I just returned from attending the first Connecticut Choosing Wisely Summit – an excellent meeting. If you are not already aware, Choosing Wisely is an initiative of the ABIM Foundation to promote the selection of care that is supported by evidence and truly necessary. It should be pointed out that the National Physicians Alliance pioneered this movement by creating lists of things primary care physicians could do in their practices to foster practical use of resources. Today’s event was hosted by the CT Choosing Wisely Collaborative and held at the Frank H. Netter MD School of Medicine of Quinnipiac University. We first heard from Dominic Lorusso, Director of Health Partnerships for Consumer Reports (one of the primary groups partnering with the ABIM Foundation in the Choosing Wisely initiative). He noted that since the initiative began in 2012, the number of partners has grown from 11 to 65. There are now 67 specialty society lists of “Five Things Physicians and Patients Should Question” as well as 74 “two-pager” monographs aimed at educating patients (check out the lists at http://www.choosingwisely.org/doctor-patient-lists/). Lorusso described their use of Wikipedia, embedding information and links to the Choosing Wisely monographs (for example, look up “sinusitis” on Wikipedia and scan the references). He introduced the list of general questions they are promoting: 5 questions to ask your doctor before you get any test, treatment or procedure:
- Do I really need this test or procedure?
- What are the risks?
- Are there simpler, safer options?
- What happens if I don’t do anything?
- How much does it cost?
As you can see, this basically constitutes elements of shared decision making, which we should be prepared to discuss anyway – although admittedly the fifth question, about the cost, can be challenging to answer. If you haven’t already seen Healthcare Bluebook, check it out; it can give you a starting point about price (even if that doesn’t represent what your patient will have to pay).
We then heard from Jasmine Dupont, JD, of Maine Quality Counts. She talked about how her group engages consumers about health care by using Choosing Wisely. She described how they selected 8 focus areas that they are encouraging providers to limit, drawn from the Choosing Wisely lists:
- Cardiac imaging for patients at low risk for heart disease
- Imaging tests for low back pain
- Antibiotics for upper respiratory infections
- Imaging tests for uncomplicated headaches
- Bone-density scans for low-risk women
- Sleeping pills or sedatives for insomnia, agitation, or delirium in older adults
- Opioids or butalbital as pain medications for treating migraine headaches
- Imaging tests of the head in emergency department for minor head injuries.
One of the highlights was the presentation by the group from Vanderbilt University. Donald Brady, Senior Associate Dean for GME, described their institution’s resident-led, leader-supported initiative around Choosing Wisely. They formed the House Staff Choosing Wisely Steering Committee (about which you can read more here). Two resident leaders, Wade Iams (Internal Medicine) and Josh Heck (Radiology), described the program. Residents selected an area of focus they were very familiar with – daily labs for hospitalized patients – and developed a plan to reduce use. They partnered with others in the institution to create a dashboard reporting use and estimates of what was avoided by limiting use: such as how many unnecessary labs were eliminated, how much blood not drawn, and how many misleading results avoided. An intensive education campaign, and some friendly competition, helped their initiative to succeed.
Breakout groups gave an opportunity to discuss ideas for implementation here at home. There were groups for Communities and Consumers, Health Professionals, Health Systems, Point of Care and Workplace. We discussed how prompts built into EMRs could be helpful and how integrating with the SIM project could give Choosing Wisely a lot of visibility in Connecticut.
I want to remind you that the ACP, as well as contributing its own list to Choosing Wisely, launched the complementary High Value Care initiative. This includes a toolkit to help facilitate patient-centered communication in the referral process, between primary care and subspecialist doctors; a curriculum for educating residents; and the online cases, which provide free CME and MOC credit. I would like to encourage you to incorporate High Value Care and Choosing Wisely into your practice.