Reining in care

It seems a fairly basic concept: If the information provided by a diagnostic test is unlikely to change a patient's treatment plan, then physicians should think twice before ordering it.

It's the idea driving the American Board of Internal Medicine Foundation-led Choosing Wisely campaign in which nine specialty societies—representing about 375,000 physicians—have each identified five commonly ordered tests or procedures “for which the use should be re-evaluated by patients and clinicians,” wrote Dr. Christine Cassel, president and CEO of the ABIM Foundation, and James Guest, president and CEO of Consumer Reports, in an article published in the Journal of the American Medical Association.

The article notes that, with “looming government deficits,” there are areas of healthcare spending that do not contribute to the health of an individual patient or a collective community, but “the polarizing political environment makes it difficult to conduct rational public discussions about this issue.” While rational public discussion is desired, the ABIM Foundation is moving to avoid using another “R” word. “Rationing is where you withhold beneficial care—this is the opposite,” said Daniel Wolfson, ABIM Foundation executive vice president and chief operating officer, adding that the “five things” lists each specialty society has developed are not to be considered “never events,” but tools to be used only when the evidence suggests they will provide useful information or lead to a positive outcome. “What we're asking for is for people to have a conversation,” he added. “If we use our resources well, we'll have enough for everybody.”

To further avoid the rationing argument, the campaign has not calculated what the savings might be to the healthcare system if its advice is followed. “Other people will make those calculations,” Wolfson said. “We don't intend to.”

The campaign has its roots in the National Physicians Alliance's Good Stewardship Project, which announced last October that if the “Top 5” list of recommendations for family practice, internal medicine and pediatrics were followed, there would be annual savings of $6.76 billion. Most of the savings ($5.8 billion) would be generated by the use of generic statin drugs for cholesterol-lowering treatment instead of brand-name drugs.

One organization objected to the “blanket recommendation” for women under 65 and men younger than 70 to skip bone-density testing. According to the American Society for Bone and Mineral Research, only 20% of women 67 or older who had an osteoporosis-related fracture had a bone-density test or a prescription to treat osteoporosis in the six months after their fracture. The society also noted that treating bone fractures for the 2 million Americans with osteoporosis costs $19 billion a year.

Wolfson said the campaign is not making blanket recommendations. “These are not rules; they are guidelines used to guide most—but not all—cases,” he said.

Dr. Rakesh Patel, an independent family physician in the Phoenix suburb of Gilbert, Ariz., agreed and called the Choosing Wisely campaign something that was “long overdue” and that, if a physician objects to the campaign's objectives and methods, he or she needs to do more research and also realize the changing nature of the profession. “These guidelines are based on science,” he said.

Patel added that “the art of medicine is different from the science,” and involves developing treatments for patients whose conditions don't fall neatly into guidelines and models. “If we practice wisely, we can still incorporate that art of medicine into everything we do,” he said.

The important message behind Choosing Wisely is to discuss options, risks and benefits with patients, Patel said. Under his practice model—a “private membership” model that provides more personal service for an additional fee—he can do that. But he wondered if other physicians who need to see more than 30 patients a day to keep their practices viable have the time to have those discussions.