Choosing Wisely—or Not?

Jeri A. MilsteadPhD, RN, NEA-BC, FAAN

Choosing Wisely® Program

Created by American Board of Internal Medicine (ABIM)

To encourage conversations between physicians and patients

Question if tests/procedures needed? duplicative? costly?

Choosing Wisely Was a Response to RWJ Survey to Physicians to

Discover:

What issues are most frequently questioned by patients

RJW extended funding to create lists of questions

Funding available: apply directly to RWJ

Idea Expanded from Physician-Pt. to Provider-Pt.

Currently nearly 100 health-related and consumer organizations participate (including American Academy of Nursing)

Over 300 medically-directed tests/procedures targeted as possibly overused or inappropriate (Nursing Outlook, 2015)

Organizations Have Created Lists of 5-10 Items Each

Each organization lists items, a brief explanation as to how the list was created, and sources used to compile the list.

All items are founded on evidence as noted in the ‘sources’ section

All Lists Are Available at:

http://www.choosingwisely.

org

American Academy of NursingList (Mason, 2015)

1. Don’t automatically use continuous electronic fetal heart rate (FHR) monitoring during labor except for women without risk factors; consider intermittent auscultation (IA) first;

AAN List (contd)

2. Don’t let older adults lay in bed or only get up to chair during their hospital stay;

3. Don’t use hospital restraints with an older hospitalized patient.

AAN List (contd)

4. Don’t wake the patient for routine care unless the patient’s condition or care requires it;

5. Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.

Choosing Wisely® linked with Consumer Reports

Disseminate brochures, articles, videos, and online resources

ABIM reviews items and provides template for selection of items

Each organization responsible for own list

Intended use of lists: to help pts & providers become aware of

research

Patients now acknowledged members of the health care team

Many pts. bring medication inserts and articles (electronic & hardcopy) to office

Smart providers accept or correct info.

Examples of Lists

1. Don’t routinely avoid influenza vaccines in egg-allergic pts. (Am. Acad. of Allergy, Ashtma, & Immunology)

2. Don’t require preliminary exam to prescribe oral contraceptives or medications (Am. Acad. of Family Physicians)

3. Don’t use glucosamine or chondroitin to treat pts. With symptomatic osteoarthritis of the knee (Am. Acad. of Orthopaedic Surgeons)

4. Cough and cold medication should not be prescribed for respiratory illness in children under 4 yrs. (Am. Acad. of Pediatrics)

5. Infant home monitoring should not routinely be used to prevent Sudden Infant Death Syndrome (Am. Acad. of Pediatrics)

6. Do not delay engaging available palliative & hospice car services for ED pts. liable to benefit (Am. College of Emergency Physicians)

7. Don’t use homeopathic medications, non-vitamin dietary supplements, or herbal supplements as treatment for disease preventive health measures. (Am. College of Medical Toxicology and Am. Acad. of Clinical Toxicology)

AAN and Oncology Nursing Society – latest questionsDon’t neglect to advise patients with

cancer to get physical activity and exercise during and after treatment to manage fatigue and other symptoms.

Don’t use L-carnitine/acetyl-L-carnitine supplements to prevent or treat symptoms of peripheral neuropathy in patients receiving chemotherapy for treatment of cancer.

AAN/ONS contdDon’t use mixed medication mouthwash,

commonly termed “magic mouthwash,” to prevent or manage cancer treatment-induced oral mucositis.

Don’t administer supplemental oxygen to relieve dyspnea in patients with cancer who do not have hypoxia.

Don’t use aloe vera on skin to prevent or treat radiodermatitis.

Not all lists have been accepted by all providers, pts., or

organizations

Some believe tests/procedures are too insignificant or questions are not robust enough

Some fear items have already been deleted from use because of evidence reported

Examples (contd)

Some fear items may be redirecting a focus away from those tests/procedures that actually drive up costs

E.g., Cardiac stress tests before low-risk surgeries on 7 specialties’ lists of top procedures to watch for overuse but were rarely done before CW effort, (Frelick, 2015)

What Do YOU Think?

1. Do you use lists from trustworthy organizations? How do you decide?

2. What are your options if the items on the list you use are duplicative of other tests?

3. How do you determine if the cost of a test exceeds the benefit?

4. What sources for seeking evidence do you find reliable? Unreliable?

5. Who has input into what items are chosen for a list?

Once you have discussed these & other questions with your

colleagues, consider:

1. What kinds of information do pts bring with them or discuss with you?

2. What can you do to check the source of the information pts. bring?

3. What can you do if you have inadequate technology to find electronic resources?

4. How do you locate legitimate resources?

5. How can you differentiate reliable from unreliable sources?

6. What do you say if a pt. is not willing to accept that his/her source is not reliable?

Conclusion

Every nurse should seek opportunities to talk with colleagues and pts.

Is Choosing Wisely® an approach you would use?

References

www.aannet.org

www.abimfoundation.org

www.choosingwisely.org

www.consumerhealthchoices.org

www.consumerreports.org

References (contd)

Frelick, M. Do societies play it too safe with Choosing Wisely® lists? Retrieved from www.medscapedailynews.com Feb. 13, 2015.

Mason, D.J. (Jan/Feb 2015). Wisdom and will. Nursing Outlook, 63(1): 6,7. President’s message.

References (contd)

American Academy of Nursing announced engagement in national Choosing Wisely®campaign. (Jan/Feb 2015). Nursing Outlook, (63)1, American Academy on Policy.

References (contd)

FAAN Mail. (AAN electronic newsletter). (June 2015). American Academy of Nursing Partners with Consumer Reports to Bring Health Care Recommendations

Developed by Nurse Leaders to Consumers.