Research Update
Researchers continue to focus on Choosing Wisely and overuse generally. This is the latest in a periodic series of articles highlighting recent articles of interest (subscription may be required to access).
Choosing Wisely® in Hematology: Have We Made a Difference?
Hilal T, et al. Health Economics. June 2020
Focusing on Choosing Wisely implementation in the hematology field, this article identified implementation barriers, interventions to improve adoption, and challenges in measuring effectiveness. Identified barriers to adoption included: implementation being dependent on practitioner education, difficulty in measuring dialogue between patients and physicians, and need for cultural change.
The authors portrayed interventions to approve adoption through examples of Choosing Wisely implementation throughout multiple institutions. Examples included electronic medical alerts at Stanford University Hospital and Banner Health facilities and one-on-one education for medical residents.
The article highlighted the relevance of Choosing Wisely in the context of the COVID-19 pandemic in avoiding potential patient harm from unnecessary testing. “As we continue to support the Choosing Wisely campaign, we need to implement strategies to document and measure the influence of our value-based recommendations on physician practices, patient care and attitudes, and healthcare costs.”
Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery – A Systematic Review
Wang T, Baskin AS, Dossett LA. JAMA Surgery. June 2020
This study evaluated national de-implementation rates of four breast cancer operations identified as low value by the Choosing Wisely campaign. Possible barriers to and facilitators for de-implementation were identified.
Results indicated decreases in national rates of axillary lymph node dissection for patients with limited nodal disease and national rates of lumpectomy margin re-excision, and increases in national rates of contralateral prophylactic mastectomy and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer. “This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.”
Choosing Wisely in Post-Acute and Long-Term Care: Evaluating internal medicine residents’ knowledge gaps. Panagiotou A, Sharma K. The Journal of Post-Acute and Long-Term Care Medicine. March 2020
Five Choosing Wisely recommendations pertaining to care of patients in the post-acute and long-term care settings were released in 2013, with five more in 2015. An anonymous survey of 58 internal medicine residents was conducted between 2014 and 2019 at Morristown (NJ) Medical Center to assess knowledge of Choosing Wisely recommendations.
Survey results from 2013 were compared to 2019 to assess knowledge improvement. Results indicated improvement in “overall knowledge pertaining to the recommendations in the post-acute and long-term care arena. However, there was a consistent knowledge gap in understanding of the benefits of careful hand feeding over PEG insertion and feeding in advanced dementia.”
Promoting appropriate utilisation of laboratory tests for inflammation at an academic medical centre.
Bartlett KJ, Vo AP, Rueckert J, Wojewoda C, Steckel EH, Stinnett-Donnelly J , Repp AB. BMJ Open Quality. February 2020
The American Society for Clinical Pathology recommends ordering C reactive protein (CRP) rather than Erythrocyte sedimentation rate (ESR) to detect acute phase inflammation in patients with undiagnosed conditions. Researchers sought to understand CRP and ESR ordering practices and reduce unnecessary use of ESR testing at their academic medical center in New England.
Physician leaders with high utilization of ESR testing were surveyed to understand overutilization practices. Based on the survey, the authors developed an intervention focused on education, clinical decision support (CDS) within the electronic medical record and quarterly audit and feedback.
Appropriateness of ESR ordering during pre-intervention and post-intervention periods were analyzed. Results indicated “sustained reductions in ESR tests and modest decreases in institutional costs. However, inappropriate ESR test ordering persisted following the intervention, suggesting opportunities for continued improvement and the possible need for more active CDS.”