Re­duc­ing waste­ful care

Re­sults of ‘Choos­ing Wisely’ among docs ques­tioned

Modern Healthcare - - THE WEEK IN HEALTHCARE - Steven Ross John­son

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.

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