WASHINGTON -- The "Choosing Wisely" initiative has done a lot to change the culture around performing unnecessary procedures, but there is still a long way to go, several speakers said Tuesday at a briefing sponsored by Health Affairs.
"I am impressed by the uptake and growth of 'Choosing Wisely' in just 5 years," said Eve Kerr, MD, professor of internal medicine at the University of Michigan in Ann Arbor. "It has allowed us to tap into our professionalism and say, 'This is really important.' But there is still much work to do."
The regarding "death panels" in Medicare made any discussions about reducing care more difficult, recalled Richard Baron, MD, president and CEO of the American Board of Internal Medicine (ABIM). "Once that was out there, there were some conversations you just couldn't have," he said. "Physicians were flummoxed; how do you take this on?"
In the meantime, conversations about how to reduce waste in the healthcare system were continuing, and in 2012, the ABIM debuted "Choosing Wisely," asking specialty groups to produce a list of five tests or procedures that may be overutilized. There were four rules that the groups had to follow, said Baron:
- It needed to be in their discipline
- It needed to have an impact -- that is, it had to be a test or procedure that was very expensive or performed a lot
- It needed to have evidence that it was being done too much
- There needed to be a transparent process for choosing each item
"Here we are 5 years later; today, 80 [medical] societies have lent their intellectual capital to thinking about this," Baron said. "How do we judge success? We go back to the idea that this is about supporting people having difficult conversations ... [and] health systems around the country are using this as a structure to have these conversations."
Eric Wei, MD, interim chief quality officer for Los Angeles County and the USC Medical Center in Los Angeles described how his organization used the program to focus on three areas: reducing pre-operative testing for cataract surgery, reducing inappropriate imaging for lower back pain, and reducing the use of antibiotics for upper respiratory infections.
In the cataract surgery area, the medical center recruited attending residents to serve as "champions" for the initiative, and they explained that although cataract surgery patients were undergoing a full panel of tests beforehand -- including x-rays and EKGs -- "not once did pre-operative testing change the ultimate management of the cataracts," Wei said.
After the initiative, the medical center saw an 80% decrease in pre-operative visits for cataract surgery and an 80% drop in pre-operative EKGs, he said. Not only that, "the median wait time for surgery dropped from 245 days to 64 days, so [patients had] 6 more months of improved vision."
Kellie Slate Vitcavage, program director for consumer engagement at Maine Quality Counts, a group focused on improving healthcare quality, said her organization decided to focus on decreasing the use of unneeded antibiotics. They used visuals to get the "Choosing Wisely" message out on this topic, including 3 foot-by-5-foot posters in waiting rooms and exam rooms. "We need these in the emergency room and we need them in walk-in clinics where people can be confronted with the cultural message. That's where we started putting things up."
"Last year, we started noticing a huge difference with patients," she said. They would say, "I understand that I don't need an antibiotic, but I'm just coming in to make sure everything is okay." The group also created a "flu care package" as a way of telling patients that they wanted them to feel better even if they weren't being dispensed antibiotics.
Often, what patients really want is reassurance, said Arthur Hong, an assistant professor at the University of Texas Southwestern Medical Center in Dallas. "I was seeing a patient who had come in for acute back pain; a few minutes in, he lets it slip that he's a radiologist," Hong said. "He says, 'I know the evidence on imaging shows it doesn't improve pain' -- [I figured out that] this guy's asking me if he can have imaging for his back pain. He's in such excruciating pain that he just wants something done."
Instead, Hong told the patient that in addition to the ibuprofen he was taking, he should add acetaminophen; Hong also recommended physical therapy. "I approached him like a [regular] patient, saying, 'Here's why we do imaging and here's what reassures me [that you don't need it]; if anything changes, we can change our management'" of your case. That approach worked well, Hong said.
Two common objections Hong hears when people talk about reducing unnecessary imaging are "the malpractice boogeyman and the idea that patients demand imaging, which is its own feedback loop. We need to talk to patients about how it's not that more care is better, but that the right care is the best."
Neel Shah, MD, MPP, founder and executive director of Costs of Care, a consulting group aimed at helping health systems provide quality care at lower cost, said that "health systems are set up where patients can be hurt in two ways: when we do too little, too late, and when we do too much, too soon." For a long time, "there were blind spots" to the latter problem, he said.
"Every case conference we had [during medical training] was about things that were exceedingly rare, and we reward people for findings things that are exceedingly rare. We'd be chastised for not doing the things we could have done, but never for doing something we didn't have to do."
In the end, "the big force driving health policy in this country ... turns out to be about money," said Michael Chernew, PhD, professor of health care policy at Harvard Medical School in Boston. "What's nice about 'Choosing Wisely' is that it brings together ways to save money and improve health."