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?
Explore This IssueACEP 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.
Brandon Maughan, MD, recently published data from a survey of emergency department chairs and division chiefs at institutions with allopathic emergency medicine training programs. Of the 134 programs invited, 78 percent participated in the survey. Of those, 84 percent had heard of the Choosing Wisely campaign, while only 45 percent of the academic chairs had discussed this directly with patients, and approximately 50 percent could recall any of the ACEP recommendations.4
Put Choosing Wisely Into Practice
It’s time to make this campaign relevant by taking it to the bedside, benefiting both patients and providers. Avoiding unnecessary tests and treatments makes the emergency physician’s job easier while providing value-added service for the patient. However, patients may not recognize that “less is more” without education. To that end, shared decision making is an excellent tool that empowers the physician, through bedside education, to align patients’ desires for quality care with the payers’ interest in reducing cost and physicians’ interest in efficiency, achieving everyone’s goal for cost-effective care.
Many physicians struggle with how to introduce these recommendations into clinical practice. However, ACEP and the ABIM Foundation have developed resources to assist. ACEP has committed to translating the ideas of Choosing Wisely into action on several fronts. The recently launched ACEP Clinical Emergency Department Registry includes the development of five quality measures that enable emergency clinicians to report on the quality of imaging decisions to the Centers for Medicare and Medicaid Services for the Physician Quality Reporting System program. ACEP was recently awarded a Transforming Clinical Practice Initiative grant from the Centers for Medicare and Medicaid Innovation to launch a national learning collaborative supporting emergency departments and individual clinicians in implementing these Choosing Wisely recommendations. Under this grant, ACEP will also be offering new eCME modules and partnering with the American Board of Emergency Medicine to integrate more Choosing Wisely topics into the Lifelong Learning and Self-Assessment and Maintenance of Certification practice improvement activities list
Below are several steps that may be useful to incorporate Choosing Wisely into your practice. Let’s take ACEP’s Choosing Wisely recommendation #9 (below), prescribing antibiotics for uncomplicated sinusitis, for example. (It is available online at www.choosingwisely.org/clinician-lists/acep-antibiotics-in-the-ed-for-sinusitis.) Many patients expect to receive antibiotics for “sinusitis.” We have to educate them about their lack of efficacy and give them a reason to not want antibiotics.
Step 1: Plant the seed of your recommendation: “You know, you may not need antibiotics, and they could be harmful to you.”
Step 2: Develop your 30-second monologue explaining Choosing Wisely. For example: “The campaign is designed to provide only valuable treatments for patients based on the current evidence from research. This also helps to avoid injury to patients from treatments they don’t need.”
Step 3: Select one of the seven supporting citations accompanying #9 to support your treatment recommendation. For example: Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;2:CD000243.
Step 4: Take one or two quotes from the article that suggest a lack of efficacy. For example, “There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80 percent of participants treated without antibiotics improved within two weeks.”
Step 5: Select one or two additional reasons the treatment may be harmful. For example:
- Antibiotic resistance is an issue. http://www.cdc.gov/drugresistance/
- Altering one’s individual microbiome may be harmful.
- Ursell LK, Metcalf JL, Parfrey LW, et al. Defining the human microbiome. Nutr Rev. 2012;70(Suppl 1):S38-S44.
Step 6: The safety zone: make a statement open to antibiotic use in the future but confirming you won’t be prescribing any today. For example: “Today it looks like you have a virus, which won’t respond to antibiotics. If you don’t get better, we can always use antibiotics at a later time, when it might be possible that you have a bacterial infection.”
Step 7: Confirm the patient is on board with the plan and document that in your medical record. If they’re still not on board, you may consider writing them a “wait-and-see prescription” (not to be filled unless their symptoms don’t improve by a certain date).
With a little preparation, we can all help translate the recommendations from the Choosing Wisely campaign into practice improvements.
Dr. Klauer is the chief medical officer–emergency medicine and chief risk officer for TeamHealth as well as the executive director of the TeamHealth Patient Safety Organization. He is an assistant clinical professor at Michigan State University College of Osteopathic Medicine and medical editor-in-chief of ACEP Now.
- Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign. Acad Med. 2014;89:990-995.
- Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175:1913-1920. Brownson RC, Kreuter MW, Arrington BA, et al.
- Brownson RC, Kreuter MW, Arrington BA, et al.Translating scientific discoveries into public health action: how can schools of public health move us forward? Public Health Rep. 2006;121(1):97-103
- Maughan BC, Baren JM, Shea JA, et al. Choosing Wisely in emergency medicine: a national survey of emergency medicine academic chairs and division chiefs. Acad Emerg Med. 2015;22:1506-1510.