Leading the Charge

Texas Physicians Are Choosing Wisely

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Quality Feature — August 2014

Tex Med. 2014;110(8):45-59. 

By Amy Lynn Sorrel
Associate Editor

When Fort Worth gastroenterologist Monte E. Troutman, DO, first heard about Choosing Wisely, it immediately changed his thinking.  

"I've been a big advocate of colorectal cancer screening my whole career, and remarkably, over the past 10 years, we've seen a dramatic decrease in the incidence of colon cancer because of aggressive screening, most noticeably colonoscopy," he said. "But there's still about 45 percent of the population who should get screened and do not. And while a lot of people say we are doing a good job, unfortunately, we may be overdoing [screenings] for the people who are already adherent to the guidelines." 

That's why Dr. Troutman chooses to focus on the American Gastroenterological Association's colorectal cancer screening guidelines not to repeat screenings for certain individuals within a certain period of time. 

The goal of the national Choosing Wisely campaign is to improve quality and reduce waste by getting physicians and patients talking about medical tests and procedures that may be unnecessary and possibly harmful. Texas physicians aim to keep the conversation going. 

So far, more than 60 national medical specialty societies have joined the initiative to identify and create lists of the top five tests and procedures they say are overused or inappropriate. (See "Three Steps to Start Choosing Wisely.")  

Dr. Troutman's patients often ask him about when they need a colonoscopy but, more often, when they can stop the screenings. Those questions open the door for physicians to not only discuss the Choosing Wisely recommendations with their patients but to also consider them in their own practice, Dr. Troutman says. 

Not all polyps are created equal, yet "a lot of times patients will come in and say, 'I had polyps.' Then you really need to get the colonoscopy and pathology reports" to find out if another test is needed, he said. "That information doesn't come to you. You and your staff have to take the time to ask, 'Where did you have it done?' and try to track it down." 

Dr. Troutman acknowledges that's not always possible, and the conversation might take a few extra minutes. But he says it's in patients' best interest that physicians attempt the extra steps instead of defaulting to another test. "Sometimes the best thing to do — and the hardest thing to do — for the patient is nothing, other than offer advice. Put the pen and prescription pad away. Sometimes when we do too much, there are consequences and risks for doing procedures if they are harmful and not necessary."

Dr. Troutman also agrees that it's probably more difficult to talk patients out of unnecessary antibiotics than colonoscopies. "You would be surprised how receptive patients are when you tell them, 'You don't need to have a colonoscopy done.'" But mostly, patients just want an explanation, he finds. "Then it doesn't take much convincing."

As a medical educator, the associate professor at the University of North Texas Health Science Center also informally incorporates the Choosing Wisely resources into resident and fellow training. He refers them to videos offering scripts to help guide physicians through a patient conversation over an unnecessary test or drug. Medical education may be changing, but "one thing we [physicians] are taught from day one is to 'first do no harm.' So maybe we should change it to 'first do no harm by choosing wisely,'" he said. 

At TexMed 2014 in May, the Texas Medical Association's Council on Health Care Quality led a continuing medical education track to educate physicians on the program, and Texas Medicine spoke to Dr. Troutman and some of the other physician panelists and participants about the recommendations they've chosen to focus on, how they are incorporating the guidelines into daily practice, and their experiences so far. 

You, too, can get on board, starting with a suite of Choosing Wisely educational tools and videos TMA developed thanks to a grant from the program's creator, the American Board of Internal Medicine (ABIM) Foundation, through the TMA Foundation. Support for the program comes from the Robert Wood Johnson Foundation. 

As the campaign gains momentum and factors into other quality improvement initiatives — including those considered by the Texas Institute of Health Care Quality and Efficiency — TMA leaders say Choosing Wisely offers physicians an opportunity to lead the charge. 

Stewarding the Health Care Dollar

Regardless of physicians' medical specialty, Lubbock emergency physician Gerad Troutman, MD, says there's something for everyone among the 300 evidence-based recommendations of the Choosing Wisely program.

The medical director of University Medical Center's Emergency Medical Services (EMS) and Lubbock Fire Rescue noticed one of the American College of Emergency Physicians (ACEP) guidelines coincides with what happens to be a national shortage of saline. He emailed his staff about incorporating the guideline to "avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children."

"In staff training, we talked about the fact that in EMS, we are in the habit of starting an IV and hanging a liter of saline on everyone, when the literature does not support this habit," particularly for children, he said. "So we agreed as we move forward to stop and think about whether patients need the saline, and if they have normal vital signs, let's not waste a bag of saline on them. A simple IV with saline lock can be used instead."

Already, the vigilance paid off. Dr. Troutman compared saline usage during a recent three-month period of implementing Choosing Wisely to the same three-month period a year ago and discovered a 25-percent decrease. "If we start thinking about that nationally, and not just Lubbock, that's a huge difference. And we should be stewards of the health care dollar."

Dr. Troutman is implementing another ACEP guideline aimed at getting hospice services to certain emergency patients sooner. Sometimes those with end- or late-stage cancer, for example, have never had an end-of-life discussion with a health care professional or don't understand their options. 

"A lot of people don't have that education. Sometimes when I bring up hospice to patients, they roll their eyes and think you are sending them home to die," he said.

So Dr. Troutman's team revisited with their hospice partners and tweaked certain protocols so that they now post hospice phone numbers in the emergency department for staff to use for referrals. This allows emergency patients to connect with hospice services sooner. 

"It's something that's always been available, but [Choosing Wisely] brought it back up again and reminded us of it," the member of TMA's Committee on EMS & Trauma said. The initiative doesn't cost anything more than "a little doctor time or effort. But hospital time and time in the emergency department are much more costly."

Changing the Conversation

In primary care, Keller family physician Gregory M. Fuller, MD, often sees respiratory infections like sinusitis and bronchitis, mostly uncomplicated cases. He and his colleagues at North Hills Family Medicine commonly get requests for antibiotics from patients who may be used to receiving the drugs elsewhere, even though they are not warranted.

Given the prevalence of antibiotic prescriptions, Choosing Wisely guidelines from roughly a dozen medical specialty societies caution against overuse of the drugs for mildly or nonsymptomatic patients or for nonbacterial infections, for example. 

For Dr. Fuller, "choosing wisely" means engaging patients in discussions over their own care and educating them about why antibiotics or other treatments aren't always the answer. By sparking that conversation, he also hopes to change it.

"I try to teach my patients what is appropriate use of an antibiotic. Not why aren't you prescribing an antibiotic, but why are you prescribing an antibiotic?" the TMA Council on Health Care Quality member said.

That education starts with what Dr. Fuller describes as a "frank" conversation with his patients about side effects and antibiotic resistance, for example. He also uses the terms "virus" or "viral" frequently in conversation when explaining why prescribing the drug won't make a difference with a viral infection and will end up wasting money. 

Physicians have a responsibility to examine their own activities, which Dr. Fuller says is an important part of improving quality of care. But taking additional steps to engage and inform patients "takes quality medical care to the next level so they can have a conversation with their physician. And hopefully that conversation will be the patient asking, 'Why are you doing this?' and not, 'Why aren't you?'"

Improving Care

When the faculty and residents at Wichita Falls Family Medicine Residency Program saw an uptick in what appeared to be external ear infections, they decided to visit recently updated guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) on proper treatment for acute otitis externa (AOE). Those guidelines call for use of topical versus systemic antibiotics and analgesics in the treatment of uncomplicated AOE. 

That's when faculty member Tania Khan, MD, and her fellow educators wondered whether residents were confusing the condition with other types of ear infections and unnecessarily prescribing certain medications. They also noticed the AAO-HNSF guidelines coincided with similar Choosing Wisely recommendations from the medical specialty society urging against prescribing oral antibiotics for uncomplicated AOE.  

Dr. Khan said the campaign helped call the practice's attention to something "we just didn't pay attention to before. This [AOE] sometimes gets confused with middle ear infection because that's the most common diagnosis. And you mostly see it in pediatrics," versus a family medicine practice like hers. 

To get a better grasp on treatment patterns within the practice, the faculty tasked residents with conducting a chart review. A key finding revealed slightly more than one-third of 23 patients seen for uncomplicated AOE between 2009 and 2014 received systemic rather than topical antibiotics. 

The data prompted a research project the residents launched to improve care within the practice. 

The plan includes:  

  • Collaborating with local family medicine, otolaryngology, and pediatric groups to collect more data on treatment patterns related to AOE;
  • Conducting a physician education campaign that includes creating a separate template to standardize treatment protocols for AOE and distributing Choosing Wisely and AAO-HNSF recommendations and practice guidelines; and 
  • Reevaluating compliance after three months. 

Dr. Khan and her residents shared the project at TMA's second annual Quality Poster Session at TexMed 2014 in May. Past Wichita Falls Family Medicine residents conducted a similar research project with foot care for diabetic patients and saw immediate care improvements, she says.

This time, residents hope their project "will not only improve treatment of AOE but will also demonstrate the effectiveness of employing the Choosing Wisely campaign in physician education," the poster states. 


One of the main reasons Choosing Wisely has attracted widespread participation is that the campaign is physician-driven, says ABIM Board Chair David H. Johnson, MD, a Dallas oncologist. 

"Instead of third-party entities like insurance companies or Medicare saying, 'Doctors must do this or can't do that,' these are recommendations that physicians are saying, 'We know by virtue of our daily practice and scientific literature that these [treatments or tests] are of low value.' And because we [physicians] are experts, we ought to be able to participate in a proactive way in controlling cost and reducing harm," Dr. Johnson said. 

Not only does the campaign allow physicians to have meaningful conversation with their patients, but it also adds gravitas to those discussions because it's not a single physician telling a single patient that a particular test or drug is not warranted, Dr. Johnson adds. Rather, it's practicing physicians working with their medical specialty societies, consumer organizations, and more recently nursing and other health professional groups, which all agree with the evidence-based recommendations. 

Physicians have room to be creative in how they incorporate the guidelines into daily practice, he adds. Some health systems integrate them into their electronic medical record system such that an alert pops up at the point of service.  

As chair of the Department of Internal Medicine at The University of Texas Southwestern Medical Center in Dallas, Dr. Johnson helped distribute the Choosing Wisely lists to each of the center's specialty department chairs to help guide physicians' decisionmaking. He also charged the school's new chief resident for quality improvement and patient safety with evaluating before-and-after outcomes in one clinic based on the recommendations for reducing testing in patients with back pain, for example.

As the campaign evolves, so do the recommendations. 

When the initiative launched in 2012, the original recommendations were what Dr. Johnson called "mostly low-hanging fruit — things most physicians would know are of minimal value. For example, a preoperative EKG in a patient without a known heart problem — most doctors know that's not something you should do."  

By contrast, more recent recommendations made by the American Society for Radiation Oncology took the "bold" step of advising against proton beam therapy to treat prostate cancer, says Dr. Johnson, who subspecializes in oncology. "There are only a dozen or so places in the United States that have proton beam therapy units. Now that Medicare reimburses at a high rate for [the therapy], suddenly everybody wants to build a new facility and use it. But the truth is, with the exception of certain childhood cancers, it has not proved to be any better than standard linear accelerators. And there are not enough kids with cancer in the country to treat with the ones already built."

Going forward, still other "more stringent" recommendations likely will call on physicians to consider the most cost-effective treatment among equally effective options, he says. The American Society of Clinical Oncology, for example, one of the Choosing Wisely founding partners, recently announced it will integrate cost information into its clinical guidelines. 

Choosing Wisely "is really capturing an energy within the medical community to say in a more constructive way, 'We are the experts. We should help society decide what can be reasonably avoided,' versus just proscribing or prescribing," Dr. Johnson said. "After all, this is about our patients."

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.


Three Steps to Start Choosing Wisely

The Choosing Wisely campaign is a no-cost initiative that promotes conversations among physicians and patients about the need, or lack thereof, for many commonly ordered tests or treatments.

Here's how to get started:  

  • Visit the TMA website to search the lists of evidence-based recommendations from national specialty medical societies. Look for guidelines that pertain to your practice, keeping in mind that some specialties, such as primary care, could cross into other areas, says TMA Council on Health Care Quality member Gregory M. Fuller, MD. Because the family physician often sees heart patients, for example, he also peruses the American College of Cardiology list.
  • Start with guidelines that relate to the conditions you see most often in your practice. The more than 300 Choosing Wisely recommendations can be overwhelming, Dr. Fuller says. "So pick three areas to work on, and once you become entrenched in doing that, look at doing others."
  • Take advantage of the numerous resources provided by Choosing Wisely and TMA, including videos, patient materials, and a list of TMA partners in Texas.  

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