COVER STORY

Providers hail value of Choos­ing Wisely, but skep­tics say ini­tia­tive comes with risk

Modern Healthcare - - NEWS -

The Choos­ing Wisely cam­paign, with par­tic­i­pat­ing med­i­cal so­ci­eties, spot­lighted a list of 135 po­ten­tially un­nec­es­sary pro­ce­dures. Crit­ics are ques­tion­ing whether pa­tients and physi­cians are see­ing the guide­lines and if they are lead­ing to any changes. But Dr. Glen Stream, left, AAFP board chair­man, says his group’s par­tic­i­pa­tion was the right choice. “It’s a proac­tive stance, driven by the med­i­cal pro­fes­sion, and it really does make con­ver­sa­tions with pa­tients eas­ier.”

Car­di­ol­o­gist Dr. Blair Erb has a new strat­egy when pa­tients with known coronary artery disease come to his Boze­man, Mont., of­fice for an­nual stress tests, which he be­lieves are al­most al­ways un­nec­es­sary. In a con­ver­sa­tion with each pa­tient—and later, in a note to the re­fer­ring physi­cian—Erb cites the Choos­ing Wisely cam­paign, a mul­tispe­cialty ini­tia­tive cre­ated to curb overuse of health­care, which ad­vises against rou­tine stress tests for CAD pa­tients un­less there is a change in clin­i­cal sta­tus.

“We have cre­ated a med­i­cal ecol­ogy based on over­pre­scrip­tion and over­con­sump­tion on the part of both physi­cians and pa­tients,” Erb said. “What Choos­ing Wisely has done is le­git­imize our abil­ity to cut back on what’s un­nec­es­sary.”

Led by the Washington-based ABIM Foun­da­tion, the ini­tia­tive part­ners with par­tic­i­pat­ing med­i­cal so­ci­eties, each of which pro­duces a list of five com­monly or­dered but usu­ally un­nec­es­sary—and some­times harm­ful—tests and pro­ce­dures, based on avail­able ev­i­dence. The goal, ac­cord­ing to the foun­da­tion, is to pro­vide physi­cians and pa­tients with a quick and easy de­ci­sion­mak­ing tool and to help fos­ter im­por­tant dis­cus­sions re­gard­ing treat­ment.

On Feb. 21, the cam­paign re­leased lists from 17 med­i­cal so­ci­eties, in­clud­ing the Amer­i­can Ge­ri­atrics So­ci­ety, the Amer­i­can Academy of Pe­di­atrics and the So­ci­ety for Vas­cu­lar Medicine. When com­bined with lists devel­oped by the first round of nine med­i­cal so­ci­eties un­veiled in April 2012, the 90 new­est ad­di­tions bring the cam­paign’s to­tal num­ber of po­ten­tially un­nec­es­sary tests and pro­ce­dures to 135.

Fif­teen more lists are ex­pected this year, the ABIM Foun­da­tion said.

The cam­paign has avoided many of the pit­falls—in­clud­ing the dreaded ra­tioning la­bel— that have faced pre­vi­ous ef­forts to com­bat in­ap­pro­pri­ate care. In fact, Choos­ing Wisely has proved suc­cess­ful at gal­va­niz­ing sup­port among physi­cian and con­sumer ad­vo­cacy groups. De­spite that en­thu­si­asm, there are some who worry whether the guide­lines are mak­ing it into the hands of physi­cians and pa­tients, and whether the lists are lead­ing to ac­tual changes in clin­i­cal prac­tice.

Choos­ing Wisely’s lat­est round of rec­om­men­da­tions ad­vise against the use of a num­ber of com­mon treat­ments and screen­ings, in­clud­ing rou­tine Pap smear tests for women 30 to 65 years of age, non­med­i­cally in­di­cated in­duc­tions of la­bor be­fore 39 weeks’ ges­ta­tion, an­tibi­otics for treat­ment of vi­ral si­nusi­tis and rou­tine CT scans for chil­dren with mi­nor head in­juries.

The Amer­i­can Academy of Hospice and Pal­lia­tive Medicine was among the or­ga­ni­za­tions that joined the ini­tia­tive last week, re­leas­ing its own list of tests and pro­ce­dures. The group had grap­pled with the de­ci­sion to par­tic­i­pate, par­tic­u­larly given pub­lic mis­con­cep­tions about death pan­els and end-of-life ra­tioning of care, said Dr. Ti­mothy Quill, a pro­fes­sor of medicine at the Univer­sity of Rochester (N.Y.), and the hospice academy’s pres­i­dent.

“We had some hes­i­tancy about get­ting in­volved, but ul­ti­mately, Choos­ing Wisely is at the cen­ter of what we in hospice and pal­lia­tive care do, which is help pa­tients nav­i­gate the health­care sys­tem and make in­formed de­ci­sions about which treat­ments are best,” Quill said.

AAHPM’s list ad­vises against de­lay­ing the involvement of pal­lia­tive care for pa­tients with se­ri­ous ill­nesses who are still seek­ing ag­gres­sive treat­ment for their disease. It also rec­om­mends against the use of feed­ing tubes in pa­tients with ad­vanced de­men­tia.

A list of five wasn’t enough for the Amer­i­can Academy of Fam­ily Physi­cians. Part of the orig­i­nal group of nine so­ci­eties that helped to launch the cam­paign last year, the AAFP also chose to re­lease a sec­ond list this last time around and is sched­uled to re­lease a third list this year.

Dr. Glen Stream, a fam­ily physi­cian in Spokane, Wash., and board chair­man of the AAFP, said the group’s high level of involvement in the cam­paign was due to a num­ber of fac­tors, in­clud­ing the broad scope of fam­ily medicine, the AAFP’s long his­tory of qual­ity im­prove­ment and its view that Choos­ing Wisely was the right ap­proach.

“It’s only been 10 months, but I think the cam­paign is off to a great start in terms of mes­sag­ing to physi­cians and pa­tients,” Stream

said. “It’s a proac­tive stance, driven by the med­i­cal pro­fes­sion, and it really does make con­ver­sa­tions with pa­tients eas­ier.”

Much of the in­spi­ra­tion for Choos­ing Wisely came from a Jan­uary 2010 per­spec­tive piece in the New Eng­land Jour­nal of Medicine, au­thored by Dr. Howard Brody, a med­i­cal ethi­cist and di­rec­tor of the Univer­sity of Texas Med­i­cal Branch’s In­sti­tute for the Med­i­cal Hu­man­i­ties. In the ar­ti­cle, Brody ar­gued that the med­i­cal so­ci­eties needed to step up to the plate on the is­sues of spi­ral­ing costs and overuse.

Three years later, Brody said he ap­plauded many of the as­pects of Choos­ing Wisely, in­clud­ing the level of buy-in from par­tic­i­pat­ing so­ci­eties and the ef­fec­tive­ness of the cam­paign’s mes­sage. “It has clearly struck a chord and res­onated, and that’s ex­cit­ing,” he said.

But he also ex­pressed con­cern that par­tic­i­pat­ing or­ga­ni­za­tions are not ad­her­ing to a rig­or­ous im­ple­men­ta­tion frame­work or col­lect­ing data about whether mem­bers are chang­ing their be­hav­ior, based on the guide­lines.

“Pub­lish­ing the lists is not enough—there needs to be accountability,” Brody said.

Un­like many other med­i­cal so­ci­eties, the Amer­i­can Col­lege of Emer­gency Physi­cians has re­peat­edly voiced reser­va­tions about the cam­paign, de­cid­ing in 2012 not to par­tic­i­pate.

In a May 2012 blog post, ACEP Pres­i­dent Dr. David Se­aberg said emer­gency medicine physi­cians have to “pick up the slack” for other med­i­cal pro­fes­sions and of­ten have lit­tle choice about what tests to or­der. They also rarely have prior pa­tient in­for­ma­tion with which to draw con­clu­sions about med­i­cal ap­pro­pri­ate­ness, he said.

Se­aberg also crit­i­cized the ABIM Foun­da­tion for re­fus­ing “to al­low any dis­cus­sion of li­a­bil­ity re­form as a com­po­nent of the Choos­ing Wisely cam­paign.”

“It is sim­ply not pos­si­ble for emer­gency physi­cians to talk about re­duc­ing ‘un­nec­es­sary’ test­ing with­out in­clud­ing mes­sages about the need for med­i­cal li­a­bil­ity re­form,” he wrote.

The ACEP has since done an about-face, an­nounc­ing on Feb. 20 that it plans to par­tic­i­pate in Choos­ing Wisely. In a blog post about the shift, Se­aberg said an ACEP task force had de­ter­mined that there were el­i­gi­ble tests that “would not in­crease the physi­cian’s li­a­bil­ity and would not neg­a­tively im­pact pay­ments for emer­gency physi­cians.”

Wor­ries per­sist for some emer­gency doc­tors, how­ever.

Dr. Wil­liam Sul­li­van, an emer­gency medicine physi­cian and health­care at­tor­ney based in Frank­fort, Ill., con­tended that a de­crease in tests—even those tests that are deemed to be of­ten un­nec­es­sary—comes with an in­creased risk of missed di­ag­noses. He gave the ex­am­ple of the Amer­i­can Col­lege of Ra­di­ol­ogy’s top-five list, which in­cludes a rec­om­men­da­tion not to im­age for sus­pected pul­monary em­bolism with­out mod­er­ate to high pre-test prob­a­bil­ity.

“Two per­cent of pa­tients who are low-risk will still have a PE,” Sul­li­van said. “And ra­di­ol­o­gists aren’t the ones who face reper­cus­sions if they are missed—we are. I’m a lawyer, and when things go wrong, no one thanks you for sav­ing their money.”

In spite of the con­cerns of Sul­li­van and oth­ers, Dr. Chris­tine Cas­sel, the ABIM Foun­da­tion’s pres­i­dent and CEO, said she has seen min­i­mal physi­cian push­back.

“I really feel like there’s been a col­lec­tive sigh of re­lief on the pro­fes­sional side,” Cas­sel said, adding that par­tic­i­pat­ing so­ci­eties are work­ing to get the mes­sage out to their mem­bers through meet­ings, jour­nal ar­ti­cles and con­tin­u­ing med­i­cal ed­u­ca­tion.

She also said the foun­da­tion has been work­ing with a num­ber of con­sumer-fac­ing

groups, in­clud­ing AARP and Con­sumer Re­ports, to dis­sem­i­nate Choos­ing Wisely’s lists among pa­tients.

“Pa­tients have to feel em­pow­ered to say, ‘Do I really need this test?’ ” Cas­sel said.

One chal­lenge go­ing for­ward, she added, will be to sus­tain mo­men­tum amid ev­er­chang­ing ev­i­dence-based guide­lines and seis­mic shifts in the health­care de­liv­ery sys­tem. “We wel­come that chal­lenge,” she said.

An­other early con­cern of many—that in­sur­ers would use the lists to deny pay­ment—has not oc­curred, said Dr. Robert Wachter, pro­fes­sor and chief of the di­vi­sion of hospi­tal medicine at the Univer­sity of Cal­i­for­nia at San Fran­cisco, and a mem­ber of the ABIM Foun­da­tion’s board of trustees. He ac­knowl­edged that pay­ers are prob­a­bly watch­ing closely, but he gave them credit for stay­ing on the side­lines.

Wachter listed a num­ber of rea­sons why Choos­ing Wisely has likely been so well­re­ceived, in­clud­ing its spon­sor­ship by the ABIM Foun­da­tion, good brand­ing and a care­fully cho­sen name.

“Think about the num­ber of past ef­forts to try to get doc­tors and pa­tients to think about tests and pro­ce­dures,” Wachter said. “We’ve seen very lit­tle trac­tion. Physi­cians were not en­gaged, pa­tients were not en­gaged. But this ef­fort has threaded the nee­dle in an amaz­ing way.”

Front cover photo by Alamy

Dr. Chris­tine Cas­sel, the ABIM Foun­da­tion’s pres­i­dent and CEO, out­lines the de­tails of the Choos­ing Wisely ini­tia­tive at a news con­fer­ence.

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