Are you “Choosing Wisely” in your professional practice?

Abstract

To enhance the value of care provided to Americans, the American Board of Internal Medicine and Consumer Reports launched the Choosing Wisely Initiative in 2012 to educate providers and patients about high frequency, low value care practices to avoid. ONS recently collaborated with the American Academy of Nursing to add the first-ever nursing-focused list to those previously submitted by over 70 specialty societies.

Most clinical practice guidelines focus recommendations on best practices to be sure to use when providing care to patients. Since 2012, the American Board of Internal Medicine’s (ABIM) “Choosing Wisely” Initiative has worked to help providers understand which outdated care practices they should not offer. Inspired by a challenge issued in an editorial in the New England Journal of Medicine to specialty societies to identify their “Top Five” frequently offered, but low-value services (Brody, 2010), the ABIM Foundation partnered with Consumer Reports to launch “Choosing Wisely.” By offering professional organizations the opportunity to self-identify areas for improved stewardship of finite resources based on their own review of available evidence, the Initiative has steadily grown from participation by nine original specialty societies to include collaborations with over 70 organizations by the end of 2015, and offers resources in both clinician and patient-friendly language, accessible at www.choosingwisely.org.

Recognizing the need

The Robert Wood Johnson Foundation sponsored a telephone-based survey conducted in the winter of 2014 to assess the perceptions of a nationally representative sample of 600 practicing physicians in the United States regarding the potential to reduce overuse of low value services. Almost 75% of respondents noted a serious problem regarding the frequency of unnecessary diagnostic tests or procedures, and 58% felt that they were best positioned to address the problem, compared with 15% of those who believed that responsibility should rest with the government (ABIM Foundation, 2014). Nearly half of the respondents reported that they received a request from a patient at least once a week to order an unnecessary test or procedure. Though 70% of physicians in that position felt that communication with these patients about why the service is not indicated often convinces the patient to withdraw the request, about half reported they would still order the test or service if the patient insisted, despite recognizing it as unnecessary (ABIM Foundation, 2014).

To help counter pressure originating from patients who request low value services, the ABIM has worked with Consumer Reports from the outset of the Initiative to engage and educate patients about how to make evidence-based treatment choices. A key aspect of the Initiative is focused on promoting open communication about the value of medical services, and how providers and patients can jointly evaluate care planning options. The ABIM Foundation worked with Drexel University to create free, interactive, provider-focused modules intended to educate about the Initiative, enhance skills and provide talking points on how to elicit patient concerns and beliefs, provide empathy and overcome barriers when talking with patients about low value care choices. For patients, printable plain language versions of many of the clinician-focused items on the specialty society lists are available, such as “Whole-Body Scans to Screen for Cancer: They don’t help find cancer—and may do more harm than good” (ABIM Foundation, 2015b). Since its inception, the Initiative’s consumer partners have grown to include 34 groups such AARP, Wikipedia and the Leapfrog Group, each charged with disseminating Choosing Wisely information through their networks. In addition, the National Business Coalition on Health developed an Employer Toolkit for business owners to use to educate their employees, especially important as many employer-provided insurance plans move towards higher deductible products, placing a greater financial burden upon patients.

The Initiative in use

Thus far, the Choosing Wisely campaign does not appear to have generated negative publicity regarding care rationing as some other efforts inadvertently have, though the program and its effects are under scrutiny. Morden and colleagues (2014) commented on the Initiative and challenges of specialty societies to determine which practices meet the campaign’s targets of high frequency, low value services, yet do not negatively impact fee for service revenue streams. They noted that many organizations targeted services provided by other specialties as those to be reduced, for example, four of the five recommendations from the American College of Physicians involved avoidance of inappropriate radiology testing. However, the Society for General Internal Medicine was highlighted for recommending avoidance of annual physicals in asymptomatic adults due to lack of evidence illustrating subsequent reductions in morbidity or mortality, and both the American College of Radiology and American Society of Clinical Pathology’s lists focused exclusively on their own specialty services (Morden, Colla, Sequist, & Rosenthal, 2014).

To track early impact of the Initiative, claims data derived from over 25 million members of Anthem Blue Cross and Blue Shield health plans were reviewed to assess changes in utilization since the Choosing Wisely campaign began. Seven low-value services (headache and low back imaging, cardiac testing, human papilloma virus (HPV) testing in young women, preoperative chest X-rays, antibiotics for uncomplicated sinusitis and inappropriate non-steroidal anti-inflammatory drug (NSAID) use) were selected and tracked from 2010 through the end of 2013. Rosenberg et al. (2015) found statistically significant improvements in the frequency of imaging tests for headache (14.9% to 13.4% (trend estimate, 0.99 [95% CI, 0.98–0.99]; P < .001) and cardiac testing for low risk patients (10.8% to 9.7% (trend estimate, 0.99 [95% CI, 0.99–0.99]; P < .001), but noted that clinically, these effects were modest, and due in part to the large sample size in the study. Two items increased significantly in frequency of use; HPV testing rates increased from 4.8% to 6.0% (trend estimate, 1.01 [95% CI, 1.00–1.01]; P < .001), and NSAID use rose from 14.4% to 16.2% (trend estimate, 1.02 [95% CI, 1.01–1.02]; P < .001). The frequency of utilization of other items did not change. The study team concluded that both additional surveillance of trends as well as a wider variety of active implementation efforts aimed at prescribing clinicians are needed to create meaningful practice changes (Rosenberg et al., 2015).

Choosing Wisely in Cancer Care

Several oncology specialty societies have contributed lists to the Initiative, including the American Society of Clinical Oncology, Society of Gynecologic Oncology, American Society for Radiation Oncology, and the Commission on Cancer. Many recommendations focus on appropriate use of cancer screening and other diagnostic tests and procedures, as well as choosing effective anti-cancer therapies based on specific patient and tumor characteristics. ONS recently collaborated with the American Academy of Nursing (AAN) to add the first-ever list of “Ten Things Nurses and Patients should Question” to the Initiative (ABIM Foundation, 2015a). Using evidence from the ONS Putting Evidence into Practice® (ONS PEP) resources, five of the ten AAN items are specific to cancer care. These include:

• Don’t use aloe vera on skin to prevent or treat radiodermatitis.

• Don’t use L-carnitine/acetyl-L-carnitine supplements to prevent or treat symptoms of peripheral neuropathy in patients receiving chemotherapy for treatment of cancer.

• Don’t neglect to advise patients with cancer to get physical activity and exercise during and after treatment to manage fatigue and other symptoms.

• Don’t use mixed medication mouthwash, commonly termed “magic mouthwash,” to prevent or manage cancer treatment-induced oral mucositis.

• Don’t administer supplemental oxygen to relieve dyspnea in patients with cancer who do not have hypoxia.

Items targeted on the Choosing Wisely lists are not necessarily useless, and not every provider who orders them may be choosing poorly. As with any clinical practice guidance, taking some time to review the rationale behind the recommendation, and to understand when a service that is appropriate for one population is not of value to another group makes all the difference. By contributing to the Initiative, the nursing profession has demonstrated one more way we promote meaningful, patient-centered care – it is now up to each of us as individuals to put these recommendations into practice every day.

AT A GLANCE.

• The Choosing Wisely Initiative offers national healthcare specialty organizations the opportunity to recommend low-value practices to avoid to promote high quality patient care.

• Over 70 specialty organizations and more than 30 consumer groups have signed on to develop and disseminate these recommendations.

• Provider and patient education and communication is essential to promote implementation of recommendations across care settings and specialties.