Research Roundup – July 2016
A periodic series in Updates from the Field, “Research Roundup” highlights recently published research related to Choosing Wisely®. (Note: Some articles require subscription.)
“Choosing Wisely®: A case study of constructive engagement in health policy” (Healthcare, May 2016): ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson authored this piece with Anthony Suchman about how the Foundation sought to change attitudes and culture to eliminate unnecessary care and to promote the idea that removing waste is an integral component of providing high quality care. The authors explore how the Choosing Wisely campaign was designed with principles from Complexity and Self-Determination Theories to embrace broad engagement guided by simple rules. Choosing Wisely, they write, gave medical specialty societies the autonomy to determine for themselves whether and when to get involved and offered an opportunity for them to highlight important patterns of overuse within their specialties. Participating societies, which now number more than 70, released evidence-based recommendations, not rules, and let physicians and patients determine what tests or treatments are appropriate in each individual case.
“Academic Physicians’ Views on Low-Value Services and the Choosing Wisely campaign: A Qualitative Study” (Healthcare, May 2016): Researchers conducted focus groups with physicians from New York’s Weill Cornell Medical College Physician Organization that explored their views about overuse. The authors reported that there was a universal view among participants that overuse of low-value services is a significant problem. The physician participants frequently said that patient expectations drove overuse and many cited a lack of time as an obstacle to solving the problem. Possible solutions proposed by the physicians included providing decision support through electronic medical records (EMRs), appealing to physicians’ internal motivations and giving physicians data about their rates of overuse.
“Physician Perceptions of Choosing Wisely and Drivers of Overuse” (American Journal of Managed Care, May 2016): Researchers surveyed clinicians practicing at Atrius Health, the largest ambulatory care provider in Massachusetts, about their views on overuse and their awareness of the Choosing Wisely campaign. The survey was conducted in 2014, two years after the launch of Choosing Wisely. It found that 47 percent of primary care physicians at Atrius were aware of the campaign, compared to 37 percent of medical specialists and 27 percent of surgical specialists. More than 90 percent in all groups agreed or somewhat agreed that Choosing Wisely was a legitimate source of guidance, and nearly all of those surveyed (97 percent) agreed that doctors need to limit unnecessary tests.
The researchers also asked about drivers of overuse. A majority (62 percent) of all physicians surveyed said they found the uncertainty involved in patient care disconcerting, while significant minorities of the sample reported believing that it was unfair to ask physicians to be both cost-conscious and concerned with patient welfare, that too much emphasis was placed on costs and/or that physicians were too busy to be concerned about costs. Surgical specialists expressed more concerns about malpractice, while primary care physicians were more likely to reference patient demands in describing drivers of overuse.
“Analysis of Thrombophilia Test Ordering Practices at an Academic Center: A Proposal for Appropriate Testing to Reduce Harm and Cost” (PLOS One, May 2016): A team at the University of Texas-Southwestern studied and sought to reduce the use of thrombophilia testing, which the American Society of Hematology has recommended against using in adult patients with venous thromboembolism that occurs in the setting of major transient risk factors, such as surgery, trauma or prolonged immobility. The team reviewed data on thrombophilia testing from October and November 2009, and presented the findings to the system’s Laboratory Advisory Committee, which prompted implementation of local guidelines to improve test utilization. After the guidelines had been in place for 22 months, testing was reduced by 84 percent; following an additional electronic consultation effort, tests fell further, for an overall reduction of 92 percent.
“Neuroimaging Wisely” (American Journal of Neuroradiology, June 2016): This article highlights the role of radiologists in ensuring appropriate use of imaging studies and reviews how radiologists can collaborate with other clinicians to promote appropriate ordering. It discusses a number of neurologic conditions in which the selection of appropriate imaging is often challenging for referring physicians, including traumatic brain injury, headache, low back pain, syncope, hearing and vision loss, other head and neck disorders, and pediatric neurologic conditions. It then provides an overview of barriers to implementing appropriate use guidelines and potential solutions to those barriers, including the Radiology Support, Communication and Alignment Network (R-SCAN) project developed by the American College of Radiology to improve imaging use for 11 topics defined in Choosing Wisely recommendations.