Since its launch in 2012, the ABIM Foundation's Choosing Wisely campaign has helped create conversations among clinicians and patients—both in the U.S. and abroad—about unnecessary care, particularly where significant risks of a test or treatment exceed its benefits. The goals of the campaign were and still are to foster discussions around avoiding wasteful health care, and to shift away from the polarizing language of "rationing" and "death panels." As evidenced in the increased number of clinical articles, continued coverage in traditional and social media, educational sessions on overuse at clinical and policy conferences, and the expansion of Choosing Wisely campaigns internationally, the conversations are indeed happening. But are conversations enough?
Choosing Wisely has been criticized for focusing on conversations instead of measures and implementation. It has also been criticized by some who said the content of the lists of unnecessary tests and procedures compiled by various specialties do not address more challenging areas of overuse. These are valid concerns.
The Choosing Wisely campaign was designed to raise the profile of the issues of waste and overtreatment in health care. Behavioral change won't come from conversations alone. We'll need to look to tried-and-true quality management approaches that go beyond education to include quality improvement (i.e. quality improvement initiatives, measurement, audit, and feedback) and system changes (e.g. policy changes, electronic medical records, and order sets). (Levinson W, Hyuhn T. Challenges and successes in implementation in Canada and US. Presented at Choosing Wisely International Conference; 2015 May 28; London, England.)
But a public education campaign—which Choosing Wisely has always been—is a spark, a spark that hopefully lights a fire. What more should the community be doing? We raise these ideas and calls to action for everyone engaged in health care.
Measure Developers
For the last 25 years or more, roughly 93 percent of quality measures and initiatives have focused on underuse. The subject of overuse has long been neglected at the peril of quality and safety. Leaders in quality measurement need to begin developing measures that lend themselves to administrative data and have the highest prevalence.
Medical Societies
Part of the success of the Choosing Wisely campaign has stemmed from the fact that the medical societies have developed and own the lists, with relatively little input from the campaign beyond a framework. Many societies have displayed remarkable leadership in addressing challenging areas head on. For example, the American Society for Radiation Oncology recommends against routine use of proton beam therapy outside clinical trials or a registry. The Society of General Internal Medicine recommends against the annual physical for asymptomatic patients — a practice deeply ingrained in our health care system.
If there are gaps in recommendations, it is up to the profession and the larger community to engage in a conversation and bring forward better recommendations. If current society lists are not meeting the needs of clinical practices, we encourage practices to develop their own lists with more relevant and meaningful recommendations.
Broader Physician Community
Efforts to develop additional lists of wasteful tests and procedures are already happening at the grassroots level, such as the Journal of Hospital Medicine's new series: Choosing Wisely: Things we do for no reason. Group practices have also begun these conversations. We welcome more and more communities to work together to discuss what unnecessary tests and procedures they may be ordering and performing.
It's Not Just Physicians
While physicians may be the primary driver of tests and procedures, other members of the health care team also can have a powerful influence on overuse. The Choosing Wisely campaign has expanded beyond physicians to include fields such as nursing and physical therapy, with additional professions to come. We welcome more health care team members to think about opportunities to reduce overuse and to work to create them.
Health Systems
Many health systems, including Cedars Sinai, Henry Ford Physician Network, Virginia Mason, Group Health Cooperative, Swedish Medical Center, and Crystal Run Healthcare (Middletown, NY), have begun implementing Choosing Wisely in their systems. These systems can be the proving ground for de-implementation of overused tests and treatments.
For example, Cedars-Sinai Health System has embedded 180 Choosing Wisely recommendations in its electronic health record (EHR) system. When physicians order a test or treatment referenced by Choosing Wisely, they are prompted with an alert providing more information about its appropriateness before they can proceed. Cedars-Sinai saw a 31.5 percent decrease in the rate of new orders for benzodiazepine for patients over the age of 65 in the first two months the system was live. More than 300 alerts are sent a day, and project leaders report no signs of alert fatigue among physicians.
Swedish Medical Center embraced Choosing Wisely recommendations from the Society of Hospital Medicine and the Critical Care Societies Collaborative warning against too-frequent ordering of lab tests. A review of ordering patterns found five or six out of a staff of 60 physicians were responsible for 50 percent of daily labs. Project leaders created a simple e-mail based intervention that included data on physician ordering patterns, coupled with educational messages explaining why daily labs were wasteful. After a year 20 percent fewer labs were ordered, equating to 14,000 less than the previous year.
The lessons learned from these systems and others can be shared more broadly with the health care community.
Evaluation And Measurement Community
While we have not measured changes in utilization stemming from of any of the recommendations, others have begun exploring this kind of measurement. One analysis included 12 Choosing Wisely recommendations and estimated potential annual savings of 0.6-2.7 percent in Medicare expenditures. Another showed 4.5 percent actual average savings on 36 recommendations in Pioneer Accountable Care Organizations.
In Washington, a Choosing Wisely taskforce developed the first state-level report to measure the use of 11 Choosing Wisely recommendations. The report found that overuse was a common issue across the state, and high levels of variation existed between the highest- and lowest-performing counties. To support clinicians in reducing overuse and variation the taskforce developed a Choosing Wisely Action Manual aimed at integrating the recommendations into practice.
Patients
Consumer Reports has been working with many patient, consumer, and employer groups to get the word out that more is not always better. Employers have engaged with Consumer Reports to intensify these efforts and broadly disseminate Choosing Wisely information to their employees. For example, IBM is working with Consumer Reports to distribute information to its 200,000 US-based employees about making healthy choices and avoiding unnecessary care. More patient and consumers groups should join the campaign.
Choosing Wisely is a platform for community engagement and participation. Many stakeholders have used the core principles of the campaign—recommendations based on evidence, a focus on conversations, quality, safety, and doing no harm—to advance efforts aimed at the reduction of unnecessary tests and treatments. Join us and help the health care system eliminate waste by choosing wisely every day.
from Health Affairs Blog http://ift.tt/1OJ7C2w
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