Choosing Wisely continued its influence on scholarly research and mainstream news coverage about overuse in health care throughout 2018. As the year draws to a close, we look back on the year’s “Top 5” must-read Choosing Wisely articles from the media and from peer-reviewed journals. Give us feedback on our list and share your favorites with us on Twitter by tagging @ABIMFoundation and using the hashtag #ChoosingWisely.
Forbes: Children With Mild Head Injuries Are Still Getting Too Many Brain Scans
In this article, Dr. Nina Shapiro dispels the health myths, fads, exaggerations and misconceptions associated with imaging for children who have suffered a minor head injury. Dr. Shapiro reports that despite better guidelines about when and when not to do a CT scan for a pediatric head injury, including recommendations from the Choosing Wisely campaign, the rate of imaging stayed the same during a nine-year study period. While one CT scan does not deliver high doses of radiation, children’s brains are more sensitive to radiation, Dr. Shapiro writes, raising potential long-term cancer risks if a youth has multiple scans during childhood.
Modern Healthcare: Wasting away: How health systems are advancing the battle against low-value care
Reporter Maria Castellucci outlines how hospitals and hospital networks such as Johns Hopkins Health System are re-examining just about every clinical practice in an effort to eliminate unnecessary care and improve efficiencies, from vitamin deficiency testing to oxygen usage to blood transfusions. Castellucci writes: “Some studies estimate that as much as 40% of U.S. blood transfusions are unnecessary. The practice is a mainstay of healthcare and clinicians have been taught since medical school to give patients two units of blood whenever they require a transfusion. But recent research shows that one unit usually is just as safe and effective for patients who aren’t actively bleeding.”
NPR: Unnecessary Medical Care: More Common Than You Might Imagine.
National Public Radio, along with many other mainstream news outlets, reports on the findings of the Washington Health Alliance’s study about health care overuse in the state: “First Do No Harm.” Journalist Marshall Allen, who writes for ProPublica, details the overuse in terms of dollars spent on unnecessary care and the number of people who received that care, adding that the report underscores the ways that large amounts of money are squandered in health care. His publication spent a year reporting on unnecessary spending in American health care.
The New York Times: Trying To Put A Value On The Doctor-Patient Relationship
In the New York Times Magazine, writer Kim Tingley ponders the dearth of research examining the financial impact of a close doctor-patient relationship. She related personal stories about her family’s primary care doctor and how changes in health care are impeding more personal care. Tingley writes: “Surprisingly little is known, though, about what the relationship between a patient and his or her primary-care doctor is actually worth, in terms of that patient’s overall well-being or medical costs, regardless of who bears them. In fact, David Meltzer, an economist and a primary-care physician at the University of Chicago, may be the first and only researcher in the country trying to quantify that relationship’s value in a randomized clinical trial, the most rigorous scientific method.”
US News & World Report: Choosing Wisely: With Your Physician
Contributing writer Dr. Ronan Factora reflects on a new direction in medical decision making: shared decision-making that encourages more conversation among patients and physicians, and many times family members, about appropriate care. The article mentions the Choosing Wisely campaign, and in particular recommendations from the American Geriatrics Society. It concludes with the observation: “The recommendations are not all-encompassing. It would be impractical and impossible to address every single potential issue or question that could come up in discussions between patients and their physicians. They do, however, provide an excellent example of how free communication and a unified set of goals between physicians, their patients and families can develop a plan of care that everyone is comfortable with.”
American Journal of Managed Care: Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes
In this analysis, clinicians at Cedars-Sinai Hospital examine the associations between adherence to Choosing Wisely recommendations embedded into clinical decision support alerts and four measures of resource use and quality: encounter length of stay, odds of 30-day readmission, odds of complications of care, and total direct costs. The observational study covered 26,424 patient encounters, with the treatment group provider adhering to all CDS alerts. In the control group, the provider did not adhere to CDS recommendations. The study found increases in all four outcome areas for the non-adherent group, and consistent improvements in the outcome measures for the treatment group. “We recommend that provider organizations consider the introduction of real-time CDS to support adherence to evidence-based guidelines,” the study concludes.
Annals of Emergency Medicine: A Broader View of Quality: Choosing Wisely Recommendations From Other Specialties With High Relevance to Emergency Care
With the Choosing Wisely lists now topping a combined 600 recommendations, the American College of Emergency Physicians (ACEP) sought to identify what recommendations from other professional societies that have the highest relevance to emergency care, and provide opportunities to improve quality and patient safety in emergency care. ACEP identified 38 recommendations from other specialties that are highly relevant to its specialty, with imaging studies and antibiotic use most represented. ACEP joined the campaign in 2013, and has published 10 recommendations.
JAMA Internal Medicine: Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments
Lead author Deborah Korenstein and two colleagues at Memorial Sloan Kettering Cancer Center explore the scope of negative consequence for patients from unnecessary medical tests and treatments, through a structured literature review and interviews with six international experts in medical overuse. They developed an evidence-based conceptual map that defines six domains of harm (physical, social, psychological, financial, treatment burden, and dissatisfaction with health care) that are either directly tied to overused services or result indirectly from downstream services. Case reports confirmed the processes and domains of the conceptual map. Korenstein states that better understanding of the breadth of negative consequences from overuse can inform efforts to reduce it.
JAMA Viewpoint: Choosing Wisely Campaigns: A Work in Progress
At the top of our summer reads for 2018, this opinion piece by Choosing Wisely Canada leaders Wendy Levinson and Karen Born and ABIM Foundation EVP and COO Daniel Wolfson discussed the use of diffusion of innovation science to explore factors that facilitated the spread of Choosing Wisely, and how these enabling factors can address challenges in dissemination and implementation. They describe how the campaign can continue to align with professional values, share simple messages, inspire “reinvention,” leverage peer connections and shift toward broader adoption.
Pediatrics: Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children’s Hospitals
Clinicians and researchers at five children’s hospitals in California, Florida, Kansas and Texas develop a report card based on five Choosing Wisely recommendations from the Society of Hospital Medicine aimed at decreasing overuse in common inpatient pediatric conditions; calculate Achievable Benchmarks of Care (ABCs); and analyze performance among hospitals in the Pediatric Health Information System (PHIS) database. (need more info)
Supportive Care in Cancer: Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study
Researchers from the University of Virginia Health System and University of Rochester Medical Center develop a three-tool assessment that identified three times more potentially inappropriate medications in health management for older adults than the Beers Criteria alone. The study authors determined that pharmacist-led de-prescribing interventions can be very effective in combating overuse and may lead to improved patient outcomes and cost savings. The authors recommend that the three-tool assessment process be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.