Curbing overuse

Cardiologist Dr. Blair Erb has a new strategy when patients with known coronary artery disease come to his Bozeman, Mont., office for annual stress tests, which he believes are almost always unnecessary.

In a conversation with each patient—and later, in a note to the referring physician—Erb cites the Choosing Wisely campaign, a multispecialty initiative created to curb overuse of healthcare, which advises against routine stress tests for CAD patients unless there is a change in clinical status.

“We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what's unnecessary.”

Led by the Washington-based ABIM Foundation, the initiative partners with participating medical societies, each of which produces a list of five commonly ordered but usually unnecessary—and sometimes harmful—tests and procedures, based on available evidence. The goal, according to the foundation, is to provide physicians and patients with a quick and easy decisionmaking tool and to help foster important discussions regarding treatment.

On Feb. 21, the campaign released lists from 17 medical societies, including the American Geriatrics Society, the American Academy of Pediatrics and the Society for Vascular Medicine. When combined with lists developed by the first round of nine medical societies unveiled in April 2012, the 90 newest additions bring the campaign's total number of potentially unnecessary tests and procedures to 135.

Fifteen more lists are expected this year, the ABIM Foundation said.

The campaign has avoided many of the pitfalls—including the dreaded rationing label—that have faced previous efforts to combat inappropriate care. In fact, Choosing Wisely has proved successful at galvanizing support among physician and consumer advocacy groups. Despite that enthusiasm, there are some who worry whether the guidelines are making it into the hands of physicians and patients, and whether the lists are leading to actual changes in clinical practice.

Choosing Wisely's latest round of recommendations advise against the use of a number of common treatments and screenings, including routine Pap smear tests for women 30 to 65 years of age, nonmedically indicated inductions of labor before 39 weeks' gestation, antibiotics for treatment of viral sinusitis and routine CT scans for children with minor head injuries.

The American Academy of Hospice and Palliative Medicine was among the organizations that joined the initiative last week, releasing its own list of tests and procedures. The group had grappled with the decision to participate, particularly given public misconceptions about death panels and end-of-life rationing of care, said Dr. Timothy Quill, a professor of medicine at the University of Rochester (N.Y.), and the hospice academy's president.

“We had some hesitancy about getting involved, but ultimately, Choosing Wisely is at the center of what we in hospice and palliative care do, which is help patients navigate the healthcare system and make informed decisions about which treatments are best,” Quill said.

AAHPM's list advises against delaying the involvement of palliative care for patients with serious illnesses who are still seeking aggressive treatment for their disease. It also recommends against the use of feeding tubes in patients with advanced dementia.

A list of five wasn't enough for the American Academy of Family Physicians. Part of the original group of nine societies that helped to launch the campaign last year, the AAFP also chose to release a second list this last time around and is scheduled to release a third list this year.

Dr. Glen Stream, a family physician in Spokane, Wash., and board chairman of the AAFP, said the group's high level of involvement in the campaign was due to a number of factors, including the broad scope of family medicine, the AAFP's long history of quality improvement and its view that Choosing Wisely was the right approach.

“It's only been 10 months, but I think the campaign is off to a great start in terms of messaging to physicians and patients,” Stream said. “It's a proactive stance, driven by the medical profession, and it really does make conversations with patients easier.”

Much of the inspiration for Choosing Wisely came from a January 2010 perspective piece in the New England Journal of Medicine, authored by Dr. Howard Brody, a medical ethicist and director of the University of Texas Medical Branch's Institute for the Medical Humanities. In the article, Brody argued that the medical societies needed to step up to the plate on the issues of spiraling costs and overuse.

Three years later, Brody said he applauded many of the aspects of Choosing Wisely, including the level of buy-in from participating societies and the effectiveness of the campaign's message. “It has clearly struck a chord and resonated, and that's exciting,” he said.

But he also expressed concern that participating organizations are not adhering to a rigorous implementation framework or collecting data about whether members are changing their behavior, based on the guidelines.

“Publishing the lists is not enough—there needs to be accountability,” Brody said.

Unlike many other medical societies, the American College of Emergency Physicians has repeatedly voiced reservations about the campaign, deciding in 2012 not to participate.

In a May 2012 blog post, ACEP President Dr. David Seaberg said emergency medicine physicians have to “pick up the slack” for other medical professions and often have little choice about what tests to order. They also rarely have prior patient information with which to draw conclusions about medical appropriateness, he said.

Seaberg also criticized the ABIM Foundation for refusing “to allow any discussion of liability reform as a component of the Choosing Wisely campaign.”

“It is simply not possible for emergency physicians to talk about reducing 'unnecessary' testing without including messages about the need for medical liability reform,” he wrote.

The ACEP has since done an about-face, announcing on Feb. 20 that it plans to participate in Choosing Wisely. In a blog post about the shift, Seaberg said an ACEP task force had determined that there were eligible tests that “would not increase the physician's liability and would not negatively impact payments for emergency physicians.”

Worries persist for some emergency doctors, however.

Dr. William Sullivan, an emergency medicine physician and healthcare attorney based in Frankfort, Ill., contended that a decrease in tests—even those tests that are deemed to be often unnecessary—comes with an increased risk of missed diagnoses. He gave the example of the American College of Radiology's top-five list, which includes a recommendation not to image for suspected pulmonary embolism without moderate to high pre-test probability.

“Two percent of patients who are low-risk will still have a PE,” Sullivan said. “And radiologists aren't the ones who face repercussions if they are missed—we are. I'm a lawyer, and when things go wrong, no one thanks you for saving their money.”

In spite of the concerns of Sullivan and others, Dr. Christine Cassel, the ABIM Foundation's president and CEO, said she has seen minimal physician pushback.

“I really feel like there's been a collective sigh of relief on the professional side,” Cassel said, adding that participating societies are working to get the message out to their members through meetings, journal articles and continuing medical education.

She also said the foundation has been working with a number of consumer-facing groups, including AARP and Consumer Reports, to disseminate Choosing Wisely's lists among patients.

“Patients have to feel empowered to say, 'Do I really need this test?' ” Cassel said.

One challenge going forward, she added, will be to sustain momentum amid ever-changing evidence-based guidelines and seismic shifts in the healthcare delivery system. “We welcome that challenge,” she said.

Another early concern of many—that insurers would use the lists to deny payment—has not occurred, said Dr. Robert Wachter, professor and chief of the division of hospital medicine at the University of California at San Francisco, and a member of the ABIM Foundation's board of trustees. He acknowledged that payers are probably watching closely, but he gave them credit for staying on the sidelines.

Wachter listed a number of reasons why Choosing Wisely has likely been so well-received, including its sponsorship by the ABIM Foundation, good branding and a carefully chosen name.

“Think about the number of past efforts to try to get doctors and patients to think about tests and procedures,” Wachter said. “We've seen very little traction. Physicians were not engaged, patients were not engaged. But this effort has threaded the needle in an amazing way.”

TAKEAWAY: Provider and consumer groups are rallying around an effort to reduce overuse of healthcare, but some skeptics still question if the initiative is really changing clinical practices.