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Patient Care Module 0.5 Credit CME

Advancing Choosing Wisely®Take action to reduce unnecessary care and avoid harm

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. Explain the aim of Choosing Wisely® and its impact on delivering more effective patient care
2. Identify ways to engage practitioners, providers, clinical support staff, and patients in the Choosing Wisely® patient-centered care approach
3. Explain the importance of an implementation plan for Choosing Wisely® within your practice
4. Discuss the importance of using Choosing Wisely® data to track performance improvement

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me reduce unnecessary care in my practice?

  1. Five STEPS to advancing Choosing Wisely in your practice

  2. Answers to frequently asked questions about Choosing Wisely

  3. Tools and resources to help you and your team implement Choosing Wisely

Introduction

Do you ever find yourself concerned that you or your colleagues are providing tests or treatments that are unnecessary or of limited benefit? Quiz Ref IDChoosing Wisely®, a campaign from the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports, aims to promote conversations between clinicians and patients to choose care that:

  • Is supported by evidence

  • Is not duplicative of other tests or procedures already received

  • Has the lowest possible risk for harm

  • Is truly necessary

The Choosing Wisely lists of “Things Providers and Patients Should Question” were created by more than 70 professional societies. These “by clinicians for clinicians” recommendations cover tests, treatments and procedures commonly encountered in a variety of specialties. Each list provides evidence physicians and patients can use in their conversations to decide whether tests and procedures are appropriate for the situation. Using Choosing Wisely lists can help you reduce low-value and unnecessary care in your practice while becoming a better steward of health care resources. Choosing Wisely is not a set of rigid guidelines, but rather a strategy for engaging with patients and colleagues.

Box Section Ref ID

Q&A

  • What defines low-value care?

    Low-value care is care that either does not improve health outcomes or does so using resources that are disproportionate to the benefit that a patient derives. Simple examples include duplicative testing, too-frequent testing, interventions that have been shown to be ineffective or unnecessary, and care that patients may not have chosen had they been better informed about the risks and benefits.

“Community health screening fairs often include unnecessary tests or tests with limited benefit, such as a carotid ultrasound screening in asymptomatic patients. False positives are common, leading these patients to be referred for a carotid endarterectomy that can be potentially harmful. It's disturbing when a patient returns to the office with a facial droop having suffered a stroke as a result of a series of unnecessary and increasingly invasive procedures.”

Marie Teresa Brown, MD, Internal Medicine, Oak Park, IL
Five STEPS to advancing Choosing Wisely® in your practice

  1. Engage your providers

  2. Engage your staff

  3. Engage your patients

  4. Establish an implementation plan for the practice

  5. Use data to understand and improve performance

Step 1 Engage your providers

Quiz Ref IDCenter the conversation around the benefit for the patient. The national Choosing Wisely campaign has found that the issues of safety and patient-centered care resonate with physicians more than discussions of waste and cost reduction. Agree to pilot Choosing Wisely in one disease area or with one diagnosis and see how it works.

It is also important to emphasize that Choosing Wisely recommendations are conversation starters, not mandates, and that medical decision-making is based on the patient's best interest. It is expected that physicians will sometimes deviate from clinical practice guidelines and the Choosing Wisely recommendations based on patients' unique circumstances and the physician's own professional judgment.

Box Section Ref ID

Q&A

  • How do we begin the conversation?

    Consider discussing the following with your colleagues as you look for areas that could be improved by following Choosing Wisely recommendations:

    • What guidelines do we currently follow?

    • Why are we concerned about inappropriate use or overuse?

    • What are we measuring and how are we measuring it?

    • What difference will it make to our practice and our patients if we reduce overuse of these specific tests or procedures?

    • Can we eliminate sources of possible harm, such as radiation exposure, by changing our procedures?

  • What are the barriers to implementing Choosing Wisely? (or “Won't this increase my malpractice risk?” or “Won't this decrease patient satisfaction?”) How do we overcome these barriers?

    Poll your team about their concerns and address them head-on. Physicians who are especially concerned about malpractice claims may be more likely to engage in defensive practices, such as ordering unnecessary tests.13 However, unnecessary testing that leads to harm could be a source of malpractice claims.

    For example, unnecessary imaging studies that are ordered unnecessarily may lead to the discovery of unanticipated findings, which can then result in further invasive testing, such as biopsies of the liver, pancreas or lung, with serious potential physical complications. This may also lead to unnecessary anxiety and depression for patients.

    Physician-patient communication is the most important factor related to patient satisfaction with treatment recommendations.4 While a parent who arrives with a child with a lingering cough may expect an antibiotic, you can use Choosing Wisely patient handouts to facilitate an informed discussion on the recommended non-antibiotic approach. Anticipating these conversations will make the move to Choosing Wisely easier. The most common barriers to moving toward this type of higher-value care, as determined by a survey of 189 clinicians at Group Health Cooperative in Seattle, are5:

    Source: AMA. Practice transformation series: advancing Choosing Wisely®. 2016.

Step 2 Engage your staff

Quiz Ref IDConsider having your clinical support staff provide patients with appropriate Consumer Reports handouts when rooming patients for specific complaints (e.g., headache, upper respiratory infection, low-back pain, cervical cancer screening). For example, when the nurse or medical assistant (MA) rooms a patient who thinks they have a sinus infection, s/he can provide the patient with the Choosing Wisely handout on sinusitis. By reading the handout ahead of the physician visit, the patient may be more likely to agree to a non-antibiotic approach to treatment.

It is important to educate the care team members who often field questions from patients, including:

  • Your MAs or nurses, who room patients and discuss after-visit summaries, could be trained to utilize Choosing Wisely materials as part of their professional development curriculum

  • Your health coaches, who may have discussions with patients about specific treatment options and tests related to chronic disease management

While engaging your staff in the Choosing Wisely initiative, it is important to acknowledge that medical decision-making should always be based on the patient's best interest. Clinicians can always deviate from clinical practice guidelines based on their own professional judgment. Local standards of care and other factors must be taken into consideration.

Step 3 Engage your patients

Much of the success of implementing Choosing Wisely hinges on your ability to engage your patients in a dialogue about the purpose of tests, treatments and procedures so they have a clear understanding of what's necessary, what's not and what could cause them harm. Initiate the dialogue by demonstrating empathy for your patient's desires, needs and concerns; their cues will tell you when they are ready for you to introduce decision aids or patient education as part of a conversation about low-value care.

Consumer Reports partnered with the ABIM Foundation and leading medical societies on the Choosing Wisely campaign to create patient-friendly materials that cover unnecessary medical care as well as specific topics, such as use of antibiotics for sinusitis, CT scans for headache, frequency of Pap smears, and imaging for back pain. For example, many patients with chronic heartburn use proton pump inhibitors on a regular basis but may be able to control their symptoms with lifestyle modifications and/or an acid blocker such as a histamine H2 receptor antagonist. The Choosing Wisely handout on heartburn can facilitate the discussion between provider and patient.

You may choose to print these handouts and make them available in the waiting area and in your exam rooms. If you use a patient portal, you might send targeted handouts to patients before their appointment. Select the handouts that are most applicable to your Choosing Wisely focus area here.

Box Section Ref ID

Q&A

  • How can we better partner with patients and families on this initiative?

    Engage patients and families early and often. Patients may be confused by conflicting information they receive from their physicians, consumer groups and medical professional societies. You may consider including questions about testing procedures and communication about tests on your patient satisfaction survey. A patient and family advisory council or patient advisory board can assist you by vetting communication materials and evaluating the rollout of your new approach. Hosting a one-time focus group where a few patients discuss these topics with the clinicians can also be valuable.

  • Don't patients feel that more is always better?

    Highlighting negative consequences of overuse, such as the fact that radiation is harmful and can cause cancer, is often all that is needed to balance patients' desire for more care with their desire to avoid harm. Initiating a conversation helps distinguish between a true demand for additional care and the physician's perception of a demand that may not in fact exist. Demanding patients are memorable, but in reality they are uncommon.12

  • Won't my patient satisfaction scores go down if I don't meet patients' requests for tests or antibiotics?

    Offering a patient with a mild respiratory infection a “delayed prescription” for antibiotics may help the physician make the right choice while also meeting the patient's expectations. Likewise, a patient with acute back pain who is requesting an X-ray is often more comfortable knowing that the test will be done if he or she does not improve over time. However, as mentioned previously, positive and productive communication between patient and provider has a greater impact on patient satisfaction than an antibiotic prescription or an order for more testing.4 It is important for organizations that measure patient satisfaction scores to keep this in mind and ensure that this unintended consequence does not occur.

Step 4 Establish an implementation plan for the practice

Some practices may want to go beyond simply increasing awareness and making handouts available at the point of care. If your practice decides to more formally implement and systematize the Choosing Wisely initiative, then your implementation plan may be more elaborate.

Quiz Ref IDImplementation could take the form of a formal educational program, as well as checklists and protocols to help standardize the new processes. You may even choose to work with your IT department to embed Choosing Wisely recommendations into clinical decision support tools within the electronic health record (EHR; with alerts, reminders and/or order sets). Be aware, however, of the unintended consequences of forcing functions and documentation of variations from the recommendations. Choosing Wisely recommendations are intended to be starting points for conversation, not rigidly imposed guidelines.

To educate your practice about Choosing Wisely, consider using the physician communication modules available at http://www.choosingwisely.org/resources/modules/. Watch the videos and learn together during a scheduled team meeting.

Step 5 Use data to understand and improve performance

Tracking and reporting will help determine if implementation of the Choosing Wisely recommendations is effective in your practice. Sharing peer comparison data over time is one of the strongest interventions available for changing practice, and should be part of any strategy.

Box Section Ref ID

Q&A

  • Where do we start with a data tracking initiative?

    Ideas for opportunities could come from reviewing data in your EHR, pre-printed order sheets, standing orders from your team members. Target the tests you suspect may be overused, inconsistently used and/or harmful to patients.

    Consider starting with clinical areas where overuse occurs frequently, such as lab testing or imaging. Another target is any area where large amounts of variation exist. Review common tests and treatments by provider, establish a baseline and then compare and contrast to identify variability. Examples include appropriate antibiotic use, X-rays for back pain or too-frequent Pap smears. Where possible, use recommendations that have tested and validated measures.

AMA Pearls

Choosing Wisely lists are a starting point for conversation, not a set of rigid guidelines.

Choosing Wisely connects patients and clinicians by focusing both communities on achieving the same goals.

Choosing Wisely recommendations are purposefully broad, allowing you to tailor them to your practice needs.

Involve patients and families in the effort—they can review educational materials, help you determine an improvement topic and test new trategies.

Make sure you anticipate unintended consequences, such as the impact on referral relationships, when you limit some tests or increase testing in other areas.

Choosing Wisely may help you find the “sweet spot” in clinical practice: not too little, not too much, but just the right amount of care.

The data strategy for evaluating Choosing Wisely effectiveness should be timely and transparent to all in the practice. Be pragmatic about the measures that will be used.

Adequate time should be allotted to define and discuss current practice patterns. Administration must be engaged to support the work of implementing and evaluating Choosing Wisely.

Box Section Ref ID
Conclusion

Advancing Choosing Wisely is possible by engaging providers, staff and patients, and committing to continue practicing evidence-based medicine. Adopting the Choosing Wisely lists will support your practice in delivering higher-quality care and minimizing potential risks to patients.

Additional Resources

AMA Wire – Choosing Wisely

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: patient care, practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Planning Committee:

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA

  • Rita LePard, CME Program Committee, AMA

  • Bernadette Lim, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, AMA

  • Allison Winkler, MPH, Senior Practice Development Specialist, Professional Satisfaction and Practice Sustainability, AMA

Author Affiliations:

  • John Bulger, DO, FACOI, FACP, Chief Quality Officer, Geisinger Health System; Matt Handley, MD, Medical Director, Quality, Group Health; Wendy K. Nickel, MPH, Director of Patient Partnership in Healthcare, American College of Physicians; Marie Brown, MD, Senior Advisor Professional Satisfaction and Practice Sustainability, American Medical Association; Christine Sinsky, MD, Vice President Professional Satisfaction, American Medical Association

Faculty:

  • Jordan Messler, MD, SFHM, Hospitalist, INCompass Health, Morton Plant Hospitalists; Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA; Christopher Moriates, MD, Assistant Dean of Healthcare Value, Dell Medical School at the University of Texas, Austin; Allison Winkler, MPH, Senior Practice Development Specialist, Professional Satisfaction and Practice Sustainability, AMA; Daniel B. Wolfson, MHSA, Executive Vice President & COO, ABIM Foundation

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

References
1.
Carrier  ER, Reschovsky  JD, Katz  DA, Mello  MM.  High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice.  Health Aff. 2013;32(8):1383–1391. http://content.healthaffairs.org/content/32/8/1383.long.Google ScholarCrossref
2.
Carrier  ER, Reschovsky  JD, Mello  MM, Mayrell  RC, Katz  D.  Physicians' fears of malpractice lawsuits are not assuaged by tort reforms.  Health Aff. 2010;29(9):1585–1592. http://content.healthaffairs.org/cgi/pmidlookup?view=long&pmid=20820012.Google ScholarCrossref
3.
Choosing Wisely.  Research Report. http://www.choosingwisely.org/about-us/research-report/. Accessed March 10, 2016.
4.
Gonzales  R, Bartlett  JG, Besser  RE,  et al.  Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background.  Ann Intern Med. 2001;134(6):521–529. http://annals.org/article.aspx?articleid=714361.Google ScholarCrossref
5.
Buist  DS, Chang  E, Handley  M,  et al.  Primary care clinicians' perspectives on reducing low-value care in an integrated delivery system.  Perm J. 2016;20(1):41–46. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732793/.Google Scholar
6.
Choosing Wisely. http://www.choosingwisely.org/. Accessed March 10, 2016.
7.
Rosenberg  A, Agiro  A, Gottlieb  M,  et al.  Early trends among seven recommendations from the Choosing Wisely campaign.  JAMA Intern Med. 2015;175(12):1913–1920. http://archinte.jamanetwork.com/article.aspx?articleid=2457401.Google ScholarCrossref
8.
Rashid  A.  “Goldilocks Medicine:” the quest for “just right.”  The BMJ. http://blogs.bmj.com/bmj/2016/01/20/ahmed-rashid-on-goldilocks-medicine-the-quest-for-just-right/. Published January20 , 2016. Accessed April 25, 2016.Google Scholar
9.
The ABIM Foundation and Choosing Wisely.  Unnecessary tests and procedures in the health care system: what physicians say about the problem, the causes and the solutions. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May1 , 2014. Accessed May 4, 2016.
10.
Brehaut  JC, Colquhoun  HL, Eva  KW,  et al.  Practice feedback interventions: 15 suggestions for optimizing effectiveness.  Ann Intern Med. 2016;164(6):435–441. http://annals.org/article.aspx?articleid=2494536.Google ScholarCrossref
11.
Grover  M, McLemore  R, Tilburt  J.  Clinicians report difficulty limiting low-value services in daily practice.  J Prim Care Community Health. 2016;7(2):135–138. http://www.ncbi.nlm.nih.gov/pubmed/26763305.Google ScholarCrossref
12.
Back  AL.  The myth of the demanding patient.  JAMA Oncol. 2015;1(1):18–19. http://oncology.jamanetwork.com/article.aspx?articleid=2108844.Google ScholarCrossref
13.
Choosing Wisely.  Lists. http://www.choosingwisely.org/doctor-patient-lists/. Accessed March 10, 2016.
14.
Kost  A, Genao  I, Lee  JW, Smith  SR.  Clinical decisions made in primary care clinics before and after Choosing Wisely.  J Am Board Fam Med. 2015;28:471–474. http://www.jabfm.org/content/28/4/471.full.pdf+html.Google ScholarCrossref
15.
AGS Choosing Wisely Workgroup.  American Geriatrics Society identifies another five things that healthcare providers and patients should question.  J Am Geriatr Soc. 2013;61(4):622–631. http://onlinelibrary.wiley.com/doi/10.1111/jgs.12770/abstract;jsessionid=470DA9A8A0F42A49B5D1B569640FAFB9.f03t04.Google ScholarCrossref
16.
Pennsylvania Patient Safety Reporting System.  The Five Rights: Not the Gold Standard for Safe Medication Practices. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/jun2(2)/documents/09.pdf. Published 2005. Accessed March 25, 2016.
17.
Consumer Reports.  Choosing Wisely. http://www.consumerreports.org/cro/health/doctors-and-hospitals/choosing-wisely/index.htm. Accessed March 10, 2016.
18.
Consumer Reports.  Choosing Wisely campaign brochures. http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials. Accessed May 6, 2016.
19.
Choosing Wisely.  Physician communication modules. http://www.choosingwisely.org/resources/modules/. Accessed March 10, 2016.
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