More Value, Less Waste, Shared Decision Making
Quality Feature – December 2012
Tex Med. 2012;108(12):25-29.
By Amy Lynn Sorrel
It was supposed to be a catchy way of challenging the medical profession to step up and lead the charge in reducing waste in the health care system and in defining quality care at the height of the health system reform debate.
Each specialty should come up with its own list of the top five diagnostic tests or treatments that it thinks are overused and have not always shown to benefit patients, wrote family physician and medical ethicist Howard Brody, MD, of The University of Texas Medical Branch Institute for the Medical Humanities, in a 2010 New England Journal of Medicine (NEJM) article.
Dr. Brody's article found a receptive audience. In what ultimately became the "Choosing Wisely" campaign, launched this spring, nine specialty medical societies compiled their lists of 45 tests and procedures. (See "Specialty Societies Identify Overused Procedure.")
Now, the Texas Medical Association is joining other state and national medical societies in considering a partnership of sorts. At TMA’s Fall Conference in October, the TMA Council on Health Care Quality voted to support the campaign. The action awaits final approval by the TMA Board of Trustees.
A recent report from the Institute of Medicine estimates that up to 30 percent of U.S. health care spending goes toward unnecessary tests, procedures, hospital stays, and other inefficiencies.
Often, such services don't benefit patients and in some cases may harm them, says Christine K. Cassel, MD. The Philadelphia internist and geriatric medicine specialist is president and chief executive officer of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, which created Choosing Wisely.
The campaign aims to help patients and physicians weigh the value of various care options. That's a critical step toward not only addressing escalating costs, but also ensuring that patients are getting high-quality care, she says. "This is a way of getting research-based information that's timely and current to both doctors and patients. We haven't actually had a good way of doing that."
Comparative effectiveness and evidence-based research have their place, but patients' eyes tend to glaze over at the sound of such discussions, Dr. Cassel says. By making such information more accessible, "maybe we can change the culture and the mindset that 'more is better,' and once we get out of that mindset, it really becomes more of a question of what is valuable care."
TMA continues to develop educational materials and clinical tools to help physicians answer that question. It is evaluating the Choosing Wisely campaign's potential as yet another vehicle to ready physicians for upcoming quality improvement, patient safety, and performance measurement challenges, says Wichita Falls pathologist Susan M. Strate, MD. She is vice speaker of the TMA House of Delegates and a former member of the TMA Council on Health Care Quality.
"As health system reform catapults ahead, there are a lot of changes coming at doctors like a tsunami, and it's clear that payment in the future is going to be linked more to value, rather than just volume," said Dr. Strate, who also serves on the Texas Institute of Health Care Quality and Efficiency Board of Directors. The governor-appointed board was established by a 2011 state law to improve health care quality in the state through methods such as care coordination models, quality measures, and data collection.
Quality and cost initiatives tied to forthcoming system changes must be physician-led, and the Choosing Wisely campaign appears to have cleared that important hurdle, she says.
"Physicians are uniquely capable of determining what's best for the patient. They are the ones with the most expertise on quality and should be leading that effort. These [Choosing Wisely] lists have been vetted and approved by doctors, and it sets up an opportunity for doctors and patients to really look at some of these treatments and dialogue about them," Dr. Strate said.
Prompted by Dr. Brody's NEJM article, the National Physicians Alliance (NPA) was the first to publish a list of overused tests and procedures in primary care – internal medicine, family medicine, and pediatrics, specifically – to help physicians promote more effective use of health care resources.
The ABIM Foundation also wanted as many medical specialties as possible to run with the idea. And they did so voluntarily, Dr. Cassel noted.
The American Medical Association also supports the campaign. The medical specialty societies who participated in developing the Choosing Wisely recommendations are members of the AMA-convened Physician Consortium for Performance Improvement. TMA also participates in the workgroup.
The lists run the gamut, but all of the recommendations start with or include "don't" or "should not" or "avoid." They include:
- Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days or symptoms worsen after initial clinical improvement.
- Don't obtain imaging studies in patients with nonspecific low back pain.
- Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in patients with hypertension or heart failure or chronic kidney disease of all causes, including diabetes.
- For a patient with functional abdominal pain syndrome, computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
- Don't perform positron emission tomography (PET), CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
Dr. Cassel says the listed services are not meant to be absolutes, rather guidelines, adding that they include indications or flags for when something may be appropriate. The lists are described as "things whose necessity should be questioned and discussed" between physicians and patients.
"The goal here is not to say, 'You should never have any of these tests or treatments, but to say "You should have a conversation with your doctor about it.' This is to get those conversations going," she said.
The lists emerged from a consensus-building process among workgroups within each specialty. They looked at factors such as the strength of the medical evidence available to evaluate a particular service, the frequency of use, the economic impact, the effect on health care quality, and the ease of implementation of a recommendation.
The NPA project formed the basis for the American Academy of Family Physician's (AAFP's) "Top Five" recommendations. The organization is working will develop five more by the end of the year, says AAFP president and Spokane, Wash., family physician Glen R. Stream, MD.
The idea was to target what he characterized as the low-hanging fruit, things that have strong scientific backing. The AAFP-approved recommendations limiting Pap smears and dual-energy x-ray absorptiometry (DEXA) scans, for example, were derived, in part, from U.S. Preventive Services Task Force guidelines, whereas those related to antibiotics and imaging use draw on independent research within the field.
Several factors may contribute to misuse of medical tests and procedures, Dr. Stream says. They include patient expectations, physician habits, a dearth of guidelines in some cases, or an overabundance of emerging medical evidence in others that is simply too much for doctors to track.
"But most of these recommendations are not news to people," he said. "The reason to focus on them is they remain commonly done, despite common knowledge that they are frequently unnecessary. And a lot of that is due to physicians' perception of what patients want or demand that they believe is in their best interest, but is quite often not."
Low back pain, for example, is a top complaint physicians hear. Yet in a vast majority of cases, the cause is hard to identify, and imaging does not offer a better idea of how to treat it than does a physical examination. That test could add not only unnecessary expense, but also unnecessary x-ray exposure.
Dr. Stream says Choosing Wisely is "as much a patient safety initiative as anything else."
At the same time, because it is ultimately patients' health at stake, the campaign recognizes that they, too, must be actively engaged in the decision-making process.
Choosing Wisely partnered with well-known consumer groups like Consumer Reports, for example, which is charged with translating and presenting the medical lists in ways that patients can understand and making them available in easy-to-read brochures, consumer publications, and on various websites, including Wikipedia.
Having information like these lists in advance or at the point of care can help ease those discussions if both doctors and patients have the same information, Dr. Stream says. "This tells your patients that you really are doing the best possible thing for them, and you are caring more and practicing good medicine, instead of the reverse."
Anything that gets physicians and patients to discuss the best treatment "without the government, or insurance companies, or attorneys dictating what's to be done is a very good thing, and this campaign does that," Dr. Strate said. More patient responsibility also could translate to less liability for doctors, she added.
Staying on Target
But physicians also remain wary that the lists themselves may be misused.
Doctors don't want to see the lists used to set a liability standard, for example, for following or not following the recommendations, Dr. Strate says. Nor do they want them to add any complexity to physicians' practices, when time already is scarce and administrative costs are climbing.
Physicians can't have every office visit turn into what Dr. Strate described as a medical economics lesson, where every time the patient comes in, doctors have to go through the cost of every single option. That's where health insurance plans can contribute, she says, by making information on patients' out-of-pocket costs more readily available.
Physicians also are casting a sharp eye on insurers' response to these lists.
While the guidelines are not meant to represent absolutes, doctors are concerned that payers, commercial or government, could interpret them that way and use the language to refuse preauthorization for certain tests or treatments or deny payment altogether.
So far, no health plan has ventured to do so, and the ABIM Foundation and professional medical organizations behind the lists are adamant that insurers shouldn't use them that way.
Nevertheless, it remains a concern.
Dr. Strate likened the scenario to inappropriate efforts by insurers to use administrative claims data for quality and payment purposes, when that data does not tell the whole story.
"If, for example, only half of your patients who need mammograms get them, that doesn't say you are a bad doctor. There may be other social or economic reasons patients did not do it. Every patient is unique. Quality care is about good clinical judgment, and nothing should supplant that. Period."
Dr. Cassel agrees and says that the campaign's goal is not cookie-cutter medicine. "It's the opposite. Every one of these treatment decisions needs to be made on an individual basis. But not every individual needs it."
Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Specialty Societies Identify Overused Procedures
As part of the Choosing Wisely campaign, nine specialty medical societies compiled their lists of 45 tests and procedures and identified five diagnostic tests or treatments they think are overused and have not always shown to benefit patients. Those specialties societies are:
- American Academy of Allergy, Asthma & Immunology,
- American Academy of Family Physicians,
- American College of Cardiology,
- American College of Physicians,
- American College of Radiology,
- American Gastroenterological Association,
- American Society of Clinical Oncology,
- American Society of Nephrology, and
- American Society of Nuclear Cardiology.
Another 20 specialty societies are expected to release their lists by early next year. Among them are the American Academy of Hospice and Palliative Medicine, the American Academy of Otolaryngology-Head and Neck Surgery, the American College of Rheumatology, the American Geriatrics Society, the American Society for Clinical Pathology, the American Society of Echocardiography, the Society of Hospital Medicine; and the Society of Nuclear Medicine.
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To Do or Not to Do?
Nine physician specialty societies, and more to come, joined the Choosing Wisely campaign in identifying their "Top Five" commonly used tests and procedures they say are often unnecessary. A sampling of the recommendations is below.
Patients can see consumer-friendly versions of the latest lists online.
- Don't order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis. (American Academy of Allergy, Asthma & Immunology)
- Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. (American Academy of Family Physicians)
- Don't perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. (American College of Cardiology)
- Don't obtain imaging studies in patients with nonspecific low back pain. (American College of Physicians)
- Don't do imaging for uncomplicated headache. (American College of Radiology)
- For pharmacological treatment of patients with gastroesophageal reflux disease, long-term acid suppression therapy (proton pump inhibitors or histamine 2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals. (American Gastroenterological Association)
- Don't use cancer-directed therapy for solid tumor patients with these characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment. (American Society of Clinical Oncology)
- Don't perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. (American Society of Nephrology)