Choosing Wisely

Logo for the campaign

Choosing Wisely is a United States-based health educational campaign, led by the ABIM Foundation. It seeks to improve doctor–patient relationships and promote patient-centered care by informing patients and physicians about overutilization of medical resources.[1]

The campaign attempts to reduce medical burdens by compiling a very large list of treatments which have been questioned. The campaign encourages doctors and patients to discuss, research, and possibly get second opinions, before proceeding with these treatments. To conduct the campaign, a coordinator from ABIM Foundation asks medical specialty professional organizations to make five recommendations for preventing overuse of a treatment in their field. Distributors then share this information with community groups nationwide, and the medical specialty societies disseminate it to their members. The intent is that patients and doctors will research and discuss the recommendations in these lists, believing that if patients and doctors communicate with each other more effectively when making health decisions, patients will have better outcomes and the medical system itself will benefit.

The campaign follows a history of proposals for both increasing doctor-patient communication and reducing waste in health care. Most commentators confirm the existence of avoidable waste in the health care system. Proponents[2][3][4][5] of the campaign say that it is a uniquely broad and much-needed effort.

Motivation

The Choosing Wisely campaign presents the following background and narrative to explain its motivation: The cost of health care in the United States is considered by some to not be very affordable.[6] According to the Organisation for Economic Co-operation and Development, the United States spends more than 20 times what comparable countries spend per person on healthcare.[7] Some analysts have proposed that identifying and eliminating waste in health care would result in significant savings for the health care system and reduced costs for employers, though without analyzing indirect effects of raising costs elsewhere.[8] A 2005 study by the National Academy of Sciences argued that 30% of the health care spending in the United States was wasteful and subsequent research has supported this finding.[9][10] Some reports indicate that countries comparable to the United States are able to provide better health care to more people while consuming fewer medical resources.[11] Reducing the cost of health care would make it accessible to more people.[12]

One of the identified causes of the waste in the health care system is a lack of communication between doctors and patients. The decisions of physicians account for most of a patient's expenses, yet physicians work under various pressures including limited time to talk with patients and review their information.[13][14] Patients sometimes make requests for treatment against their doctor's advice in cases where more effective choices would be made if doctors had time to consult expert medical opinion.[15]

The campaign has been described as an attempt to encourage doctors and patients to recognize the illusion of control or "therapeutic illusion" in choices to use treatments which have a basis outside of evidence-based medicine.[16]

History

In 2002 the ABIM Foundation published Medical professionalism in the new millennium: a Physician Charter.[1][17] The charter states that physicians have a responsibility to promote health equity when some health resources are scarce.[1] As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members.[1][18][19] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists".[1][20][21] Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.[1][20][22]

Continuing this project, Choosing Wisely was created to organise the creation of more "lists of five" and their distribution to more physicians and patients.[1][23] Physicians participate by joining their specialty society in identifying practices which their field may overuse, and engaging their patients in conversations aimed at reducing unnecessary care, and hence reduce healthcare costs.[1] Each recommendation in the program must have the support of clinical guidelines, evidence, or expert opinion.[1]

Campaign

To participate in Choosing Wisely, each society developed list of five tests, treatments, or services which that specialty commonly overuses.[1] The society shares this information with their members, as well as organizations who can publicize to local community groups, and in each community patients and doctors can consider the information as they like.[1]

The campaign has been criticized by the former head of the Texas Medical Association, Dr. Bob Lanier M.D. In his article, "Think Twice Before Choosing Wisely".[24] He believes that the campaign does not follow standards of practice or research, is biased against diagnostic testing, and is an effort by supporters of single-payer healthcare to reduce costs so that single-payer healthcare becomes affordable.

As of April 2018, there were 552 recommendations targeting a range of procedures to either question or avoid without special consideration.[25] They can be searched online by key words, such as "back pain" but the numerous supporting footnotes with evidence for each recommendation are only in a pdf on the clinician page, without links to the papers.[26] Since most papers are behind paywalls, links to free copies on researchers' sites are particularly important.[27] [28]

Examples

Some examples of the information shared in Choosing Wisely include the following:

  • Acknowledge that physicians are increasing their use of diagnostic procedures without a proportional increase in patient outcomes. Consider the effects of overuse of diagnostic services.[29]
  • Physicians overuse radiography services. In many cases this fails to improve patient outcomes. This also subjects patients to unnecessary ionizing radiation and the possibility of further unnecessary testing.[30]
  • Before the 39th week of pregnancy, doctors should not perform a Caesarean section or induce labor unless medically necessary.[31]

Difficulties

The Choosing Wisely campaign identifies the following difficulties in achieving its goals:

  • In communicating with patients a major challenge in the campaign is the problem inherent in patient-centered care of giving patients some basis for understanding how to make decisions about their health care.[32] Many recommendations in the campaign require clinical education to understand fully.[32] Also many patients tend to follow the recommendations of their physicians without question, even if they have questions.[32]
  • The United States medical system is based on a fee-for-service model, in which doctors are paid on the basis of ordering individual tests and procedures, so that most doctors will not get paid when they do not recommend (or recommend against) a given treatment.[32] This system creates incentives for doctors to recommend additional treatments, rather than exercising evidence-based restraint.[32]
  • Critics tend to view efforts to reduce medical services as "healthcare rationing in the United States".[32] Since doctors do not want to be seen as withholding care, they are hesitant to change established behavior in any way that lessens the amount of treatment they order.[32][33][34] Doctors say that they often feel pressure to engage in defensive medicine by conducting extra testing to avoid lawsuits.[35]

Reception

Many of the leading medical societies in the United States are participating in the campaign as partners and in that way have demonstrated their support.

The New York Times said that the campaign was likely to "alter treatment standards in hospitals and doctors' offices nationwide" and one of their opinion writers found that many tests were unnecessary.[2][3] CBS News said that "the evidence is on the initiative's side."[4] USA Today noted that the campaign was "a rare coordinated effort among multiple medical societies".[5] A Vogue reviewer said that Choosing Wisely was a counter to defensive medicine practices by doctors and a counter to patients who demand extra procedures without understanding the risks involved.[36] In February 2013 the Robert Wood Johnson Foundation provided USD $2.5 million in funding for the campaign, saying that the foundation wanted to "help increase the tangible impact of the Choosing Wisely campaign".[37]

However, Robert Goldbert, for The American Spectator, criticized the program saying that it was "designed to sustain the rationale and ideology that shaped Obamacare" (the Patient Protection and Affordable Care Act), that the lists were "redundant and highly subjective", and that participants in the effort would greedily benefit at the expense of others if the campaign succeeded.[38] A related critique is that considering cost as a basis for making health care decisions is not ideal.[39]

While expressing the need for evidence-based healthcare recommendations, The Economist found the Choosing Wisely recommendations to be weak because they are not enforceable.[40] In an editorial published in the Southwest Journal of Pulmonary and Critical Care, Richard Robbin and Allen Thomas express concern that the campaign could be used by payers to limit options for doctors and patients. However, they declare the Choosing Wisely recommendations a "welcome start."[41]

Critics in the Southwest Journal of Pulmonary & Critical Care said, "the present Choosing Wisely campaign has fundamental flaws—not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship."[42]

A study reported that some patients and physicians find it challenging to use Choosing Wisely recommendations.[43]

Impact

The Choosing Wisely campaign makes no provision to scientifically research its own efficacy, but academic centers are making plans to independently report on the impact of the campaign.[44] The campaign has been cited as being part of a broader movement including many comparable campaigns.[45] The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system.[46] In April 2014, Choosing Wisely Canada launched.[47] Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs.[48]

By 2015 and following the Choosing Wisely precedent established in the United States, health leaders from Australia, Canada, Denmark, England, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, and Wales committed to bring ideas from the Choosing Wisely and sometimes even the actual campaign itself into their own countries.[49]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 Cassel, C. A.; Guest, J. A. (2012). "Choosing Wisely - Helping Physicians and Patients Make Smart Decisions About Their Care". JAMA: The Journal of the American Medical Association. 307 (17): 1801–1802. doi:10.1001/jama.2012.476. PMID 22492759.
  2. 1 2 Rabin, Roni Caryn (April 4, 2012). "Doctor Panels Urge Fewer Routine Tests - NYTimes.com". The New York Times. New York: NYTC. ISSN 0362-4331. Retrieved 10 October 2012.
  3. 1 2 Rosenthal, Elisabeth (2 June 2012). "Let's (Not) Get Physicals". The New York Times. New York: NYTC. ISSN 0362-4331. Retrieved 16 October 2012.
  4. 1 2 Jaslow, Ryan (April 4, 2012). "Doctors unveil 'Choosing Wisely' campaign to cut unnecessary medical tests". CBS News. New York: CBS. Retrieved 10 October 2012.
  5. 1 2 Hellmich, Nanci (4 April 2012). "Coalition of medical societies urges questioning treatments". USA Today. McLean, VA: Gannett. ISSN 0734-7456. Retrieved 15 October 2012.
  6. ↑
    • Rosenbaum, L.; Lamas, D. (2012). "Cents and Sensitivity — Teaching Physicians to Think about Costs". New England Journal of Medicine. 367 (2): 99–101. doi:10.1056/NEJMp1205634. PMID 22784112.
    • Kravitz, R. L. (2012). "Cost-Containment Redux: Time for Physicians to Engage". Journal of General Internal Medicine. 27 (9): 1093–1094. doi:10.1007/s11606-012-2148-8. PMC 3514992. PMID 22790616.
  7. ↑ Levey, Noam N. (20 February 2013). "Doctors list overused medical treatments". Los Angeles Times. Los Angeles: Tribune Co. ISSN 0458-3035. Retrieved 22 February 2013.
  8. ↑ Hackbarth, A. D. (2012). "Eliminating Waste in US Health Care". JAMA: The Journal of the American Medical Association. 307 (14): 1513–1516. doi:10.1001/jama.2012.362.
  9. ↑ Reid, Proctor P.; Compton, W. Dale; Grossman, Jerome H.; Fanjiang, Gary (2005). Building a better delivery system : a new engineering/health care partnership. Washington, D.C.: National Academies Press. ISBN 978-0-309-09643-0.
  10. ↑ Vastag, Brian (4 April 2012). "Doctors groups call for end to unnecessary procedures". The Washington Post. Washington DC: WPC. ISSN 0190-8286. Retrieved 15 October 2012.
  11. ↑ Davis, Karen; Schoen, Cathy; Stremikis, Kristof (June 2010). Mirror, Mirror on the Wall - How the Performance of the U.S. Health Care System Compares Internationally - 2010 Update (PDF) (Report). Commonwealth Fund. Retrieved 18 October 2012. Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries
  12. ↑ Redberg, R. F. (2012). "Getting to Best Care at Lower Cost<alt-title>Getting to Best Care at Lower Cost</alt-title>". Archives of Internal Medicine. 173 (2): 91–2. doi:10.1001/jamainternmed.2013.1271. PMID 22961503.
  13. ↑ Detsky, A. S. (2012). "A New Model for Medical Education: Celebrating Restraint". JAMA: The Journal of the American Medical Association. 308 (13): 1329–1330. doi:10.1001/2012.jama.11869. PMID 23032547.
  14. ↑ Crosson, F. J. (April 27, 2009). "Change the Microenvironment". Commonwealth Fund and Modern Healthcare. Retrieved 24 October 2012.
  15. ↑ Brett, A. S. (2012). "Addressing Requests by Patients for Nonbeneficial Interventions". JAMA: The Journal of the American Medical Association. 307 (2): 149–150. doi:10.1001/jama.2011.1999. PMID 22235082.
  16. ↑ Casarett, David (31 March 2016). "The Science of Choosing Wisely — Overcoming the Therapeutic Illusion". New England Journal of Medicine. 374 (13): 1203–1205. doi:10.1056/NEJMp1516803. PMID 27028909.
  17. ↑ American Board of Internal Medicine; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine (2002). "Medical professionalism in the new millennium: A physician charter". Annals of Internal Medicine. 136 (3): 243–246. doi:10.7326/0003-4819-136-3-200202050-00012. PMID 11827500.
  18. ↑ Brody, H. (2010). "Medicine's Ethical Responsibility for Health Care Reform — the Top Five List". New England Journal of Medicine. 362 (4): 283–285. doi:10.1056/NEJMp0911423. PMID 20032315.
  19. ↑ Brody, H. (2012). "From an Ethics of Rationing to an Ethics of Waste Avoidance". New England Journal of Medicine. 366 (21): 1949–1951. doi:10.1056/NEJMp1203365. PMID 22551106.
  20. 1 2 Kuehn, B. M. (2012). "Movement to Promote Good Stewardship of Medical Resources Gains Momentum". JAMA: The Journal of the American Medical Association. 307 (9): 895–903. doi:10.1001/jama.2012.218. PMID 22396505.
  21. ↑ Good Stewardship Working, G. (2011). "The "Top 5" Lists in Primary Care - Meeting the Responsibility of Professionalism". Archives of Internal Medicine. 171 (15): 1385–1390. doi:10.1001/archinternmed.2011.231. PMID 21606090.
  22. ↑ Kale, M. S.; Bishop, T. F.; Federman, A. D.; Keyhani, S. (2011). ""Top 5" Lists Top $5 Billion". Archives of Internal Medicine. 171 (20): 1856–1858. doi:10.1001/archinternmed.2011.501. PMID 21965814.
  23. ↑ Dismuke, S. E.; Miller, S. T. (2013). ""Choosing wisely"--medicine's ethical responsibility for Healthcare Reform. The top five list". Tennessee medicine : journal of the Tennessee Medical Association. 106 (5): 23–26. PMID 23691867.
  24. ↑ "Think Twice Before Choosing Wisely". www.texmed.org. March 2015. Retrieved 2018-05-22.
  25. ↑ "Search Recommendations". www.choosingwisely.org. Retrieved 2018-04-20.
  26. ↑ "All Choosing Wisely Recommendations" (PDF). Retrieved 2018-04-20.
  27. ↑ Matthews, David (7 April 2016). "Do academic social networks share academics' interests?". Times Higher Education. Retrieved 2016-04-22.
  28. ↑ "Online collaboration: Scientists and the social network". Nature. 13 August 2014. Retrieved 2014-11-06.
  29. ↑
    • Graber, M. L. (2012). "Bringing Diagnosis into the Quality and Safety Equations - Bringing Diagnosis into Quality and Safety Efforts". JAMA: The Journal of the American Medical Association. 308 (12): 1211–1212. doi:10.1001/2012.jama.11913.
    • Emanuel, E.; Tanden, N.; Altman, S.; Armstrong, S.; Berwick, D.; De Brantes, F. O.; Calsyn, M.; Chernew, M.; Colmers, J.; Cutler, D.; Daschle, T.; Egerman, P.; Kocher, B.; Milstein, A.; Oshima Lee, E.; Podesta, J. D.; Reinhardt, U.; Rosenthal, M.; Sharfstein, J.; Shortell, S.; Stern, A.; Orszag, P. R.; Spiro, T. (2012). "A Systemic Approach to Containing Health Care Spending". New England Journal of Medicine. 367 (10): 949–954. doi:10.1056/NEJMsb1205901. PMID 22852883.
  30. ↑
    • Quinn, K. (2012). "Reducing Radiology Use on an Inpatient Medical Service: Choosing Wisely". Archives of Internal Medicine. 172: 1606–8. doi:10.1001/archinternmed.2012.4293. PMID 22928182.
    • Forman, H. P.; Larson, D. B.; Kazerooni, E. A.; Norbash, A.; Crowe, J. K.; Javitt, M. C.; Beauchamp, N. J.; Mendelson, E. B. (2012). "Masters of Radiology Panel Discussion: Hyperefficient Radiology—Can We Maintain the Pace?". American Journal of Roentgenology. 199 (4): 838–843. doi:10.2214/AJR.12.9648. PMID 22997376.
  31. ↑ Szabo, Liz (22 February 2013). "Doctors group says some tests should be used sparingly". USA Today. McLean, VA: Gannett. ISSN 0734-7456. Retrieved 22 February 2013.
  32. 1 2 3 4 5 6 7 Volpp, K. G.; Loewenstein, George; Asch, David A. (2012). "Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing". JAMA: The Journal of the American Medical Association. 308 (16): 1635–1636. doi:10.1001/jama.2012.13616. PMC 3994996. PMID 23093160.
  33. ↑ Bloche, M. G. (2012). "Beyond the "R Word"? Medicine's New Frugality". New England Journal of Medicine. 366 (21): 1951–1953. doi:10.1056/NEJMp1203521. PMID 22551108.
  34. ↑
    • Berry, Emily (16 April 2012). "'Choosing Wisely' list is about good judgment, not curtailing care, medical societies say". ama-assn.org. Retrieved 18 January 2013.
    • Knox, Richard (4 April 2012). "Doctors Urge Their Colleagues To Quit Doing Worthless Tests". npr.org. Retrieved 18 January 2013.
    • Aliferis, Lisa (April 5, 2012). "Please, Don't Call It Rationing". blogs.kqed.org. Retrieved 18 January 2013.
  35. ↑
    • Emanuel, E.; Tanden, N.; Altman, S.; Armstrong, S.; Berwick, D.; De Brantes, F. O.; Calsyn, M.; Chernew, M.; Colmers, J.; Cutler, D.; Daschle, T.; Egerman, P.; Kocher, B.; Milstein, A.; Oshima Lee, E.; Podesta, J. D.; Reinhardt, U.; Rosenthal, M.; Sharfstein, J.; Shortell, S.; Stern, A.; Orszag, P. R.; Spiro, T. (2012). "A Systemic Approach to Containing Health Care Spending". New England Journal of Medicine. 367 (10): 949–954. doi:10.1056/NEJMsb1205901. PMID 22852883.
    • Katz, David (9 April 2012). "Choosing (Medicine) Wisely: Good Answers for Good Questions". The Huffington Post. Retrieved 24 October 2012.
    • Badri, M. (2012). "Wise but Difficult Choices". Southern Medical Journal. 105 (9): 491–492. doi:10.1097/SMJ.0b013e31826418a5.
  36. ↑ Dunn, Jancee (November 2012). "Inside Scan". Vogue: 204–205.
  37. ↑ Quote taken from Forbes.
    • Japsen, Bruce (21 February 2013). "Doctors Call Out 90 More Unnecessary Medical Tests, Procedures - Forbes". forbes.com. Retrieved 22 February 2013.
    • "Leading Medical Specialty Societies Identify 90 Tests and Treatments to Question | 2013 News | ABIM Foundation". abimfoundation.org. 21 February 2013. Retrieved 22 February 2013.
    • "Advancing the Choosing Wisely campaign to build awareness about the importance of avoiding unnecessary medical care - Robert Wood Johnson Foundation". rwjf.org. 13 December 2012. Retrieved 22 February 2013.
  38. ↑ Goldberg, Robert M. (13 April 2012). "Obamacare's Medical Mercenaries". The American Spectator. Retrieved 16 October 2012.
  39. ↑ Boer, M. -J.; Wall, E. E. (2012). "Choosing wisely or beyond the guidelines". Netherlands Heart Journal. 21 (1): 1–2. doi:10.1007/s12471-012-0352-0. PMC 3528861. PMID 23203730.
  40. ↑ "Evaluating medical treatments: Evidence, shmevidence". economist.com. 16 June 2012. Retrieved 16 October 2012.
  41. ↑ Robbins, Richard A.; Allen R. Thomas (2012). "Will Fewer Tests Improve Healthcare or Profits?". Southwest Journal of Pulmonary and Critical Care. 4: 111–113. Retrieved 10 October 2012.
  42. ↑ Robbins, Richard A.; Thomas, Allen R. (4 June 2013). "Choosing Wisely-Where Is the Choice?". Southwest Journal of Pulmonary & Critical Care. Retrieved 19 November 2013.
  43. ↑ Zikmund-Fisher, BJ; Kullgren, JT; Fagerlin, A; Klamerus, ML; Bernstein, SJ; Kerr, EA (February 2017). "Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers". Journal of General Internal Medicine. 32 (2): 210–217. doi:10.1007/s11606-016-3853-5. PMC 5264674. PMID 27599491.
  44. ↑ Wang, Shirley S. (20 February 2013). "Group Urges Health-Test Curbs". The Wall Street Journal. New York: Dow Jones. ISSN 0099-9660. Retrieved 22 February 2013.
  45. ↑ Tiefer, L.; Witczak, K.; Heath, I. (2013). "A call to challenge the "Selling of Sickness"". BMJ. 346: f2809. doi:10.1136/bmj.f2809. PMID 23674139.
  46. ↑ Strech, Daniel (30 May 2013). "Eine Choosing Wisely Initiative für Deutschland?". Informationsdienst Wissenschaft (in German). Retrieved 7 June 2013.
  47. ↑ http://www.cmaj.ca/content/186/8/E239.full?sid=ffcd5fbf-46e3-46b6-b068-45459c989ceb
  48. ↑ Morden, N. E.; Colla, C. H.; Sequist, T. D.; Rosenthal, M. B. (2014). "Choosing Wisely — the Politics and Economics of Labeling Low-Value Services". New England Journal of Medicine. 370: 140122140218007. doi:10.1056/NEJMp1314965. PMC 4104300. PMID 24450859.
  49. ↑ Levinson, W.; Kallewaard, M.; Bhatia, R. S.; Wolfson, D.; Shortt, S.; Kerr, E. A.; Burgers, J.; Cucic, C.; Daniels, M.; Forde, I.; Geerlings, S.; Gogol, M.; Haverkamp, M.; Henderson, A.; Howson, H.; Huynh, T.; Kievit, J.; Klemperer, D.; Koizumi, S.; Lindner, R.; Maughan, D.; McDonald, K.; Peul, W.; Post, H.; Rodondi, N.; Santa, J.; Schoeler, R.; Smid, H.; Stephenson, T.; Trier, H.; van Barneveld, T.; van der Kraan, J.; Vernero, S.; Wagner, C. (2014). "'Choosing Wisely': a growing international campaign". BMJ Quality & Safety. 24 (2): 167–174. doi:10.1136/bmjqs-2014-003821. ISSN 2044-5415.

Further reading

  • Roehr, B. (2012). "US specialties list five tests and treatments that doctors and patients can safely avoid". BMJ. 344: e2601. doi:10.1136/bmj.e2601. PMID 22495568.
  • Kuehn, B. M. (2012). "Materials Educate Patients to Make Wise Choices on Tests and Procedures". JAMA: The Journal of the American Medical Association. 307 (21): 2245–2246. doi:10.1001/jama.2012.5341. PMID 22706814.
  • Wolfson, D. B. (2012). "Are the Top 5 Recommendations Enough to Improve Clinical Practice? Comment on "Application of 'Less is More' to Low Back Pain" - Top 5 Recommendations to Improve Clinical Practice". Archives of Internal Medicine. 172 (13): 1020–1022. doi:10.1001/archinternmed.2012.1943. PMID 22664829.
  • for an example of local public journalism of the campaign, consider Zamosky (10 May 2013). "Saying no to surgery - latimes.com". Los Angeles Times. Los Angeles: Tribune Co. ISSN 0458-3035. Retrieved 4 June 2013.
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