Choosing Wisely is a United States-based health educational campaign, led by the American Board of Internal Medicine (ABIM). It seeks to improve doctor-patient relationships and promote patient-centered care by informing patients and physicians about overutilization of medical resources.
The campaign addresses the problem of patients receiving unnecessary health care, 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 of the campaign say that it is a uniquely broad and much-needed effort.
Video Choosing Wisely
Motivation
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. 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. 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. 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. 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. Reducing the cost of health care would make it accessible to more people.
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. 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.
The campaign has been described as an attempt to encourage doctors and patients to recognize the illusion of control or "therapeutic illusion" in choices to use treatments which have a basis outside of evidence-based medicine.
Maps Choosing Wisely
History
In 2002 the ABIM Foundation published Medical professionalism in the new millennium: a Physician Charter. The charter states that physicians have a responsibility to promote health equity when some health resources are scarce. 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. In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists". Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste.
Continuing this project, Choosing Wisely was created to organise the creation of more "lists of five" and their distribution to more physicians and patients. 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. Each recommendation in the program must have the support of clinical guidelines, evidence, or expert opinion.
Campaign
To participate in Choosing Wisely, each society developed list of five tests, treatments, or services which that specialty commonly overuses. 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.
As of April 2018, there were 552 recommendations targeting a range of procedures to either question or avoid without special consideration. They can be searched online by key words, such as "back pain" but the numerous supporting footnotes with evidence for each recommendation are only in a pdf on the clinician page, without links to the papers. Since most papers are behind paywalls, links to free copies on researchers' sites are particularly important.
Examples
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.
- 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.
- Before the 39th week of pregnancy, doctors should not perform a Caesarean section or induce labor unless medically necessary.
Difficulties
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. Many recommendations in the campaign require clinical education to understand fully. Also many patients tend to follow the recommendations of their physicians without question, even if they have questions.
- The United States medical system is based on a fee-for-service model, in which doctors are paid on the basis of ordering individual tests and procedures, so that most doctors will not get paid when they do not recommend (or recommend against) a given treatment. This system creates incentives for doctors to recommend additional treatments, rather than exercising evidence-based restraint.
- Critics tend to view efforts to reduce medical services as "healthcare rationing in the United States". 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. Doctors say that they often feel pressure to engage in defensive medicine by conducting extra testing to avoid lawsuits.
Reception
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. CBS News said that "the evidence is on the initiative's side." USA Today noted that the campaign was "a rare coordinated effort among multiple medical societies". 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. 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".
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. A related critique is that considering cost as a basis for making health care decisions is not ideal.
While expressing the need for evidence-based healthcare recommendations, The Economist found the Choosing Wisely recommendations to be weak because they are not enforceable. 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."
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."
A study reported that some patients and physicians find it challenging to use Choosing Wisely recommendations.
Impact
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. The campaign has been cited as being part of a broader movement including many comparable campaigns. The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system. In April 2014, Choosing Wisely Canada launched. Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs.
By 2015 and following the Choosing Wisely precedent established in the United States, health leaders from Australia, Canada, Denmark, England, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, and Wales committed to bring ideas from the Choosing Wisely and sometimes even the actual campaign itself into their own countries.
ABIM Foundation
Choosing Wisely is an initiative of the ABIM Foundation, a not-for-profit foundation established by the American Board of Internal Medicine (ABIM) in 1999 to advance medical professionalism to improve health care. In 2002 the ABIM Foundation, along with the ACP Foundation and European Federation of Internal Medicine published Medical Professionalism in the New Millennium: A Physician Charter. Dr. Hal Sox, Editor of Annals of Internal Medicine remarked, "I hope that we will look back upon its publication as a watershed event in medicine."
The Physician Charter sets forth a series of professional principles and responsibilities that physician should seek to embody in their practice, including the principles of the primacy of patient welfare, patient autonomy, and social justice. The Physician Charter has been endorsed by more than 130 organizations, translated into 12 languages, and 100,000 copies have been distributed. In 2014 the ABIM Foundation partnered with McGraw-Hill to publish Understanding Medical Professionalism. The book was authored by medical professionalism experts Wendy S. Levinson, MD; Shiphra Ginsburg, MD; Frederic W. Hafferty, PhD; and Catherine R. Lucey, MD.
In 2011 the ABIM Foundation created the Professionalism Article Prize. The award "recognizes outstanding contributions to the field of medical professionalism" and is given to up to three winners annually. Previous winners have included articles published in Academic Medicine, the Joint Commission Journal on Quality and Patient Safety and the New England Journal of Medicine.
On 10 March 2015, an article written by Kurt Eichwald for Newsweek raised skepticism of the ABIM Foundation and its merit. ABIM Board Chair David Johnson, responded with a statement stating "The author also presents an untrue and misleading interpretation of information from ABIM and ABIM Foundation's tax returns. His reporting reflects a poor understanding of that information and a highly selective presentation of information designed to prove his faulty premises." David also responded to the assertion that ABIM has a monopoly on certifying internists and other accusations.
Other partners
Nine specialty societies agreed to participate at the project's start. These include the following:
Societies that began to participate starting in February 2013 include the following:
Societies beginning their participation between September 2013 and March 2015 include the following:
Societies which have expressed intent to participate in Choosing Wisely in the future include the following:
- American Academy of Physical Medicine and Rehabilitation
- AABB
- American Association of Neurological Surgeons
- American Association for the Study of Liver Diseases
- American Society of Colon and Rectal Surgeons
Consumer Reports creates and distributes versions of the information written in plain English. Communication partners to the public include the following:
International
Following its start in the United States, the "Choosing Wisely" campaign inspired similar initiatives around the world, such as in the following countries:
Americas
- Choosing Wisely Brazil
- Canada (Choosing Wisely Canada)
- United States (Choosing Wisely)
Asia
- India
- Japan (Choosing Wisely Japan)
- South Korea
Europe
- Austria
- Denmark
- France
- Germany (Klug entscheiden)
- Italy (Slow Medicine)
- Netherlands
- Switzerland (Smarter Medicine - Choosing Wisely Switzerland)
- United Kingdom (Choosing Wisely UK)
- Wales (Choosing Wisely Wales)
Oceania
- Australia (Choosing Wisely Australia)
References
Further reading
- Roehr, B. (2012). "US specialties list five tests and treatments that doctors and patients can safely avoid". BMJ. 344: e2601. doi:10.1136/bmj.e2601. PMID 22495568.
- Kuehn, B. M. (2012). "Materials Educate Patients to Make Wise Choices on Tests and Procedures". JAMA: The Journal of the American Medical Association. 307 (21): 2245-2246. doi:10.1001/jama.2012.5341. PMID 22706814.
- Wolfson, D. B. (2012). "Are the Top 5 Recommendations Enough to Improve Clinical Practice? Comment on "Application of 'Less is More' to Low Back Pain" - Top 5 Recommendations to Improve Clinical Practice". Archives of Internal Medicine. 172 (13): 1020-1022. doi:10.1001/archinternmed.2012.1943. PMID 22664829.
- for an example of local public journalism of the campaign, consider Zamosky (10 May 2013). "Saying no to surgery - latimes.com". Los Angeles Times. Los Angeles: Tribune Co. ISSN 0458-3035. Retrieved 4 June 2013.
External links
- Official website
- Dr. Daniel Wolfson's posts on ABIM Foundation's blog Since March 2012, This person has posted commentary about Choosing Wisely
- Living well with breast cancer by choosing wisely: A conversation with Amy Berman, personal testimony from a geriatric care expert
Source of the article : Wikipedia
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