Reducing wasteful care
Results of ‘Choosing Wisely’ among docs questioned
As more of the country’s physician specialty societies join the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, questions still remain about how effective it has been in getting doctors to stop ordering services of questionable medical value.
What began in April 2012 with nine medical organizations has since expanded to include 50 groups, each producing an evidence-based list of the top five tests or procedures in their specialty area that are overused and potentially harmful.
The “Choosing Wisely” campaign recently announced that more than 30 national medical societies will release their lists of unnecessary services beginning in September, marking the third round of recommendations. Among the groups slated to present lists for the first time is the American College of Emergency Physicians, which declined to participate in the campaign last year citing the need to address changes in the medical liability system.
“We’re presenting things that we think are valuable that will save money, that we should have conversations with patients about, and that we will change behavior with and make progress,” ACEP President Dr. Andrew Sama said. ACEP will release its first list Oct. 14.
Sama said he hoped the “Choosing Wisely” campaign’s recommendations would lead to stronger quality measures and movement toward legal protections from malpractice lawsuits for physicians who follow the guidelines.
Since its launch, “Choosing Wisely” has presented 130 recommendations for procedures and tests that should first be questioned and discussed before they are performed. The recommendations include not performing CT scans for routine evaluations of abdominal pain in children, and avoiding dual-energy X-ray absorptiometry screening for osteoporosis in women younger than 65 or in men younger than 70 who don’t have any risk factors.
For some physician groups, the campaign has led to clinical practice changes as doctors have begun implementing the recommendations. Dr. Marylou Buyse, chief medical director of the Scott & White Health Plan, said her group began in the spring to use 15 recommendations as part of the group’s monthly evaluations of its physicians.
“We don’t have penalties right now (for noncompliance) because we don’t think that’s the way to deal with this,” Buyse said. “We give doctors feedback about where they are in following these methods and let them know if they are average, whether their practice is being noncompliant or whether they doing really well.”
Experts believe that such efforts to get doctors to stop ordering tests, procedures and other services that aren’t shown by research data to be effective are badly needed to control U.S. healthcare spending. Some have estimated that 30% of spending is wasteful. But many physicians have long decried moves to cut back on services as rationing and interference with their professional judgment and autonomy. And there have been public backlashes to other efforts to limit testing, such as the U.S. Preventive Services Task Force guideline that women be screened less frequently for breast cancer.
“I think the intent (of ‘Choosing Wisely’) is good, but I think that we really have to question the unintended consequences of some of the recommendations,” said Dr. William Sullivan, an emergency medicine physician and attorney who has been an outspoken critic of the campaign. “We have to be careful when we label something as being unnecessary that we make sure the general public realizes that just because something has a low yield doesn’t necessarily mean that it’s unnecessary.”
While the campaign has clearly raised awareness about the issue of overutilization, many physician specialty organizations that present recommendations do not track how many of their own members follow the guidelines.
Dr. Audrey Uknis, president of the American College of Rheumatology, said the campaign coincided with work her organization was already doing in developing quality-ofcare standards. Since most rheumatologists already accepted the recommendations listed in “Choosing Wisely” as common practice, her organization intended its list for physicians outside the field of rheumatology who handle rheumatology-related patient issues.
“We would like to help them understand what the appropriate standard for a rheumatology patient is so regardless of what kind of doctor the patient may see, that standard remains the same,” she said. To that end, Uknis said her organization plans to conduct education programs to help physicians understand the impact of performing unnecessary procedures and tests.
Uknis said her organization has not collected data on how many of its members follow the “Choosing Wisely” guidelines. She noted, however, that physician feedback was used to help determine what services were deemed overused, which played a role toward the organization developing its recommendations. She added that the campaign has thus far been well received by members who have
expressed mostly positive feedback about the recommendations.
Dr. Howard Brody, director of the University of Texas Medical Branch’s Institute for the Medical Humanities, has questioned how medical specialty groups plan to ensure their members follow the “Choosing Wisely” recommendations. He argued that more needs to be done to hold doctors accountable.
“I think it’s definitely a good first step, but there’s certainly a follow-up that’s needed if it’s going to live up to its promise,” said Brody, whose January 2010 opinion piece in the New England Journal of Medicine was the inspiration behind the campaign.
“The question obviously is if you’re a society that has come up with this list, and you say here are five things that we should stop doing because they don’t bring any benefit to patients, what are you going to do as an organization to get your members not to do these things anymore?” he said.
Dr. Wells Shoemaker, medical director for the California Association of Physician Groups, said trying to enforce the recommendations would unjustly penalize doctors who may at times be forced to disregard the guidelines because of the circumstances of a particular case. He argued that the campaign’s primary focus should be education.
“Guidelines are ideally going to work for 85% to 95% of the situations where you apply them,” Shoemaker said. “There will always be individual circumstances that a doctor needs to take into account.”
ABIM Foundation Executive Vice President Daniel Wolfson said education will continue to be the focus of “Choosing Wisely.” In April, the foundation awarded grants to 21 state medical associations, specialty societies and regional health collaboratives for projects that promote the campaign’s recommendations among their member physicians. Funded by the Robert Wood Johnson Foundation, the program is scheduled to run through March 2015.
Some of the projects, such as the one involving grantee Better Health Greater Cleveland, will use the funding to integrate “Choosing Wisely” within its physician training programs. According to the campaign’s website, training methods will include the creation of education videos for doctors and consumers, dissemination of the recommendations through electronic health records and the creation of a website.
“People who are interested in moving away from volume to value are interested in this campaign,” Wolfson said.
Among the “Choosing Wisely” recommendations is not performing CT scans for routine evaluations of abdominal pain in children.