In 2012, the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports formally launched the Choosing Wisely campaign in order to reduce the utilization of diagnostic tests and treatments that provide no meaningful benefit to patients.1 After widespread acceptance in the house of medicine and many consumer groups and with expansion of the program internationally, the question remains, is this just a “feel-good program,” or will this program have any true impact on utilization?
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ACEP Now: Vol 35 – No 02 – February 2016
Despite the success of raising awareness and gaining buy-in for this program, the early data suggest that little impact has been made in curbing utilization in the areas noted in the 70 lists containing approximately 400 recommendations.2 Emergency medicine is no exception. ACEP was cautious yet agreed to participate and provided a total of 10 recommendations. However, it seems that this simply isn’t enough. Choosing Wisely and its participating specialty societies have been talking the talk, but now it’s time to walk the walk.
Although garnering widespread support for this program must have had its challenges, it seems the real challenges lie ahead. Just like any practice update, simply knowing what is right is very different from incorporating that information into clinical practice. When you ask physicians to “choose wisely” and those choices include changing the way they practice and interact with their patients, you’ve reached the crossroads of knowing and doing. In other words, knowledge translation is where the rubber hits the road and where Choosing Wisely may have blown a tire.
To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications. —Louis Pasteur
Pasteur’s quote, cited in a 2006 article about knowledge translation, defines exactly what Choosing Wisely aspires to be. The article further defined translation as to “synthesize research findings and convert them into a form applicable to a target population or audience in the context of the conditions in which its members live and interact.” Brownson and colleagues reported an average of 17 years for 14 percent of original “discovery” to actually reach practice.3
Can we wait 17 years to implement these recommendations? I doubt it. This campaign provides an opportunity to remedy overutilization, which is largely under our control. Failing to bring these recommendations to the bedside will only result in additional well-intentioned, but ill-informed, bureaucratic intervention to reduce spending on health care in the United States.
Choosing Wisely in Action—or Not
In a study published in October 2015, 25 million members of Anthem-affiliated BlueCross and BlueShield plans were assessed over a two- to three-year period through 2013. Medical and pharmacy claims were assessed for the following seven Choosing Wisely recommendations2:
- Imaging tests for uncomplicated headache
- Cardiac imaging without history of cardiac conditions
- Low back pain imaging without red-flag conditions
- Preoperative chest X-rays with unremarkable history and physical examination results
- Human papillomavirus (HPV) testing for women younger than 30 years
- Use of antibiotics for acute sinusitis
- Use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease
The first two, imaging for headache and cardiac imaging, showed a small decline from 14.9 percent to 13.4 percent and 10.8 percent to 9.7 percent, respectively. Two recommendations, prescribing NSAIDs for certain conditions and HPV testing for women younger than 30 years, showed increased utilization. Antibiotics for sinusitis remained stable, while preoperative chest X-rays and imaging for low back pain remained high without a statistically significant change.2 The data cannot confirm a cause-and-effect relationship, and with such a large sample size, the small changes noted could simply be due to chance. However, it certainly suggests that more work is needed to ensure that providers are actively engaged with this campaign. Although two of these recommendations, antibiotics for sinusitis and imaging for low back pain, have also been submitted by ACEP, much of the data sample precedes ACEP’s involvement. Even if we evaluated utilization following ACEP’s submissions, should we expect different results? I don’t think so. It has been difficult for all involved to move the knowledge translation needle for Choosing Wisely.
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5 Responses to “Emergency Physicians Should Put Choosing Wisely Recommendations Into Action”
March 13, 2016
AliseWithout tort reform choosing wisely are just empty words. Nobody is rewarded for ordering less. Start from the beginning..if choosing wisely was accompanied by incentives that didn’t conflict with the rewards of the current system perhaps it would be more successful.
March 13, 2016
William Fisher, MDYou guys just don’t get it. Choosing wisely is a euphemism for saying “help decrease the cost of medical care and be liable for any of your mistakes.” Without tort reform that gives me complete protection if I follow choosing wisely and safe harbor guidelines, I do not intend to modify my practice in any way. I’ll say it again, I will not participate in any program that increases my medical liability. When legislation is passed that says I cannot be sued if I follow choosing wisely or Safe Harbor guidelines, I will be happy to modify my practice.
March 13, 2016
Jerry W. Jones, MD FACEPIn order to implement these recommendations, every physician or healthcare provider must feel assured that he/she isn’t missing a red flag or overlooking a finding that would indeed indicate the utilization of one of these tests. However, in order to achieve this degree of assurance, one must perform a good history and physical examination. That doesn’t happen nowadays.
The “history” consists of a few perfunctory questions asked from a computer template that often has little association with the top two or three conditions in the patient’s differential diagnosis. It is typically acquired without the physician ever looking at the patient and without giving the patient an opportunity to interject a comment.
The physical exam – if done at all – consists of a “stethoscope tap” in which the diaphragm of the scope is placed on the right and left upper chest for less than one second in each location – and the “belly pat,” in which one hand is placed on the patient’s abdomen – usually with the patient fully-clothed, without even indenting the contour of the abdomen. In fact, you can find more and more physicians who pride themselves on NOT doing a physical examination, claiming that a physical exam is a dinosaur and no longer pertinent in a digital, technologically-advanced world. I recently attended a symposium in which a number of speakers actually mocked physicians who still do physical exams.
Thus, the only way left nowadays for many physicians to feel “assured” that they are not missing a “red flag” is to order an abundance of unnecessary tests that would have been obviated by a decent history and physical examination.
March 13, 2016
Freda Lozanoff DO FACEPThe patients who come to the ER want tests, not a dissertation on why they are not necessary. This is the mind set. Every survey has shown that more tests, even negative, generate better evaluations and insure your job.
March 13, 2016
joelDr Klauer
I enjoyed reading your article and agree!
For me, the challenge remains how to we not give a patient what he/she wants (regardless of need!) and still obtain 5/5 on our patient satisfaction scores?
Patients expect antibiotics for everything and new exciting scans and tests even if the onset of the symptoms is exactly 5 minutes longer than their door to provider time. We expect them to pay a ridiculous copay in credit card or cash at the time they are seen. (My employer’s plan has a $250 copay for every ED visit.) Then we “refuse” to give them what they want and we expect them to be happy for it and give us positive reviews? I have worked in several large EM groups and have heard numerous clinicians state they have dramatically increased their patient satisfaction scores by 1. ordering every scan patients want and 2. giving patients any prescription they want regardless of indication, medical necessity or need.
For many years providers were able to tell patients “this is not in your best interest and can even be detrimental to your health” “studies have shown . . . . ” when discussing tests, treatments, scans and prescriptions. “No ma’am your child does not need a CT scan of his head after being shot in the head with a Nerf gun from across the room his risk of cancer from the scan FAR outweighs any potential benefit.” You can explain and produce research until the cows come home, but mom is in the ED to get a CT scan and sending her home without it leads to an unsatisfied patient experience, resulting in patient complaints, poor satisfaction scores and directly effects both your income and the income of your employing institution.
My family went out to eat last night. If the server had refused to serve the food I ordered because I am expanding at the waist line and hundreds of studies and years of research had shown this particular dish to be detrimental to my health, I likely would have refused to pay the bill, skipped the tip and posted something unflattering on a web site reviewing that establishment. Lets be honest most patients are not in the ED to hear about what is best for them or what a study shows, patients are in the ED to get what they want. And if they don’t they will be unsatisfied with their visit, period. If IV Vancomycin “cured my sniffles in 30 seconds flat last time I was here,” then they expect IV Vancomycin at every visit for those complaints.
Until this issue is resolved providers will read articles like this nod their heads in agreement and then sadly ignore these recommendations in favor of income and employment security.
Respectfully yours,
Joel