Advancing the Choosing Wisely® Campaign

Objectives

• Why Choosing Wisely?

• Genesis and overview Of Choosing Wisely

• SHM Adult Recommendations

• Other Recommendations and Discussion

Commonwealth Fund, via Ezra Klein, et. al., Washington Post, Wonkblog

http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/

Sources of waste

Berwick D. JAMA. 2012;307(14):1513-1516.

Overview

http://www.choosingwisely.org

• A unique partnership with 35 medical societies

• Main objective - to foster communications between doctors and patients about commonly performed tests and procedures that may fail to provide value or enhance patient outcomes

• Consumer Reports as additional partner

• Specific

• Evidence-based

• Recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.

http://www.choosingwisely.org/

“Five Things Patients and Physicians Should Question”

• Participating societies developed top 5 recommendations for consideration

• Lists include evidence-based recommendations to assist with making decisions about selecting the right care at the most appropriate time

• SHM developed a list of five adult and five pediatric recommendations

The campaign aims to educate patients and physicians and provoke dialogue about improved resource utilization to achieve more optimal outcomes.

http://www.spotlight-on-science.com/2010/10/breast-cancer-awareness-month.html

How can the Choosing Wisely® campaign impact patient care?

Overutilization of healthcare resources has significant implications for health care costs, patient care and outcomes as well as system sustainability In 2010, $2.6 trillion dollars were spent on healthcare, an

increase of $1.3 trillion between 2000 and 2010 ten times the $256 billion spent in 1980

As much as 30% of health care spending may be wasted A larger healthcare expenditure does not necessarily

translate into better patient outcomes

http://www.kaiseredu.org/issue-modules/us-health-care-costs/background-brief.aspx

http://choosingwisely.org/

http://www.choosingwisely.org/doctor-patient-lists/society-of-hospital-medicine-adult-hospital-medicine/

• Urinary tract infections (UTI) ~ 30% of all healthcare-associated infections- Usually related to urinary catheters- Catheter-associated UTI (CA-UTI) affects 900,000

patients per year (U.S.)• Increased morbidity, mortality, hospital cost and

length of stay

• Anemia• Morbidity• Increased cost

Pediatrics SHM Recommendations1. Don’t order chest radiographs in children with uncomplicated asthma or

bronchiolitis.2. Don’t routinely use bronchodilators in children with bronchiolitis.3. Don’t use systemic corticosteroids in children under 2 years of age with an

uncomplicated lower respiratory tract infection.4. Don’t treat gastroesophageal reflux in infants routinely with acid

suppression therapy.5. Don’t use continuous pulse oximetry routinely in children with acute

respiratory illness unless they are on supplemental oxygen.

More RecommendationsAmerican Society of Nephrology• Don’t administer erythropoiesis-stimulating agents (ESAs) to

chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.

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

American Academy of Hospice and Palliative Medicine• Don’t recommend percutaneous feeding tubes in patients

with advanced dementia; instead, offer oral assisted feeding.

More RecommendationsAmerican Academy of Neurology• Don’t perform imaging of the carotid arteries for simple

syncope without other neurologic symptomsAmerican Academy of Ophthalmology• Don’t perform preoperative medical tests for eye surgery

unless there are specific medical indications.American College of Cardiology• 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.

More Recommendations

American College of Physicians• 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.

American College of Rheumatology• Don’t test ANA sub-serologies without a positive ANA and

clinical suspicion of immune-mediated disease.

More RecommendationsAmerican Geriatrics Society• Don’t use benzodiazepines or other sedative-

hypnotics in older adults as first choice for insomnia, agitation or delirium.

The Society of Thoracic Surgeons• Patients who have no cardiac history and good

functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.

More RecommendationsAmerican Academy of Family Physicians• Don’t schedule elective, non-medically indicated

inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

• Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days OR symptoms worsen after initial clinical improvement.

• Don't do imaging for low back pain within the first six weeks, unless red flags are present.

More RecommendationsAmerican Academy of Family Physicians• Don't perform Pap smears on women under the age of

21 or women who have had a hysterectomy for non-cancer disease.

• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

• Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

SHM HQPS Choosing Wisely Subcommittee members

Center for Hospital Innovation and Improvement, SHM

Discussion

John B. Bulger, DO, MBAjbulger@geisinger.edu