspected

erythema

migrans

(cutaneous

Lyme disease)

Added "Oral antibiotics ≥ 10 days" The primary care provider should treat

erythema migrans with oral antibiotics, as

these have been shown to be effective in

eradicating Borrelia bacteria.

Infections of the

Skin, Fungal

Changed indication "Tinea versicolor" to

"Tinea (pityriasis) versicolor"

This change was made to reflect current

medical terminology.

Infections of the

Skin, Fungal

Tinea capitis Changed "Continued findings after oral

antifungal Rx ≥ 6 wks" to "Continued

findings after oral antifungal treatment ≥ 4

weeks"

Treatment for 4, not 6, weeks is sufficient to see

improvement in tinea capitis.

Infections of the

Skin, Fungal

Tinea barbae Changed "Oral antifungal Rx ≥ 6 wks" to

"Oral antifungal treatment ≥ 4 weeks"

Treatment for 4, not 6, weeks is sufficient to see

improvement in tinea barbae.

Infections of the

Skin, Viral

Removed indication "Molluscum

contagiosum"

Molluscum contagiosum can be managed by

the primary care provider.




Infections of the

Skin, Viral

Herpes simplex Changed "≥ 5 episodes in 1 year, with

continued findings despite prophylactic

treatment" to "≥ 5 episodes in 1 year, with

continued findings despite suppressive

treatment"



Infections of the

Skin, Viral

Herpes simplex Changed "< 5 episodes in 1 year, with

continued findings after abortive

treatment" to "< 5 episodes in 1 year, with

continued findings after episodic

treatment"



Insect Infestations Scabies Changed "Continued findings after topical

permethrin x2 applications" to "Continued

findings after topical permethrin x2

applications, ≥ 1 week apart"

This change was made to clarify the time

between permethrin applications.




Insect Infestations Scabies Added "Crusted (Norwegian) scabies"

under "Findings"

Crusted scabies is treated differently than

classic scabies.

Insect Infestations Scabies Changed "Household contacts treated" to

"Close contacts treated"

All close contacts, not only household

members, should be treated, as they can

transmit scabies even if asymptomatic.

Neoplasms and

Hyperplasias of the

Skin, Benign

Skin tag

(acrochordon)

Removed "Diagnosis" as a reason for

specialty involvement

Skin tags can be diagnosed by the primary

care provider and referral to the specialist is

not needed.

Neoplasms and

Hyperplasias of the

Skin, Benign

Keloid or

hypertrophic

scar

Added "Symptomatic," "Pain or pruritus," or

"Sensitive to touch or hyperesthesia," or

"Interferes with activities of daily living

(ADLs)"

In addition to growth or the need for

counseling, specialist involvement may be

appropriate for keloids or scars that are

symptomatic or interfere with functioning.

Neoplasms of the

Skin, Malignant and

Premalignant

Melanoma Changed "Change in shape/size/ color" to

"Evolution or change in shape or size or

color"

This change was made to complete the

ABCDE's of skin changes that make one

suspect melanoma.




Neoplasms of the

Skin, Malignant and

Premalignant

Dysplastic nevus Changed "Change in shape/size/ color" to

"Evolution or change in shape or size or

color"

This change was made to complete the

ABCDE's of skin changes that make one

suspect dysplastic changes.

Neoplasms of the

Skin, Malignant and

Premalignant

Squamous cell

carcinoma

Removed "Plastic Surgeon" from the list of

specialists appropriate for referral for

“Periodic Assessment”

The dermatologist, not the surgeon who

removed the patient's lesion, would

periodically assess the patient.

Neoplasms of the

Skin, Malignant and

Premalignant

Basal cell

carcinoma

Removed "Plastic Surgeon" from the list of

specialists appropriate for referral for

“Periodic Assessment”

The dermatologist, not the surgeon who

removed the patient's lesion, would

periodically assess the patient.

Neoplasms of the

Skin, Malignant and

Premalignant

Periodic skin

screening

examination for

high−risk patient

Changed “Frequent sunburns/chronic sun

exposure by Hx” to “Frequent sunburns or

chronic sun exposure or indoor tanning

bed use by history”

The use of indoor tanning booths, as well as

frequent sunburns or chronic sun exposure, can

put the patient at increased risk of developing

skin cancer.




Neoplasms of the

Skin, Malignant and

Premalignant

Periodic skin

screening

examination for

high−risk patient

Changed "Oculocutaneous albinism by Hx"

to "Oculocutaneous albinism or basal cell

nevus syndrome by history or physical

examination"

Basal cell nevus syndrome can put a young

adult at risk for the early development of basal

cell carcinoma.

Neoplasms of the

Skin, Malignant and

Premalignant

Periodic skin

screening

examination for

high−risk patient

Added "Red hair color or multiple freckles

by physical examination" and

"Immunocompromised patient"

These findings put the individual at higher risk of

developing skin cancer and periodic

assessment by the dermatologist is

appropriate.

Psoriasis Psoriasis by

physical

examination

Added "≥ 10% body surface area (BSA),"

"Guttate or pustular or nail psoriasis,"

"Localized disease causing functional

impairment or affecting hands or feet or

face or genitals or intertriginous areas," and

"Psoriatic arthritis present"

These findings justify referral to a dermatologist

without any treatment by the primary care

provider prior, as these findings require

treatment with therapies provided by the

specialist (e.g., phototherapy, biologic

agents).




Psoriasis Psoriasis by

physical

examination

Added "Treatment x 2 weeks and face or

genitalia or flexures involved" under

"Continued findings after topical

corticosteroid"

Topical corticosteroid use should be limited to

2 weeks when treating psoriasis of the face,

genitals, or flexure surfaces.

Seborrheic

Dermatitis

Added indication "Seborrheic dermatitis by

history"

Periodic assessment by a dermatologist is

reasonable for individuals with seborrheic

dermatitis who require maintenance therapy.

Seborrheic

Dermatitis

Seborrheic

dermatitis by

physical

examination

Changed "Continued findings after

antiseborrheic shampoo/cream ≥ 2 wks" to

"Scalp and ketoconazole or zinc pyrithione

or selenium sulfide or ciclopirox shampoo ≥

4 weeks" and "Non scalp and

ketoconazole and hydrocortisone cream ≥

4 weeks" under "Localized and continued

findings after treatment"

Evidence supports these first-line treatments

and recommends at least 4, not 2, weeks of

therapy prior to considering second-line

medications.




Seborrheic

Dermatitis

Seborrheic

dermatitis by

physical

examination

Added "Distribution," "Widespread or

severe disease," and "Localized and

continued findings after treatment"

Early referral is appropriate for severe or

widespread disease without the need for

treatment by the primary care provider prior to

referral.

Skin

Symptoms/Findings,

Unknown Etiology

Changed indications "Localized pruritus"

and "Diffuse pruritus" to "Acute pruritus" and

"Chronic pruritus"

The work-up of pruritus is typically based on

duration, not location, of the pruritus.

Skin

Symptoms/Findings,

Unknown Etiology

Acute pruritus Added "Pruritus < 6 weeks" Acute pruritus is defined as itching lasting less

than 6 weeks.

Skin

Symptoms/Findings,

Unknown Etiology

Acute pruritus Added "Aggravating medications or

substances," "Avoidance ≥ 2 weeks," and

"Not applicable"

This change was made to address any

medications or substances, if applicable, that

could be causing pruritus.




Skin

Symptoms/Findings,

Unknown Etiology

Chronic pruritus Added "Pruritus ≥ 6 weeks" Chronic pruritus is defined as itching lasting 6 or

more weeks.

Skin

Symptoms/Findings,

Unknown Etiology

Chronic pruritus Added "Aggravating medications or

substances," "Avoidance ≥ 2 weeks," and

"Not applicable"

This change was made to address any

medications or substances, if applicable, that

could be causing pruritus.

Skin

Symptoms/Findings,

Unknown Etiology

Exanthematous

or morbilliform or

maculopapular

eruption

Added "Generalized or widespread

eruption" under "Findings"

Immediate referral without a period of

observation is appropriate if the skin eruption is

widespread.

Skin

Symptoms/Findings,

Unknown Etiology

Petechiae Added "Hematologist" to the list of

specialists appropriate for referral

A hematologist may be helpful in the

evaluation of petechiae, as they may be

secondary to vasculitis or thrombocytopenia.

Urticaria and

Angioedema

Acute urticaria Removed "Oral corticosteroid," "Rx ≥ 1 wk,"

and "Contraindicated/not tolerated" under

Antihistamine monotherapy is preferred for

treating acute urticaria; corticosteroids would




"Continued symptoms or findings after

treatment"

only be necessary if there were respiratory

symptoms.

Urticaria and

Angioedema

Acute urticaria Changed "Antihistamine ≥ 1 wk" to

"Antihistamine ≥ 2 weeks"

Acute urticaria will usually resolve with

treatment in 10 to 14 days, so 2 weeks, not 1

week, of treatment should be tried before

considering referral.

Urticaria and

Angioedema

Chronic urticaria Added “Continued symptoms or findings

after treatment” and "Antihistamine ≥ 2

weeks"

Antihistamine treatment is standard in cases of

chronic urticaria and should be tried by the

primary care provider prior to referral.

Urticaria and

Angioedema

Angioedema

with systemic

symptoms

Added "Critical Care Specialist" to the list of


Patients with angioedema with systemic

symptoms are at risk of airway edema and the

need for mechanical ventilation and may

require management in the intensive care unit.




Vasculitis Involving

the Skin

Suspected

vasculitis

Added "Hepatitis B and C serology," "HIV,"

"Streptococcal titer," and "Chest x-ray"

under "Test results available"

These tests, in addition to the others listed,

should be done to evaluate the presence of

infection or hepatitis as a cause of the

vasculitis.

Category: Endocrine Disorders


Adrenal

Disorders

Changed indication "Incidental unilateral

adrenal mass" to "Incidental adrenal mass"

Evaluation by a specialist is appropriate for both

unilateral and bilateral incidental masses.

Adrenal

Disorders

Incidental adrenal

mass

Changed “24 hr urine VMA/metanephrine”

or "24-hour urine total catecholamines" to

“24-hour urinary fractionated metanephrine”

or "24-hour urinary total catecholamines"

under “Pheochromocytoma screening

results available”

24-hour urinary fractioned metanephrine is

preferred over a VMA test to screen for

pheochromocytoma. Either test is appropriate

to have available for pheochromocytoma

screening prior to referral to a specialist for an

incidental adrenal mass.




Adrenal

Disorders

Incidental adrenal

mass

Added Endocrinologist to the list of specialists

appropriate for referral under “≥ 4 cm or

malignant appearing” for “By imaging”

Although masses 4 cm or greater are typically

removed, intermediate sized masses (4 to 6 cm) may

be monitored with imaging if they are benign

appearing and have not changed in size.

Adrenal

Disorders

Enlarging adrenal

mass

Changed “24-hr urine VMA/metanephrine” or

"24-hour urine total catecholamines" to “24-hour

urinary fractionated metanephrine” or "24-hour

urinary total catecholamines" under

“Pheochromocytoma screening results available”

24-hour urinary fractioned metanephrine is preferred

over a VMA test to screen for pheochromocytoma.

Either test is appropriate to have available for

pheochromocytoma screening prior to referral to a

specialist for an adrenal incidental mass.

Adrenal

Disorders

Pheochromocy-

toma

Changed “24 hr urine VMA/metanephrine” to

“24-hour urinary fractionated metanephrine”

under “Pheochromocytoma screening results

available”

24-hour urinary fractioned metanephrine is preferred

over a VMA test to screen for pheochromocytoma.

Adrenal

Disorders

Pheochromocy-

toma

Changed “Plasma catecholamine > normal” to

“Plasma free metanephrine > normal”

Plasma free metanephrine is preferred over plasma

catecholamine as the initial serum test for

pheochromocytoma.




Adrenal

Disorders

Cushing syndrome Changed “24 hour urine free cortisol” or “Late-

night salivary cortisol” and “Abnormal low-dose

dexamethasone suppression test” to ’24-hour

urine free cortisol’ or “Late-night salivary cortisol”

or “Abnormal low-dose dexamethasone

suppression test”

Specialty referral is indicated based on an abnormal

24-hour urine free cortisol or late-night salivary cortisol

test without the additional testing with a low-dose

dexamethasone suppression test.

Adrenal

Disorders

Hypoaldosteronism Changed “K ≥ 4.8” to “K ≥ 5.5 mEq/L (5.5

mmol/L)” under “Suspected hypoaldosteronism”

An elevated potassium (5.5) is an indication of

hypoaldosteronism.

Diabetes

Insipidus (DI)

Diabetes Insipidus

(DI)

Changed “Polyuria ≥ 2.5 L/day” to “Polyuria ≥ 3.0

L/day”

Diabetes insipidus is suspected in adults when the

urine output is 3 liters or more per day.

Diabetes

Insipidus (DI)

Diabetes Insipidus

(DI)

Changed “Serum osmolality ≥ 280 mOsm/kg (300

mmol/kg)” to “Serum osmolality ≥ 300 mOsm/kg

(300 mmol/kg)”

A serum osmolality of 300 or greater, with a urine

osmolality of less than 200, is an indication of diabetes

insipidus.

Diabetes

Mellitus (DM)

Added "Continuous glucose monitoring (CGM)" Decisions regarding the use of continuous glucose

monitoring should involve a diabetes specialist.




Diabetes

Mellitus (DM)

Diabetic

ketoacidosis (DKA)

Changed "Glucose > 200 mg/dL (11.0 mmol/L)" to

"Glucose > 250 mg/dL (13.88 mmol/L)"

Glucose levels are generally greater than 250 mg/dL,

not 200 mg/dL, in patients with diabetic ketoacidosis.

Diabetes

Mellitus (DM)

Diabetic

ketoacidosis (DKA)

Changed "≥ 2 episodes w/in 6 mos" to "≥ 2

episodes"

Patients who have had recurrent episodes of diabetic

ketoacidosis should be evaluated by a diabetes

specialist for education on risk factors and

medication adherence, regardless of when the

episodes occurred.

Diabetes

Mellitus (DM)

Hyperosmolar

hyperglycemic state

Added "No acidosis," "Ketones absent,"

"Venous/arterial pH ≥ 7.3," and "No anion gap"

Hyperosmolar hyperglycemia is usually distinguished

from diabetic ketoacidosis because there is no

acidosis by testing.

Diabetes

Mellitus (DM)

Poorly controlled

diabetes mellitus

(DM)

Removed "Requiring insulin ≥ 6 mos" under "Type 2

DM"

The PCP should be able to manage a Type 2 diabetic

patient who requires insulin.

Diabetes

Mellitus (DM)

Poorly controlled

diabetes mellitus

(DM)

Changed "Erratic glucose measurements ("brittle"

Type 1 DM)" to "Erratic glucose measurements

(brittle DM)"

Some experts believe that brittle diabetes can occur

in patients with Type 2, as well as Type 1, diabetes

mellitus.




Diabetes

Mellitus (DM)

Pregnancy Removed "Ophthalmologist" from the list of

specialists appropriate for referral for “Current

pregnancy and diabetes mellitus (DM) by history”

An ophthalmologist would only need to be involved in

the care of a diabetic woman if she had eye

problems, regardless of whether she was pregnant or

not.

Diabetes

Mellitus (DM)

Pregnancy Removed "Ophthalmologist" from the list of

specialists appropriate for referral for “Pregnancy

planned within 12 weeks and diabetes mellitus

(DM) by history”

An ophthalmologist would only need to be involved in

the care of a diabetic woman if she had eye

problems, regardless of whether she was planning on

getting pregnant or not.

Diabetes

Mellitus (DM)

Diabetic neuropathy Added "Co-Management" as a reason for

specialty involvement for “Peripheral neuropathy

with continued symptoms or findings after

treatment”

Because diabetic neuropathy is a chronic condition,

the specialist may need to manage the patient with

the PCP.

Diabetes

Mellitus (DM)

Foot care Added "Nail clipping/callus trimming" under

"Periodic assessment, high-risk patient"

Nail and callus care by a foot care specialist may

prevent foot ulceration.




Diabetes

Mellitus (DM)

Perioperative

management

Changed "Perioperative management of Type 1

DM" to "Perioperative management"

All patients with diabetes, not only those with Type 1

diabetes mellitus, should be monitored before and

after surgery.

Diabetes

Mellitus (DM)

Diabetes education Changed “Periodic Assessment" to "Limited

Management" as a reason for specialty

involvement for "New onset DM (Type 1/Type 2)"

Education for the individual with new onset diabetes

would occur over a few visits. Their continued

education would then be covered by the "Periodic

diabetes education" criteria.

Diabetes

Mellitus (DM)

Peripheral arterial

disease (PAD) with

claudication

Changed "Smoking cessation or reduction ≥ 6

months or nonsmoker" to "Smoking cessation or

reduction ≥ 12 weeks or nonsmoker"

Referral to a specialist is appropriate after 12 weeks,

rather than 6 months, of documented smoking

cessation or reduction in a smoker.

Diabetes

Mellitus (DM)

Peripheral arterial

disease (PAD) with

claudication

Changed "Cholesterol management ≥ 6 months"

to "Statin ≥ 12 weeks or contraindicated or not

tolerated"

Statin therapy improves cardiovascular and limb

outcomes in patients with claudication and other

cholesterol medications have not been shown to

have the same effect. Twelve weeks, rather than 6

months, is sufficient to determine if treatment is

effective.




Diabetes

Mellitus (DM)

Peripheral arterial

disease (PAD) with

claudication

Changed "Medication," "Cilostazol or

pentoxyfilline ≥ 6 months," and "Contraindicated

or not tolerated" to Cilostazol ≥ 12 weeks or

contraindicated or not tolerated"

Pentoxyfilline is not effective in the treatment of

claudication. Twelve weeks, rather than 6 months, is

sufficient to determine if treatment is effective.

Hypoglycemia Hypoglycemia,

nondiabetic patient

Changed "Glucose ≤ 50 mg/dL (2.8 mmol/L) to

"Glucose ≤ 55 mg/dL (3 mmol/L)”

Hypoglycemia in a nondiabetic patient is defined as

glucose ≤ 55 mg/dL, not 50 mg/dL.


nondiabetic patient

Changed "Glucose > 50 mg/dL (2.8 mmol/L) and

< 70 mg/dL (3.8 mmol/L) ≥ 1 episode" to "Glucose

> 55 mg/dL (3 mmol/L) and < 70 mg/dL (3.8

mmol/L)"

Referral may be appropriate for any episode of mild

hypoglycemia defined as a glucose between 55

mg/dL (not 50 mg/dL) and 70 mg/dL.


nondiabetic patient

Added "Whipple triad," "Symptoms consistent with

hypoglycemia," "Low plasma glucose

concentration," and "Resolution of symptoms

after plasma glucose concentration raised to

normal level"

The Whipple triad defines true hypoglycemia which

requires further investigation.





nondiabetic patient

Changed "Aggravating medications

identified/withdrawn" to "Aggravating

medications or substances," "Identified and

withdrawn," and "Not applicable”

This change was made to cover cases when there

are no medications or substances responsible for

causing the hypoglycemia.

Paget Disease

of Bone

Changed subset title "Paget's Disease" to "Paget

disease of bone"

This change was made to clarify that these criteria

address Paget's disease of the bone and do not

include Paget's disease of the breast.

Paget Disease

of Bone

Changed indication "Paget's disease with

complications" to "Untreated Paget disease of

bone" and "Retreatment of Paget disease of

bone planned"

This change was made to allow for specialist

involvement when the patient requires retreatment of

their Paget disease of bone.

Paget Disease

of Bone

Untreated Paget

disease of bone

Added "Fracture" under "Symptomatic" Involvement of bone by Paget disease can result in

fracture.

Paget Disease

of Bone

Untreated Paget

disease of bone

Added "Rheumatologist" to the list of specialists


A rheumatologist, in addition to an endocrinologist,

may evaluate a patient with Paget disease of bone

who develops arthritis.




Paget Disease

of Bone

Untreated Paget

disease of bone

Added "Disease in weight-bearing

bone/adjacent to joint/vertebral body,"

"Osteolytic lesion," and "Hypercalcemia or

hypercalciuria" under "Asymptomatic or high-risk"

These findings in a patient with Paget disease of bone

should be followed, regardless of whether the patient

has symptoms or not.

Paget Disease

of Bone

Untreated Paget

disease of bone

Changed "Alkaline phosphatase > normal" to

"Alkaline phosphatase or bone markers > normal"

Markers of bone resorption, as well as alkaline

phosphatase, may be elevated in Paget disease of

bone.

Pituitary

Disorders

Pituitary tumor by CT

or MRI

Added “FSH and LH” under “No visual defect with

test results available”

Hormone evaluation includes testing for insufficient

secretions of gonadotropins before referral.

Pituitary

Disorders

Acromegaly Changed “GH level > 2 mcg/L after glucose

load” to “GH level ≥ 1 ug/L after glucose load”

A GH level of 1 ug/L or higher is used to indicate

imaging may be appropriate for suspected

acromegaly.

Pituitary

Disorders

Hyperprolactemia Added “Known hyperprolactemia” Specialty referral may be appropriate for periodic

assessment and to consider options when medical

treatment has not been successful.




Pituitary

Disorders

Cushing disease Added “Periodic assessment” as a reason for

specialty involvement for “Known Cushing

disease”

Specialty referral may be appropriate to monitor

medication management or post surgery follow-up.

Pituitary

Disorders

Hypogonadotropic

hypogonadism

Changed “FSH or LH inappropriately low” to “FSH

or LH inappropriately low related to low

testosterone level” under “Male”

A low FSH or LH level may suggest a pituitary problem

when it is related to a low testosterone level.

Pituitary

Disorders

Hypogonadotropic

hypogonadism

Changed “Estrogen < normal” to “Estrogen ≤

normal” under “Premenopausal female” and

“Postmenopausal female”

A normal estrogen level in conjunction with a low FSH

or LH may warrant specialist evaluation for a pituitary

disorder.

Category: Gastroenterologic Disorders


Cancer

Surveillance

Changed indication "Screening exam for patient

age ≥ 50 and ≤ 75 with no risk factors" to

Average-risk patients with gastrointestinal symptoms

should receive diagnostic testing instead of screening

and would be covered in another subset.




"Screening examination for asymptomatic patient

age ≥ 50 and ≤ 75 with no risk factors"

Cancer

Surveillance

Changed indication "Surveillance exam for high-

risk patient with familial syndrome" to "Surveillance

examination for high-risk patient with polyposis or

nonpolyposis syndrome"

Not all polyposis or nonpolyposis syndromes (e.g.,

serrated polyposis syndrome) have a proven genetic

component and referral to the specialist for

colonoscopy may be appropriate for any of these

syndromes.

Cancer

Surveillance

Colonic polyp Added "New polyp by barium enema or CT

colonograpy"

Any new polyp found by barium enema or CT

colonography necessitates colonoscopic follow up.

Cancer

Surveillance

Colonic polyp Changed “New adenomatous polyp by

BE/sigmoidoscopy” to “Adenomatous polyp by

sigmoidoscopy”

Any adenomatous polyps found by sigmoidoscopy

necessitates examination of the remaining colon for

additional polyps or cancer.

Cancer

Surveillance

Colonic polyp Changed "Incomplete excision of adenomatous

polyp" to Incomplete excision of adenomatous or

large polyp"

A follow-up post procedure is recommended for any

large colonic polyp to evaluate for, or remove, any

remaining polyp tissue.




Cancer

Surveillance

Screening

examination for

patient with

positive family

history

Changed “Age ≥ 40” to “Age ≥ 40 and ≤ 85”

under “Colorectal cancer by history in ≥ 2 first

degree relatives and”

Evidence does not support colorectal screening in

patients 85 or older who have family risk factors in first

degree relatives.

Cancer

Surveillance

Screening

examination for

patient with

positive family

history

Changed “Age ≥ 40” to “Age ≥ 40 and ≤ 85”

under “First degree relative with colorectal cancer

onset or adenomatous colonic polyp diagnosed

age < 60 and”

Evidence does not support colorectal screening in

patients 85 or older who have family risk factors in first

degree relatives.

Cancer

Surveillance

Surveillance

examination for

high−risk patient

with polyposis or

nonpolyposis

syndrome

Added “Serrated polyposis syndrome by

colonoscopy”

Serrated polyposis syndrome is a polyposis syndrome

that needs referral for closer surveillance with

colonoscopy than the randomly appearing polyps.




Dysphagia Changed indication "Neuromuscular or transfer

dysphagia" to "Oropharyngeal dysphagia"

This change was made to reflect current medical

terminology, as well as to address mechanical, not

only neuromuscular, disorders.

Dysphagia Oropharyngeal

dysphagia

Changed "CVA by Hx" to "Neurologic disorder by

history"

Other neurologic conditions (e.g., amyotrophic lateral

sclerosis, multiple sclerosis, Parkinson disease), not only

stroke, can cause dysphagia.

Dysphagia Oropharyngeal

dysphagia

Changed “Nasal regurgitation” to “Oral or nasal

regurgitation”

Patients with oropharyngeal dysphagia may have

oral, as well as nasal, regurgitation.

Dysphagia Changed indication "Dysphagia with known

esophageal disease" to "Esophageal dysphagia"


terminology.

Dysphagia Esophageal

dysphagia

Changed "Stricture" to "Esophageal stricture or

web or ring"

Esophageal webs and rings, as well as strictures, can

cause dysphagia.

Dysphagia Esophageal

dysphagia

Added "Esophagitis or esophageal cancer" and

"Radiation or caustic injury or esophageal surgery

by history"

Dysphagia caused by any of these conditions should

be evaluated by the specialist.




Nausea and

Vomiting

Nausea and

vomiting, unknown

etiology

Changed "Amylase normal" to "Amylase or lipase

normal"

Lipase, as well as amylase, can be done to exclude

pancreatitis as a cause of the patient's symptoms.

Nausea and

Vomiting

Nausea and

vomiting, unknown

etiology

Added "TSH normal" Hypothyroidism can result in nausea and vomiting.

Nausea and

Vomiting

Nausea and

vomiting, unknown

etiology

Added "Medications deemed noncontributory" Certain medications can result in nausea and

vomiting and should be excluded prior to referral to a

specialist.

Weight Loss,

Involuntary

Involuntary weight

loss, unknown

etiology

Changed "Involuntary weight loss > 10 lbs (4.5 kg)

w/in 12 wks" to "Involuntary weight loss > 10 lbs (4.5

kg) or ≥ 5% within 12 weeks"

An unexpected weight loss of 5% or more (not only 10

pounds of weight loss) in 3 months is worrisome and

should be evaluated.

Weight Loss,

Involuntary

Involuntary weight

loss, unknown

etiology

Removed "HIV," "Negative," and "Not indicated"

under "Lab tests normal"

HIV testing should only be considered in a patient who

has risk factors, not in everyone with involuntary weight

loss.




Weight Loss,

Involuntary

Involuntary weight

loss, unknown

etiology

Removed "UGI" under "Imaging studies

nondiagnostic for etiology of weight loss"

The decision on whether an UGI is necessary in the

work-up of involuntary weight loss is best left to the

specialist.

Weight Loss,

Involuntary

Involuntary weight

loss, unknown

etiology

Changed "Abdominal US/CT" to "Abdominal CT" CT is more informative than abdominal ultrasound in

patients with involuntary weight loss.

Category: Pulmonary Disorders


Asthma Asthma with

complication or

comorbidity

Changed "Pco2 ≥ 40 mmHg (5.3 kPa)" to "Pco2 ≥

45 mmHg (5.3 kPa)" under "Acute respiratory

compromise"

This value more accurately reflects respiratory distress.

Asthma Asthma with

complication or

comorbidity

Changed "Mechanical ventilation w/in 5 yrs by

Hx" to "ICU admission or mechanical ventilation by

history"

Referral is reasonable for a patient with asthma who

required mechanical ventilation or needed intensive

care at any time in the past.




Asthma Asthma with

complication or

comorbidity

Added "High-risk Obstetrician" to the list of

specialists appropriate for referral for “Pregnancy”

The obstetrician should work with the pulmonologist to

determine if a change in management is necessary.

Asthma Continued asthma

after treatment

Changed "Nighttime awakenings ≥ 2 w/in 1 wk" to

"Nighttime awakenings"

Any awakening at night due to asthma indicates poor

control and referral is reasonable.

Chronic

Obstructive

Pulmonary

Disease (COPD)

Chronic obstructive

pulmonary disease

(COPD) with

complication or

comorbidity

Changed "Mechanical ventilation w/in 5 yrs by

Hx" to "ICU admission/mechanical ventilation by

history"

Referral is reasonable for a patient with chronic

obstructive pulmonary disease who required

mechanical ventilation or needed intensive care at

any time in the past.

Chronic

Obstructive

Pulmonary

Disease (COPD)

Chronic obstructive

pulmonary disease

(COPD) with

complication or

comorbidity

Added "High-risk Obstetrician" and removed

"Critical Care Specialist" from the list of specialists

appropriate for referral for "Pregnancy"

An obstetrician, not a critical care specialist, may

need to work with the pulmonologist to determine if a

change in management is necessary.

Chronic

Obstructive

Continued chronic

obstructive

Changed "Beta-agonist ≥ 8 wks" and

"Anticholinergic ≥ 8 wks" to "Beta-agonist ≥ 4

Referral may be appropriate when the patient with

chronic obstructive pulmonary disease continues to




Pulmonary

Disease (COPD)

pulmonary disease

(COPD) after

treatment

weeks" and "Anticholinergic ≥ 4 weeks," under

"Therapy"

have symptoms after at least 4, not 8, weeks of

treatment.

Chronic

Obstructive

Pulmonary

Disease (COPD)

Chronic

corticosteroid use

Removed "Inhaled corticosteroids ≥ 4 wks" The PCP can manage the patient with chronic

obstructive pulmonary disease who is on inhaled

corticosteroids.

Cough,

Unknown

Etiology

Changed indications "Daily cough > 3 weeks and

no smoking by history" and "Daily cough > 3

weeks and smoking by history" to "Subacute or

chronic cough (daily cough > 3 weeks) and no

smoking by history" and "Subacute or chronic

cough (daily cough > 3 weeks) and smoking by

history"

This change was made to clarify that referral is being

made for aid in the treatment and diagnosis of a

subacute or chronic cough. The primary care provider

can manage an acute cough without the need for

specialist involvement.

Cough,

Unknown

Etiology

Subacute or chronic

cough (daily cough

Added "Diagnosis" as a reason for specialty

involvement

A pulmonologist may be helpful in establishing the

diagnosis of a cough lasting more than 3 weeks when




> 3 weeks) and no

smoking by history

the primary care physician has not been able to

make a definitive diagnosis.

Cough,

Unknown

Etiology

Subacute or chronic

cough (daily cough

> 3 weeks) and no

smoking by history

Changed "Intranasal corticosteroid or cromolyn

spray" to "Intranasal corticosteroid"

Cromolyn is not as effective as intranasal

corticosteroids in the treatment of cough.

Cough,

Unknown

Etiology

Subacute or chronic

cough (daily cough

> 3 weeks) and no

smoking by history

Changed "Beta-agonist ≥ 2 wks" to "Beta-agonist

use ≥ 3 doses/week" when "Symptoms of asthma

present after treatment"

This dose of beta-agonists more accurately reflects

poor asthma control necessitating specialist

involvement.

Cough,

Unknown

Etiology

Subacute or chronic

cough (daily cough

> 3 weeks) and

smoking by history

Changed "Inhaled corticosteroid ≥ 2 wks" to

"Corticosteroids ≥ 4 weeks" when "Symptoms of

asthma present after treatment"

Referral is reasonable if at least 4, not 2, weeks of

corticosteroids, not only inhaled but oral as well, do

not control the patient's asthma.

Cough,

Unknown

Etiology

Subacute or chronic

cough (daily cough

Changed "Beta-agonist ≥ 2 wks" to "Beta-agonist

use ≥ 3 doses/week" when "Symptoms of asthma

present after treatment"

This dose of beta-agonists more accurately reflects

poor asthma control necessitating specialist

involvement.




> 3 weeks) and

smoking by history

Hemoptysis Blood-streaked

sputum

Changed “Continued blood-streaked sputum

after Abx Rx ≥ 10 days” to “Continued blood-

streaked sputum after antibiotic treatment

completed” under “Findings” under “Nonsmoker

and”

Duration of antibiotic treatment may vary and referral

to the specialist is appropriate following completion of

the antibiotic course.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

Changed indication “Thorax bone abnormality”

to “Thoracic bone abnormality by imaging”

An abnormality of a bone in the thoracic region may

be discovered by either CT or x-ray.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

New nodule or mass Added “Spiculated margins” under “Suspicious

morphology” under “Lung” under “Findings”

Benign nodules typically have smooth margins,

whereas a nodule with spiculated margins is more

likely to be malignant.




Imaging Study

Abnormalities

(Pulmonary

Disorders)

New nodule or mass Added “History of emphysema or pulmonary

fibrosis” and “Nodule located in upper lobe”

under “Lung” under “Findings”

History of emphysema or pulmonary fibrosis or a

nodule located in the upper lobe are all risk factors for

malignancy and referral to the specialist is

appropriate if these findings are present with a new

lung nodule on imaging.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

New nodule or mass Added “Interventional Radiologist” to the list of

specialists appropriate for referral for “New

nodule or mass” for “Hilum” and “Mediastinum”

An interventional radiologist, in addition to a

pulmonologist or thoracic surgeon, may be

involved in the evaluation of patients with a

hilar or mediastinal nodule or mass.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

Lymphadenopathy

by chest x-ray or CT

Added “Interventional Radiologist” to the list of



pulmonologist or thoracic surgeon, may be involved

in the evaluation of patients with hilar or mediastinal

lymphadenopathy.

Imaging Study

Abnormalities

Pneumothorax by x-

ray

Changed “Not resolved by CXR ≥ 2 wks” to “Not

resolved by x-ray ≥ 1 week” under “< 20%

pneumothorax”

If a small pneumothorax has not resolved within 1

week, referral to a specialist is appropriate as there is

risk for expansion to a larger pneumothorax.




(Pulmonary

Disorders)

Imaging Study

Abnormalities

(Pulmonary

Disorders)

Vascular

abnormality

Removed “Aortic abnormality by CT/MRA/MRI” The user should refer to the indication “Aortic

abnormality” within the “Imaging Study Abnormalities

(Cardiovascular Disorders)” criteria subset.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

Vascular

abnormality


specialists appropriate for referral for “Hilar vessel

abnormality by CT or MRI”

An interventional radiologist, in addition to a vascular

surgeon, cardiologist, or cardiothoracic surgeon, may

be involved in the evaluation of patients with a hilar

vessel abnormality.

Imaging Study

Abnormalities

(Pulmonary

Disorders)

Vascular

abnormality

Added “Pulmonary arteriovenous malformation

(AVM) by testing”

Referral to a specialist is appropriate to diagnose and

manage a pulmonary arteriovenous malformation

observed by testing.

Imaging Study

Abnormalities

Thoracic bone

abnormality

Added “Thoracic Surgeon” to the list of specialists


A thoracic surgeon, in addition to an orthopedic

surgeon, oncologist, or interventional radiologist, may




(Pulmonary

Disorders)

be involved in the evaluation of patients with a

thoracic bone abnormality.

Pleural Effusion Added indication “Pleural effusion by chest x-ray

or CT, unknown etiology”

Referral to a specialist is appropriate for a

thoracentesis to determine the type of pleural effusion

present on imaging.

Pleural Effusion Changed indication “Suspected hemothorax” to

“Hemothorax” and added “Suspected

hemothorax by chest x-ray or CT” and “Known

hemothorax by thoracentesis”

This change was made to more clearly indicate that

referral to a specialist is appropriate for either a

suspected or known hemothorax. Thoracentesis may

not be required for a hemothorax that is suspected

based on imaging findings and the patient's history,

and treatment of the hemothorax may be required

urgently.

Pleural Effusion Changed indication “Empyema” to “Known

empyema by thoracentesis”

This change was made to more clearly indicate that a

thoracentesis has been done and, therefore, referral

to the specialist is appropriate to manage the

empyema.




Pleural Effusion Changed indication “Exudative effusion,

unknown etiology” to “Known exudative effusion

by thoracentesis”




exudative effusion.

Pleural Effusion Changed indication “Transudative effusion” to

“Known transudative effusion by thoracentesis”




transudative effusion.

Pleural Effusion Changed indication “Chylous effusion” to

“Known chylous effusion by thoracentesis”



to the specialist is appropriate to manage the chylous

effusion.

Pleural Effusion Removed indication “Thoracentesis not yet

performed”

Thoracentesis is usually performed by the specialist,

not by the PCP.

Pleural Effusion Malignant effusion Changed “Newly discovered” to “Initial

malignant effusion by thoracentesis”






to the specialist is appropriate to manage the initial

malignant effusion.

Pleural Effusion Malignant effusion Changed “Recurrent” to “Recurrent malignant

effusion by chest x-ray or CT”

In a patient with a previous malignant pleural effusion,

a recurring effusion on imaging is likely to be

malignant and referral to the specialist is appropriate

without a repeat thoracentesis.

Pleural Effusion Malignant effusion Added “Pulmonologist” and “Interventional

Radiologist” to the list of specialists appropriate

for referral for “Initial malignant effusion by

thoracentesis”

A pulmonologist and interventional radiologist, in

addition to a thoracic surgeon, radiation oncologist,

and oncologist, may be involved in the management

of patients with a malignant effusion.

Pleural Effusion Malignant effusion Changed “Surgeon” to “Thoracic Surgeon” in the

list of specialists appropriate for referral for “Initial

malignant effusion by thoracentesis”

Referral to a thoracic surgeon, rather than a surgeon,

is appropriate to manage a malignant pleural

effusion.

Pleural Effusion Malignant effusion Added “Periodic Assessment” as a reason

for specialty involvement for “Recurrent

malignant effusion by chest x-ray or CT”

Periodic assessment may be appropriate for

patients with recurrent malignant effusions as

these are likely to keep recurring.




Pleural Effusion Malignant Effusion Added “Pulmonologist,” “Interventional

Radiologist,” “Radiation Oncologist,” and

“Oncologist” to the list of specialists appropriate

for referral for “Recurrent malignant effusion by

chest x-ray or CT”

A pulmonologist, interventional radiologist, radiation

oncologist, and oncologist, in addition to a thoracic

surgeon, may be involved in the evaluation of

patients with a recurrent malignant effusion.

Pleural Effusion Known empyema by

thoracentesis

Added “Pulmonologist” to the list of specialists


A pulmonologist, in addition to a thoracic surgeon,

interventional radiologist, and infectious disease

specialist, may be involved in the management of

patients with an empyema.

Pleural Effusion Known exudative

effusion by

thoracentesis

Removed “Sputum cytology negative,” “CXR

nondiagnostic for etiology of effusion,” “Chest CT

nondiagnostic for etiology of effusion,” and

“Thoracentesis performed and pleural fluid tests

available”

Referral to the specialist is appropriate to determine

the etiology of a known exudative effusion and

ordering the appropriate testing is best left to the

specialist.


effusion by

thoracentesis

Removed “Diagnosis” and added “Limited

Management” as a reason for specialty

involvement

Referral is for management, not diagnosis, of an

exudative effusion.





effusion by

thoracentesis

Removed “Thoracic Surgeon” from the list of


A pulmonologist, not thoracic surgeon, would be

appropriate for the management of an exudative

effusion.

Pleural Effusion Known transudative

effusion by

thoracentesis

Changed “Not on peritoneal dialysis” to “Not on

dialysis”

Patients on hemodialysis, as well as peritoneal dialysis,

are at risk for development of a transudative effusion.


effusion by

thoracentesis

Removed “Thoracentesis performed and pleural

fluid cytology negative”

Referral to the specialist may be appropriate to

determine the etiology of a transudative effusion

diagnosed by thoracentesis and ordering the

appropriate testing is best left to the specialist.


effusion by

thoracentesis

Removed “Diagnosis” and added “Limited

Management” as a reason for specialty

involvement

Referral is for management, not diagnosis, of a known

transudative effusion.

Pleural Effusion Known chylous

effusion by

thoracentesis

Added “Pulmonologist” and “Interventional

Radiologist” to the list of specialists appropriate

for referral

A pulmonologist and interventional radiologist, in

addition to a thoracic surgeon, may be involved in

the management of patients with a chylous effusion.




Pneumonia Pneumonia with

complication or

comorbidity

Changed "Systolic BP < 100 mmHg" to "Systolic BP

< 90 mmHg or < 110 mmHg with chronic

hypertension" and added "HR > 120/min,

sustained," "Orthostatic changes," "Sustained

decrease in systolic BP ≥ 20 mmHg within 3

minutes of sitting or standing," and "Sustained

decrease in diastolic BP ≥10 mmHg within 3

minutes of sitting or standing" under

"Hemodynamic instability"

These criteria more accurately reflect the findings

seen in individuals with hemodynamic instability.


complication or

comorbidity

Changed "COPD with FEV1 < 1.5 L" to "Asthma or

chronic obstructive pulmonary disease with FEV1

< 1.5 L" and added "Sleep apnea" under

"Comorbidity" and "Pulmonary disease"

Patients with asthma or sleep apnea are at risk of

developing complications from pneumonia.


complication or

comorbidity

Added "Chronic liver or kidney disease" and

"Diabetes mellitus" under "Comorbidity"

Patients with these conditions are at risk of developing

complications from pneumonia.





complication or

comorbidity

Added "Multi-drug resistant organism" under

"Unusual infection" and "Organism"

Specialist input may be helpful when the patient has

pneumonia secondary to infection with a multi-drug

resistant organism.


complication or

comorbidity

Removed "Osteomyelitis" under "Pneumonia with

infectious complication" and removed

“Orthopedic Surgeon” from Purpose of Specialist

Involvement note

Osteomyelitis would be a very rare complication of

pneumonia.


complication or

comorbidity

Added "Pleural effusion" under "Pneumonia with

infectious complication"

Evidence shows worse outcomes in patients who

present with both pleural effusion and pneumonia.

Pneumonia Pneumonia,

nonresponsive to

treatment

Changed "Temperature ≥ 100.4 F (38 C)" to

"Temperature ≥ 100.4 F (38 C) increasing" under

"Findings"

Referral would only be necessary if the patient with

pneumonia had worsening of their fever, not just a

persistent fever.


unresolved

Changed "Antibiotics (intravenous/oral) ≥ 10

days" to "Antibiotics (intravenous/oral) ≥ 7 days"

One week, not 10 days, of antibiotics should be

sufficient to see improvement.





unresolved

Changed "Dyspnea increasing by history or

physical examination" to "Dyspnea by history or

physical examination" under "Findings"

Any dyspnea, not just dyspnea that is worsening,

could be evaluated by a specialist.


unresolved

Changed "PO2 or O2 sat decreasing" to "PO2 or

O2 sat decreased"

Referral is appropriate when the patient treated for

pneumonia has decreased oxygenation, not

necessarily oxygenation that is getting worse.

Preoperative

Evaluation

(Pulmonary

Disorders)

Abnormal

pulmonary function

Changed "DLCO ≥ 60% predicted" to "Abnormal

DLCO" and “≥ 60% predicted” OR "Dyspnea by

history"

Referral is appropriate for any DLCO abnormality, not

only when 60% or less, if the patient has shortness of

breath.

Preoperative

Evaluation

(Pulmonary

Disorders)

Abnormal

pulmonary function

Added "FEV1/FVC ratio < 0.7" This value represents airway restriction and evaluation

by a pulmonologist is justified.

Preoperative

Evaluation

High−risk surgery Removed "Age ≥ 60" under "Risk factors" Age alone is not a risk factor for postoperative

pulmonary complications.




(Pulmonary

Disorders)

Preoperative

Evaluation

(Pulmonary

Disorders)

High−risk surgery Added "Anticipated surgical duration ≥ 3 hours"

under "Risk factors"

There is a greater risk of pulmonary complications the

longer the duration of upper abdominal or thoracic

surgery.

Pulmonary

Embolism (PE)

Suspected

pulmonary embolism

(PE)

Added “Urgent” designation A suspected pulmonary embolism requires immediate

attention and preauthorization may not be able to be

done prior to referral to the specialist.

Pulmonary

Embolism (PE)

Suspected

pulmonary embolism

(PE)




pulmonologist or cardiologist, may be involved in the

evaluation of patients with suspected pulmonary

embolism.

Pulmonary

Embolism (PE)

Suspected

pulmonary embolism

(PE)

Added “Tachycardia,” “Hypotension,” and “New

cough” under “Symptoms or findings”

People with pulmonary embolism commonly present

with these symptoms or findings.




Pulmonary

Embolism (PE)

Suspected

pulmonary embolism

(PE)

Removed “Suspected DVT by exam and LE

duplex US nondiagnostic for DVT” and “Known

DVT by imaging and”

When pulmonary embolism is suspected in a patient

with tachycardia or new cough, referral to a specialist

is appropriate independent of suspicion or presence

of a deep vein thrombosis.

Pulmonary

Embolism (PE)

Suspected

pulmonary embolism

(PE)

Changed “CTA nondiagnostic for PE” to “CTA or

MRA or V/Q scan nondiagnostic for pulmonary

embolism (PE)”

Referral to a specialist is appropriate for a patient with

a suspected pulmonary embolism and a

nondiagnostic MRA or V/Q scan, not just CTA.

Pulmonary

Embolism (PE)

Pulmonary embolism

(PE) by imaging

Added “Urgent” designation A known pulmonary embolism requires immediate

attention and preauthorization may not be able to be

done prior to referral to the specialist.

Pulmonary

Embolism (PE)

Pulmonary embolism

(PE) by imaging



An interventional radiologist, in addition to a critical

care specialist, pulmonologist, or thoracic surgeon,

may be involved in the evaluation of patients with

pulmonary embolism by imaging.

Pulmonary

Embolism (PE)

Pulmonary embolism

(PE) by imaging

Removed “Vascular Surgeon” from the list of


An interventional radiologist, critical care specialist,

pulmonologist, or thoracic surgeon would be




consulted regarding pulmonary embolism, not a

vascular surgeon.

Pulmonary

Function Test

(PFT)

Abnormalities

Abnormal

pulmonary function

tests

Added "Peak expiratory flow ≥ 60% predicted"

and "FEV1/FVC ratio < 0.7"

These values represent airway restriction and

evaluation by a pulmonologist is justified.

Tuberculosis (TB) TST ≥ 5 mm and high

risk for tuberculosis

Added "Silicosis” Silicosis puts a patient at high risk for developing

tuberculosis.

Tuberculosis (TB) TST ≥ 10 mm and < 15

mm and low to

intermediate risk for

tuberculosis

Removed "Silicosis" under "Medical conditions

which increase the risk of tuberculosis"

Silicosis puts a patient at high, not low or intermediate,

risk for developing tuberculosis and this condition is

now covered under "TST ≥ 5 mm and high risk for

tuberculosis."

Tuberculosis (TB) IGRA positive or

indeterminate or

borderline

Added indication "IGRA positive or indeterminate

or borderline"

The interferon gamma release assay (IGRA) test may

be done for tuberculosis screening instead of a

tuberculin skin test (TST).




Tuberculosis (TB) Suspected

tuberculosis

Added "Cavitary air space disease" under "By

imaging"

This is an imaging finding associated with active

tuberculosis.


tuberculosis

Changed "PPD" "Reactive" to "TST reactive" under

"Screening test"


terminology.


tuberculosis

Changed "PPD nonreactive in high-risk group" to

"TST nonreactive or IGRA negative in high-risk

group"


terminology. IGRA was added, as it is an option to

tuberculin skin testing.


tuberculosis

Added "IGRA positive or indeterminate or

borderline" under "Screening test"

IGRA was added, as it is an option to tuberculin skin

testing.


tuberculosis

Added "Chest x-ray results available" CXR should always be done in the evaluation of

suspected tuberculosis.



Category: Renal & Urologic Disorders


Hematuria Gross hematuria Removed "CT nondiagnostic for etiology of

hematuria"

CT is not necessary prior to referral for gross

hematuria.

Hematuria Microscopic

hematuria

Removed "Prostatitis," "Excluded by Hx & PE,"

and "Not indicated"

Evaluation for prostatitis is not routinely done prior

to referral to a specialist for hematuria.

Nephrolithiasis

(Kidney/Ureteral/Bladder

Stones)

Nephrolithiasis

without

obstruction

Changed "Aggressive Hydration 24 hrs" to

"Hydration 24 hours" under "Continued

symptoms after treatment"

Hydration for 24 hours or longer is appropriate but

the nature of that hydration would be

determined on a case by case basis.

Nephrolithiasis

(Kidney/Ureteral/Bladder

Stones)

Recurrent

nephrolithiasis

Changed "Medications deemed

noncontributory" to "Medications necessary

or deemed noncontributory"

Medications may continue to be necessary

regardless of their contribution to the condition.

Proteinuria Non−nephrotic

proteinuria of

unknown etiology

Removed "Urine protein electrophoresis"


Urine protein electrophoresis is not routinely

tested prior to specialty referral.




Proteinuria Non−nephrotic

proteinuria of

known etiology,

worsening after

treatment

Removed "BP controlled" under "Worsening

proteinuria after treatment" under "Therapy"

Blood pressure does not need to be controlled

prior to referral to a specialist.

Proteinuria Nephrotic−range

proteinuria

Removed "Urine protein electrophoresis"


Urine protein electrophoresis is not necessary

prior to referral to a specialist.

Renal Insufficiency Acute renal failure

without

obstruction

Changed "Creatinine increase 0.5 mg/dL

(44 µmol/L) over 24 hours" to Creatinine

increase 0.3 mg/dL (26.5 µmol/L) over 48

hours" under "Acute creatinine elevation"

A creatinine elevation of 0.3 mg/dL over

48 hours is considered an acute elevation and

demonstrates acute renal failure appropriate for

specialty referral.


without

obstruction

Added "Creatinine 1.5 fold from baseline

within 7 days" under "Acute creatinine

elevation"

Creatinine 1.5 fold from baseline within 7 days is

an indicator of acute renal failure and justifies

further evaluation.





with obstruction

Changed "Creatinine increase 0.5 mg/dL

(44 µmol/L) over 24 hours" to Creatinine

increase 0.3 mg/dL (26.5 µmol/L) over 48

hours" under "Acute creatinine elevation"

A creatinine elevation of 0.3 mg/dL over 48 hours

is considered an acute elevation that justifies

further evaluation.


with obstruction

Added "Creatinine 1.5 fold from baseline

within 7 days" under "Acute creatinine

elevation"

Creatinine 1.5 fold from baseline within 7 days is

an indicator of acute renal failure.

Renal Insufficiency Chronic renal

insufficiency

Added "GFR below normal" Referral to a specialist is appropriate for patients

with a below normal glomerular filtration rate.

2018 clinical revisions - interqual review manager · american medical association, 515 ... review...

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