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Advancing the Choosing Wisely ® Campaign. Objectives Why Choosing Wisely? Genesis and overview Of Choosing Wisely SHM Adult Recommendations Other Recommendations.

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Presentation on theme: "Advancing the Choosing Wisely ® Campaign. Objectives Why Choosing Wisely? Genesis and overview Of Choosing Wisely SHM Adult Recommendations Other Recommendations."— Presentation transcript:

1 Advancing the Choosing Wisely ® Campaign

2 Objectives Why Choosing Wisely? Genesis and overview Of Choosing Wisely SHM Adult Recommendations Other Recommendations and Discussion

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


5 Sources of waste Berwick D. JAMA. 2012;307(14):1513-1516.

6 Overview

7 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

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

9 “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

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


12 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




16 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

17 Minimizing Foley utilization Safety National Patient Safety Goal Infection risk Increased morbidity: sepsis, antimicrobial overuse, patient immobility and discomfort Reimbursement Negative financial implications

18 Not indicated outside of ICU Increases pneumonia Increases C. diff Increases hospital and after-hospital costs Am J Health-System Pharm. 1999;56:347–379.

19 Transfusion restrictive strategy Critical patients – consider Tx if Hb < 7 g/dL Post-op surgical patients - consider Tx: – Hb < 8 g/dL – Symptomatic (angina; orthostatic hypotension; tachycardia refractory to IVF resuscitation, CHF) Carson JL, et al. Ann Intern Med. 2012 Jul 3;157(1):49-58.

20 Resource and level of care Impacts flow Can lead to other tests and treatment Circulation 2004; 110:2721–2746. Society for Pacing and Electrophysiology. 1999; 100: 886-893. Chest 2002; 122:517–523. Cleveland Clinic Journal of Medicine, 2009; 368-372. Stroke 2007 May;38(5):1655-711.

21 Anemia Morbidity Increased cost

22 Pediatrics SHM Recommendations 1.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.

23 More Recommendations American 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.

24 More Recommendations American Academy of Neurology Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms American 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.

25 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.

26 More Recommendations American 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.

27 More Recommendations American 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.

28 More Recommendations American 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.

29 SHM HQPS Choosing Wisely Subcommittee members Center for Hospital Innovation and Improvement, SHM

30 Discussion John B. Bulger, DO, MBA

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