What we can learn from Choosing Wisely- an initiative of the ABIM Foundation

Who is responsible for driving healthcare reform? Since 2009, hospitals, insurers, drug and device manufacturers, and other major industries have all made efforts or at least positive gestures to get behind healthcare reform. But what about physicians?

A 2010 article in the New England Journal of Medicine suggests that the medical profession has an ethical obligation to support changes directed at cutting healthcare costs. Part of the author's argument is that physicians who pride themselves on putting patient welfare first should do all they can to make way for legislation that would extend insurance to Americans who currently lack coverage. The anticipated ever-rising costs of healthcare have become a huge hurdle for such legislation. So, cutting costs should be a priority for doctors.

The author of the NEJM article, Howard Brody, MD, PhD, called for each specialty to create a "Top 5" list enumerating the five tests or treatments that are "very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered."

In other words, doctors are perhaps the best group to recommend the best ways to save money without sacrificing quality of care.

Brody's article spurred the National Physicians Alliance and the American Board of Internal Medicine (ABIM) Foundation to launch a campaign called "Choosing Wisely." Kicked off in 2012, the effort aims to both decrease a waste in resources and increase patient safety by avoiding risks associated with unnecessary treatment.

Currently, more than 70 medical specialty societies are involved, and they have published more than 400 evidence-based recommendations regarding overused tests and procedures that should warrant patient-physician discussion.

"The Choosing Wisely initiative is an important voice in the national conversation about health care reform. In fact is it resonates with AMR and its purpose that 'we believe every patient should receive quality healthcare,'" said Dr. Lousine Alpern, VP of Clinical Services/ Chief Compliance Officer of Advanced Medical Reviews. "When physicians make their concerns about over-testing and over-treating heard, patients listen and respond."

Common lists of topics that providers and patients should question can be found on the Choosing Wisely website, covering everything from antibiotic use and blood transfusions to cancer treatment and end-of-life care. The group makes it clear, however, that its recommendations are meant to educate and inspire questions, not to determine a treatment path or advise for or against insurance coverage:

"Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together."

Additional Choosing Wisely Resources

Choosing Wisely has also developed a set of interactive instructional modules that delve deeper into the recommendations. Utilizing video presentations, post-tests and downloadable patient handouts, the modules offer practitioners examples of how to speak to patients about the recommendations as well as helpful educational materials to boost patient understanding. The modules are available free of charge on the Choosing Wisely website.

Helping or harming?

Most Choosing Wisely recommendations are fairly straightforward. One such example is advising patients with osteoarthritis not to take glucosamine based on the lack of reliable evidence that the supplement has any effect on symptoms. A Medscape Business of Medicine article, “Why 'Choosing Wisely' Won't Protect You in a Lawsuit,” by William Sullivan, DO, JD, raises the concern, however, that doctors may open themselves to malpractice charges if following Choosing Wisely guidelines results in a missed diagnosis.

Sullivan points out that certain circumstances, such as non-specific lower back pain, can be associated with dangerous conditions - albeit rarely. In such a case, overriding a doctor's clinical judgment to order imaging could result in negative patient outcomes that might have been avoided.

Clinical practice guidelines issued by professional organizations can be used to show that a physician's actions were within the standard of care. In this way, such recommendations may reduce a practitioner's malpractice risk by preventing a charge of negligence, which is a prerequisite for medical malpractice action. Would citing Choosing Wisely guidelines do the same? Sullivan suggests the answer to that question may be no, and he advises that:

"Guidelines relating to payment issues should not be used for clinical or medicolegal purposes without strong clinical research supporting their conclusions. While clinical practice guidelines may be useful for both clinical and medicolegal purposes, the recommendations should be compared with current medical literature to determine whether the guidelines constitute appropriate medical care.

The author strongly recommends that practitioners familiarize themselves with the evidence that any guidelines are based on and treat them as "general outlines that are subject to change as our knowledge of medicine evolves."