Dr. Frost

SHM is participating in the ABIM Foundation's Choosing Wisely Campaign (CWC).¹ Launched earlier this year, the CWC aims to increase awareness about medical practices that may be of little or no benefit to patients. Presently, 26 physician organizations have teamed with the ABIM Foundation to each create a list of “five things physicians and patients should question.” In addition, Consumer Reports (the product ratings organization well known for grading the quality of such items as automobiles and vacuum cleaners) is coordinating the efforts of 11 consumer groups to advance the CWC agenda.

The CWC aims to highlight two pillars of healthcare reform that will receive enhanced attention in the near future: 1. Cost of care, and 2. Patient experience of care. Heretofore healthcare reform efforts have largely been focused on the quality and patient-safety movements. Equally important, however, to policymakers is affordability and care experience. By focusing on tests and procedures of questionable benefit, the CWC aims to directly address costly unnecessary treatment by encouraging care planning that incorporates patient preferences. This is necessary work because research suggests that physician decisions account for 80% of healthcare expenditures, while the tradition of patients entrusting their doctors with complete decision-making authority leads to care that they do not want.²

Choosing Wisely Begins with Medical Professionalism

In 2002, the ABIM Foundation collaborated with the American College of Physicians Foundation and the European Federation of Internal Medicine to jointly author “Medical Professionalism in the New Millennium: A Physician Charter.”³ The charter has since been endorsed by more than 130 organizations and triggered countless improvement initiatives to advance its fundamental principles of patient welfare, patient autonomy, and social justice.

Through project grant support, the ABIM Foundation is emphasizing two key Physician Charter commitments (see Table 1) to advance appropriate healthcare decision-making and encourage stewardship of healthcare resources. The CWC naturally augments this work by focusing on care affordability and decision-making through shared discussions between patients and providers.

Table 1. Tenets of medical professionalism that physicians must embrace³

Honesty that empowers patients to decide on the course of therapy;

Just distribution of finite resources based on cost-effective management;

Professional competence;

Patient confidentiality;

Maintaining appropriate relations with patients;

Improving quality of care;

Improving access to care;

Scientific knowledge;

Maintaining trust by managing conflicts of interest;

Professional responsibilities.

SHM’s Involvement

SHM convened a workgroup of hospital medicine quality improvement experts led by John Bulger, DO, the chief quality officer at Geisinger Health System in Pennsylvania. This group solicited from SHM committee members 150 suggested tests and treatments that HM clinicians and their patients should question. After critical analysis, the list was narrowed to exclude suggestions already being advanced by the CWC while focusing on those that represent the largest opportunity for hospitalists to impact on affordability and patient experience.

The list was then submitted to SHM members for comment via survey, resulting in 11 recommended medical interventions that were subjected to comprehensive literature review. Workgroup members then rated these 11 interventions according to the following criteria: validity of supporting evidence, feasibility and degree of hospitalist impact, frequency of occurrence, and cost of occurrence.

Finally, the workgroup collaborated with the SHM board of directors to submit to the ABIM Foundation the ultimate list of “five things hospitalists and their patients should question.” Ricardo Quinonez, MD, at Baylor College of Medicine in Houston, Texas, led a similar process that generated a list of questionable practices in pediatric HM. It, too, was submitted to the ABIM Foundation.

The CWC anticipates publishing SHM’s list in February 2013. In the meantime, please consult the CWC website to find practices commonly performed by hospitalists that have been deemed to be of unclear benefit by other professional medical societies (see “2012 CWC Recommendations for Hospitalists,” left).

SHM plans to build upon this work in the future. Expect to see Choosing Wisely sessions and discussions at the HM13 SHM Annual Meeting in May (www.hospitalmedicine2013.org) focused on creating and teaching QI strategies to implement CWC recommendations. Furthermore, the Center for Hospital Innovation and Improvement will be identifying opportunities to develop mentored implementation QI programs related to Choosing Wisely and its principles.

What You Can Do

Hospitalists can make a huge impact on affordability and patient experience given that most of the country’s healthcare dollar is spent in the hospital, and patients are at their most vulnerable to receiving treatment that they may not want when they are acutely ill. Hospitalists, thus, are uniquely positioned to make a positive impact by embracing the Choosing Wisely Campaign’s principles.

Please commit to assisting SHM by visiting the CWC website and learning about other medical society’s thoughts on “things physicians and patients should question.” Pledge thereafter to engage your patients and their families in healthcare decision-making, especially in situations where the benefits of tests and therapies are unclear.

Attention to care affordability and experience are essential to reforming our broken healthcare system, so let’s lead the charge in these areas and help others who are doing the same.

Dr. Frost is president of SHM.

2012 CHoosing Wisely campaign Recommendations Hospitalists Need to know about¹

Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non cardiac surgery.

Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology;

In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).

In patients with low pretest probability of venous thromboembolism (VTE), obtain a high sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with

hypertension or heart failure or CKD of all causes, including diabetes.

Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10g/dL without symptoms of anemia.

Don’t place peripherally inserted central catheters (PICC) in stage III-IV CKD patients without consulting nephrology.

Don’t initiate chronic dialysis without ensuring a shared decision making process between patients, their families, and their physicians.

Don’t do imaging for uncomplicated headache.

Don’t obtain imaging studies in patients with non-specific low back pain;

Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Don’t use white cell stimulating

factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.

For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

SHM will publish its list of recommendations in February. View all the recommendations from specialty societies taking part in Choosing Wisely.

References

The ABIM Foundation. Choosing Wisely: An initiative of the ABIM Foundation. Choosing Wisely website. Available at: http://www.choosingwisely.org. Accessed Sept. 25, 2012.

The ABIM Foundation. Principles Guiding Wise Choices. ABIM Foundation website. Available at: www.abimfoundation.org/Initiatives/~/media/Files/2011-Forum/110411_ABIM%20Stewardship.ashx. Accessed Sept. 25, 2012.

ABIM Foundation, ACP–ASIM Foundation, European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136(3):243.

Shaun Frost: Society of Hospital Medicine Supports the Choosing Wisely Campaign (CWC)