Good Medicine: Choosing What to Do and What Not to Do.

The Choosing Wisely® campaign was launched in 2012 by the ABIM Foundation to encourage patients and clinicians to think about the tests and treatment choices they are implementing or requesting, and to avoid those tests that have proven to be overused and inappropriate.

Over the past three years, this initiative has engaged nearly 100 national and state medical specialty societies, regional health collaborative and consumer organizations. These organizations have identified more than 300 tests and procedures that must be scrutinized for their efficacy and efficiency before they are ordered.

In the Commonwealth of MA, Massachusetts Health Quality Partners (MHQP) is leading a multi-stakeholder effort to advance the Choosing Wisely campaign.

“The Massachusetts health care environment provides a fertile ground for Choosing Wisely to take hold,” said Barbra G. Rabson, executive director of MHQP. ” As a Commonwealth, we have made it a priority to find ways to achieve high quality and affordable care  Choosing Wisely is another step in that direction.”

The Choosing Wisely Massachusetts Campaign:
• Engages providers to integrate Choosing Wisely recommendations and materials in their practice.
• Engages patients and families to use Choosing Wisely consumer materials to become better informed about the decisions and choices they need to make about their health and health care.
• Identifies ways to engage providers and patients to better communicate in using Choosing Wisely materials.

Dr. Paul Hattis, Massachusetts Health Policy Commissioner and public health professor at Tufts University Medical School stated in an interview that patients typically do not challenge their doctors. “They usually accept the advice that their clinicians offer.  So empowering and engaging patients to filter their choices takes education to help them better understand the consequences of their decisions,” he said.

There are five key questions developed by Consumer Reports, a partner in the Choosing Wisely campaign, that patients and clinicians need to answer before tests and procedures that have become automatic and standard are ordered. These questions include:
1. Do I really need this test or procedure?
2. What are the risks?
3. Are there simple safer options?
4. What happens if I don’t do anything? Will my condition get worse or better if I wait?
5. How much does it cost? Are there less expensive equally effective ways to treat this problem?

The following are examples of common health problems where there has been a tendency to rush to tests, when studies and data indicate there are other considerations to be taken into account.
Low Back Pain

It has long been thought that the treatment of low back pain should begin with life-style modification, with imaging deployed when other avenues of treatment have been exhausted. In 2012, Atrius Health, one of the MHQP partners formally began studying practice data on the use of imaging tests for acute low back pain. They conducted site-by-site clinical meetings to review guidelines on imaging use; and shared the findings from the analysis.

Based on the Choosing Wisely recommendations from the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP), Atrius health distributed patient materials developed by Consumer Reports Health to educate patients and to open up a dialogue between patients and their clinicians regarding low back pain and the use of imaging tests. The Atrius Health approach helps to guide conversations with patients in productive ways – to reassure them that their pain is not concerning and to allow adequate time to discuss at-home and other treatments that help the patient make a safe recovery.

Atrius Health consists of four leading community-based groups who joined together to form a non-profit alliance, for the delivery of health care in Eastern Massachusetts. These medical groups serve 675,000 adult and pediatric patients in over 2.2 million visits annually to 42 practice locations and include more than 750 physicians and a total of almost 6,800 employees.

Pap Tests

New guidelines released just one month ago from The American College of Obstetricians and Gynecologists (ACOG) – and supported by The American Cancer Society – indicate that most women only need a Pap test, which screens for cervical cancer, every 3 to 5 years, rather than annually.   Two decades of research with conclusive proof that certain high-risk strains of HPV cause cervical cancer has reinforced how this disease is transmitted; how few infected women actually develop cancer; and how slowly this cancer progresses.

Additionally, the technique for collecting and analyzing cervical cells for the Pap test has improved.  As a result of this new knowledge, it is advised that a safe option for women is to get regular, but less frequent, Pap tests, unless they have certain risk factors and health issues, regardless of age.  These risk factors include women who have HIV/AIDS, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, or have been treated for cervical intraepithelial neoplasia (CIN) or cervical cancer.

The American Academy of Nursing (AAN), an organization dedicated to advancing health policy and practice, has also adopted the Choosing Wisely mantra. In most settings, nurses spend more time with patients than other clinicians. This positions nurses to have conversations with the patients about the best practices that promote health and healing. The AAN has issued several cautions that nurses routinely encounter that are often avoidable and unnecessary.  Among these are:

• Don’t automatically initiate electronic fetal heart rate monitoring for low-risk women during labor.  Evidence does not support routine use of continuous monitoring among women with low-risk pregnancies.  Such monitoring has been associated with an increase in cesarean and instrumental births, without an associated improvement in perinatal outcomes.
• Don’t let older adults lie in bed or only get up into a chair during their hospital stay.  Walking while in the hospital is critical for maintaining functional ability. Evidence shows a lack of walking increases the length of hospital stays and the need for rehabilitation services while elevating the risk of falling after being discharged.
• Don’t wake patients from sleep for routine care unless the patient’s condition or care specifically requires it.  There is a long-standing perception that patient safety requires patient assessment and monitoring at pre-determined intervals around the clock.  Studies, however, show that sleep deprivation negatively affects cognitive function, the ability to perform physical activities and ventilator, circulatory, immunologic, hormonal and metabolic stability.
• Don’t place or maintain a urinary catheter in a patient unless there is a specific reason for doing so.  Catheter-associated urinary tract infections are among the most common healthcare-associated infections in the U.S. and most are related to the use of urinary catheters.

There are United States health care provider organizations representing more than one million providers who have developed lists of Things Physicians and Providers Should Question in recognition of the importance of conversations to improve care and eliminate unnecessary tests and procedures. These lists represent specific, evidence-based recommendations providers and patients should discuss together in order to make wise decisions about the most appropriate care, based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.

Many challenges lie ahead for the Choosing Wisely agenda, not the least of which is convincing all stakeholders that reducing unnecessary tests frees up needed health resources without compromising patient outcomes. Additionally, making the leap from publication to practice and turning these recommendations into action will involve the collective support of patients, clinicians, payers and other healthcare professionals. MHQP and Choosing Wisely Massachusetts have aggressively taken this to the next level.

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