Choosing Wisely

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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 addresses the problem of patients receiving unnecessary health treatment, reasoning that this results in poor outcomes for the patient and could create significant waste in the United States healthcare system. 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 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[edit]

The Choosing Wisely campaign presents the following background and narrative to explain its motivation: The cost of health care in the United States is not affordable for many people or the nation.[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.[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]

History[edit]

Christine K. Cassel explains the Choosing Wisely campaign

In 2002 the ABIM Foundation published Medical professionalism in the new millennium: a Physician Charter.[1][16] 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][17][18] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists".[1][19][20] Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.[1][19][21]

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][22] 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[edit]

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] As of February 2013, there there 135 recommendations targeting a range of procedures to either question or to avoid without special consideration.[23]

Examples[edit]

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.[24]
  • 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.[25]
  • Before the 39th week of pregnancy, doctors should not perform a Caesarean section or induce labor unless medically necessary.[26]

Difficulties[edit]

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.[27] Many recommendations in the campaign require clinical education to understand fully.[27] Also many patients tend to follow the recommendations of their physicians without question, even if they have questions.[27]
  • The United States medical system is designed so that most doctors get paid when they provide treatment and not paid when they do not recommend treatment.[27] This system creates a pattern for doctors to recommend more treatment.[27]
  • Critics tend to view efforts to reduce medical services as "healthcare rationing in the United States".[27] 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.[27][28][29] Doctors say that they often feel pressure to engage in defensive medicine by conducting extra testing to avoid lawsuits.[30]

Reception[edit]

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.[31] 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".[32]

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.[33] A related critique is that considering cost as a basis for making health care decisions is not ideal.[34]

While expressing the need for evidence-based healthcare recommendations, The Economist found the Choosing Wisely recommendations to be weak because they are not enforceable.[35] 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."[36]

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."[37]

Impact[edit]

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.[38] The campaign has been cited as being part of a broader movement including many comparable campaigns.[39] The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system.[40] In August 2013 the Canadian Medical Association proposed having a similar program for Canada.[41] The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs.[42]

Partners[edit]

Choosing Wisely is an initiative of the ABIM Foundation. Organizations from various fields have different roles in the campaign.[43]

Nine specialty societies agreed to participate at the project's start.[44] These include the following:

Societies that began to participate starting in February 2013 include the following:[52]

Societies beginning their participation between September 2013 and March 2014 include the following:[52]

Societies which have expressed intent to participate in Choosing Wisely in the future include the following:[52]

Consumer Reports creates and distributes versions of the information written in plain English.[1] Communication partners to the public include the following:[68]

References[edit]

  1. ^ a b c d e f g h i j k l 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.  edit
  2. ^ a b 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. ^ a b 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. ^ a b 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. ^ a b 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. ^
  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.  edit
  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 (Report). Commonwealth Fund. http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf. 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): 1–0. doi:10.1001/jamainternmed.2013.1271.  edit
  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.  edit
  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.  edit
  16. ^ 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. PMID 11827500.  edit
  17. ^ 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.  edit
  18. ^ 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.  edit
  19. ^ a b 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.  edit
  20. ^ 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.  edit
  21. ^ 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.  edit
  22. ^ 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.  edit
  23. ^ Begley, Sharon (21 February 2013). "Just say don't: Doctors question routine tests and treatments". reuters.com. Retrieved 22 February 2013. 
  24. ^
    • 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.  edit
    • 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.  edit
  25. ^
    • Quinn, K. (2012). "Reducing Radiology Use on an Inpatient Medical Service: Choosing Wisely". Archives of Internal Medicine: 1–0. doi:10.1001/archinternmed.2012.4293.  edit
    • 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.  edit
  26. ^ 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. 
  27. ^ a b c d e f g Volpp, K. G. (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.  edit
  28. ^ 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.  edit
  29. ^
  30. ^
  31. ^ Dunn, Jancee (November 2012). "Inside Scan". Vogue: 204–205. 
  32. ^ Quote taken from Forbes.
  33. ^ Goldberg, Robert M. (13 April 2012). "Obamacare's Medical Mercenaries". The American Spectator. Retrieved 16 October 2012. 
  34. ^ 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.  edit
  35. ^ "Evaluating medical treatments: Evidence, shmevidence". economist.com. 16 June 2012. Retrieved 16 October 2012. 
  36. ^ 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. 
  37. ^ a b 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. 
  38. ^ 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. 
  39. ^ 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.  edit
  40. ^ Strech, Daniel (30 May 2013). "Eine Choosing Wisely Initiative für Deutschland?". Informationsdienst Wissenschaft (in German). Retrieved 7 June 2013. 
  41. ^ McDiarmid, Jessica (22 August 2013). "Canadian doctors to tackle unnecessary medical tests". Toronto Star. Retrieved 5 September 2013. 
  42. ^ 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: 140122140218007. doi:10.1056/NEJMp1314965.  edit
  43. ^ "About the Campaign". Choosing Wisely. Retrieved 16 October 2012. 
  44. ^ Rao, Vijay M.; Levin, David C. (16 October 2012). "The Overuse of Diagnostic Imaging and the Choosing Wisely Initiative". Annals of Internal Medicine 157 (8): 574–576. doi:10.7326/0003-4819-157-8-201210160-00535. Retrieved 16 October 2012. 
  45. ^
    • Siwek, J. (2012). "Choosing wisely: Top interventions to improve health and reduce harm, while lowering costs". American family physician 86 (2): 128–133. PMID 22962925.  edit
    • Brown, M. (2012). "Aafp Participates in Campaign to Cut Unnecessary Medical Interventions". The Annals of Family Medicine 10 (4): 373–310. doi:10.1370/afm.1427.  edit
  46. ^ Scott, I.; Phelps, G.; Rubin, G.; Gow, P.; Kendall, P.; Lane, G.; Frost, G.; Yee, K. C. (2012). "Putting professionalism and delivery of value-added healthcare at the heart of physician training and continuing professional development". Internal Medicine Journal 42 (7): 737–741. doi:10.1111/j.1445-5994.2012.02835.x. PMID 22805685.  edit
  47. ^
  48. ^ Williams, A. W.; Dwyer, A. C.; Eddy, A. A.; Fink, J. C.; Jaber, B. L.; Linas, S. L.; Michael, B.; O'Hare, A. M.; Schaefer, H. M.; Shaffer, R. N.; Trachtman, H.; Weiner, D. E.; Falk, A. R. J.; on behalf of the American Society of Nephrology Quality, and Patient Safety Task Force (2012). "Critical and Honest Conversations: The Evidence Behind the "Choosing Wisely" Campaign Recommendations by the American Society of Nephrology". Clinical Journal of the American Society of Nephrology 7 (10): 1664–1672. doi:10.2215/CJN.04970512. PMID 22977214.  edit
  49. ^ Coleman, Matthew (February 2012). "ASN Targets Unnecessary Interventions Through ABIM Campaign". Nephrology Times: 5 (2): 10–11.  edit
  50. ^
  51. ^
  52. ^ a b c "Choosing Wisely - ABIM Foundation". abimfoundation.org. Retrieved 18 January 2013. 
  53. ^ Fischberg, D.; Bull, J.; Casarett, D.; Hanson, L. C.; Klein, S. M.; Rotella, J.; Smith, T.; Storey Jr, C. P.; Teno, J. M.; Widera, E.; Hpm Choosing Wisely Task, F. (2013). "Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine". Journal of Pain and Symptom Management 45 (3): 595–605. doi:10.1016/j.jpainsymman.2012.12.002. PMID 23434175.  edit
  54. ^ Butcher, L. (2012). "What Diagnostic Tests Are Unnecessary? Neurology Weighs in on 'Choosing Wisely'". Neurology Today 12 (15): 1–3. doi:10.1097/01.NT.0000418589.06631.26.  edit
  55. ^ Parke, D. W.; Coleman, A. L.; Rich, W. L.; Lum, F. (2013). "Choosing Wisely: Five Ideas that Physicians and Patients Can Discuss". Ophthalmology 120 (3): 443–444. doi:10.1016/j.ophtha.2013.01.017. PMID 23714602.  edit
  56. ^ "Choosing Wisely: Our List". Otolaryngology -- Head and Neck Surgery 148 (4): 534–6. 2013. doi:10.1177/0194599813479577. PMID 23449780.  edit
  57. ^ Sulaski Wyckoff, Alyson (2013). "Antibiotics to CT scans: Academy joins Choosing Wisely campaign to reduce overtreatment". AAP News 34 (3): 25. doi:10.1542/aapnews.2013343-25.  edit
  58. ^ a b "Choosing wisely: The American College of Rheumatology's top 5 list of things physicians and patients should question". Arthritis Care & Research 65 (3): 329. 2013. doi:10.1002/acr.21930.  edit
  59. ^ "The Choosing Wisely®Campaign and Nurses' Role in Dissemination". Journal of Gerontological Nursing 39 (5): 4–6. 2013. doi:10.3928/00989134-20130417-01. PMID 23634765.  edit
  60. ^ Dillehay, GL (2013). "Choosing wisely in nuclear medicine and molecular imaging". Journal of nuclear medicine 54 (3): 17N–18N. PMID 23457355.  edit
  61. ^ Wood, D. E.; Mitchell, J. D.; Schmitz, D. S.; Grondin, S. C.; Ikonomidis, J. S.; Bakaeen, F. G.; Merritt, R. E.; Meyer, D. M.; Moffatt-Bruce, S. D.; Reece, T. B.; Smith, M. A. (2013). "Choosing Wisely: Cardiothoracic Surgeons Partnering with Patients to Make Good Health Care Decisions". The Annals of Thoracic Surgery 95 (3): 1130–1135. doi:10.1016/j.athoracsur.2013.01.008. PMID 23434251.  edit
  62. ^ Coldiron, B. M.; Fischoff, R. M. (2013). "American Academy of Dermatology Choosing Wisely List: Helping dermatologists and their patients make smart decisions about their care and treatment". Journal of the American Academy of Dermatology 69 (6): 1002. doi:10.1016/j.jaad.2013.07.035. PMID 24238155.  edit
  63. ^ a b &Na; (2013). "New 'Choosing Wisely' Lists from American College of Surgeons and Commission on Cancer". Oncology Times 35 (19): 18. doi:10.1097/01.COT.0000436593.70453.4f.  edit
  64. ^ Loder, E.; Weizenbaum, E.; Frishberg, B.; Silberstein, S. (2013). "Temporarily Withdrawn:Choosing Wisely in Headache Medicine: The American Headache Society's List of Five Things Physicians and Patients Should Question". Headache: the Journal of Head and Face Pain: n/a. doi:10.1111/head.12278.  edit
  65. ^ Vance, J. (2013). "AMDA—Choosing Wisely". Journal of the American Medical Directors Association 14 (9): 639–641. doi:10.1016/j.jamda.2013.07.004. PMID 24011659.  edit
  66. ^ Digiulio, Sarah (24 September 2013). "First Reactions to ASTRO's Choosing Wisely List". journals.lww.com. Retrieved 19 November 2013. 
  67. ^ Venkatesh, A. K.; Schuur, J. D. (2013). "A "Top Five" list for emergency medicine: A policy and research agenda for stewardship to improve the value of emergency care". The American Journal of Emergency Medicine 31 (10): 1520–1524. doi:10.1016/j.ajem.2013.07.019. PMID 23993868.  edit
  68. ^ "Consumer Partners: Choosing Wisely". choosingwisely.org. 2013. Retrieved 21 February 2013. 
  69. ^ Self-published sources say, "The Wikipedia community, through a dedicated Wikipedian in Residence". See the Cassel video, as well as official listings and other mentions of Wikipedia in these:

Further reading[edit]

External links[edit]