2 DisclosuresDaniel Wolfson has no relevant financial relationships with commercial interests and will not be discussing non-FDA approved uses of any drugs nor has he received any financial compensation in connection with the initiative described in the following presentation.
3 Stand-up if you have witnessed unnecessary care harming patients
4 Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.4
6 ABIM Foundation/ACP Foundation/EFIM Physician CharterA Commitment toProfessional competenceHonesty with patientsPatient confidentialityMaintaining appropriate relations with patientsImproving quality of careImproving access to careA just distribution of finite resourcesScientific knowledgeMaintaining trust by managing conflicts of interestProfessional responsibilitiesFundamental PrinciplesPrimacy of patient welfarePatient autonomySocial justice66
7 Motivating behavior change: Self-Determination Theory Autonomy“One form of autonomous motivation is identified regulation, in evidence when one personally endorses or identifies with the value or importance of a behaviour or health practice.”Competence“…support for competence is afforded when practitioners provide effectance relevant inputs and feedback.”Relatedness“In this process a sense of being respected, understood, and cared for is essential to forming the experiences of connection and trust that allow for internalization to occur.”Ryan, R. M., Patrick, H., Deci, E. L., & Williams, G. C. (2008). Facilitating health behaviour change and its maintenance: Interventions based on self-determination theory. The European Health Psychologist, 10, 2-5.
8 Activating Professionalism Societies were free to determine the process for creating their lists with the following requirements:Each item was within the specialty’s purview and controlProcedures should be used frequently and/or carry a significant costShould be generally-accepted evidence to support each recommendationProcess should be thoroughly documented and publicly available upon request8
9 Choosing Wisely By The Numbers 60 specialty society partners230 recommendations to date (will exceed 300 by mid 2014)23 grantees (funded by Robert Wood Johnson Foundation)163+ journal articles discussing CW36 participants in CW Health System Leaders Network
11 From: Eliminating Waste in US Health Care The “wedges” model for US health care follows the approach based on the model by Pacala and Socolow. The solid black “business as usual” line depicts a current projection of health care spending, which is estimated to grow faster than the gross domestic product (GDP), increasing the percentage of GDP spent on health care; the dashed line depicts a more sustainable level of health care spending growth that matches GDP growth, fixing the percentage of GDP spent on health care at 2011 levels. Between these lines lies the “stabilization triangle”—the reduction in national health care expenditures needed to close the gap. The 6 colored regions filling the triangle show one possible set of spending reduction targets; each region represents health care expenditures as a percentage of GDP that could be eliminated by reduction of spending in that waste category over time.Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhilJAMA. 2012;307(14): doi: /jama
12 “Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little.”
13 60% of surveyed physicians believe that trial lawyers do; According to the results of a survey of more than 2,400 physicians, when asked who has a “major responsibility” for controlling health care costs,60% of surveyed physicians believe that trial lawyers do;59% believe that health insurance companies do;56% believe hospitals and health systems do;56% also believe pharmaceutical and device manufacturers do;52% believe patients do; and,44% believe government does.36% reported that practicing physicians have“major responsibility.”
14 Call to the Profession: Where are the Health Care Cost Savings? Deficit pressures are making cost control inevitable. It will only be successful if physicians stop looking to others to find solutions and focus on approaches that improve the care for patients with chronic illnesses.-Ezekiel J. Emanuel, MD, PhD
15 How do we reduce health care costs? Reduce wasteInitiatives such as Choosing Wisely that identify areas of potential waste (unnecessary tests and procedures) and encourage physicians to openly discuss options with patientsPhysician decisions account for 80% of all health care expendituresCrosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 27 Apr 2009One-third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessaryCampbell EG, et al. Professionalism in medicine:results of a national survey of physicians.Ann Intern Med. 2007; 147(11):
16 Choosing Wisely Partners Societies That Announced Lists April 2012American Academy of Allergy Asthma & ImmunologyAmerican Academy of Family PhysiciansAmerican College of CardiologyAmerican College of PhysiciansAmerican College of RadiologyAmerican Gastroenterological AssociationAmerican Society of Clinical OncologyAmerican Society of NephrologyAmerican Society of Nuclear CardiologySocieties That Announced Lists February 2013American Academy of Family PhysiciansAmerican Academy of Hospice and Palliative MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Otolaryngology-Head and Neck SurgeryAmerican Academy of PediatricsAmerican College of Obstetricians and GynecologistsAmerican College of RheumatologyAmerican Geriatrics SocietyAmerican Society for Clinical PathologyAmerican Society of EchocardiographyAmerican Urological AssociationSociety of Cardiovascular Computed TomographySociety of Hospital MedicineSociety of Nuclear Medicine and Molecular ImagingSociety of Thoracic SurgeonsSociety of Vascular Medicine
17 Societies Announcing Lists in Late in 2013 and Early 2014 American Academy of Clinical ToxicologyAmerican Academy of DermatologyAmerican Academy of Family PhysiciansAmerican Academy of NeurosurgeryAmerican Academy of Orthopaedic SurgeonsAmerican Association of Blood BanksAmerican Association of Clinical EndocrinologistsAmerican Association for Pediatric Ophthalmology and StrabismusAmerican College of Chest PhysiciansAmerican College of Emergency PhysiciansAmerican College of Medical ToxicologyAmerican College of Occupational and Environmental MedicineAmerican College of RheumatologyAmerican College of SurgeonsAmerican Geriatrics SocietyAmerican Headache SocietyAMDA—Dedicated to Long Term Care MedicineAmerican Medical Society for Sports MedicineAmerican Psychiatric AssociationAmerican Society of AnesthesiologistsAmerican Society of Clinical OncologyAmerican Society of Colon and Rectal SurgeonsAmerican Society of HematologyAmerican Society of Plastic SurgeonsAmerican Society for Radiation OncologyAmerican Society for Reproductive MedicineAmerican Thoracic SocietyCommission on CancerThe Endocrine SocietyHeart Rhythm SocietyNorth American Spine SocietySociety for Cardiovascular Angiography and InterventionsSociety of Cardiovascular Magnetic ResonanceSociety of Critical Care MedicineSociety of General Internal MedicineSociety of Gynecologic OncologySociety for Maternal-Fetal Medicine
18 Through Partnership with Consumer Reports Consumer GroupsThrough Partnership with Consumer ReportsAARPAlliance Health NetworksCovered CaliforniaLeapfrog GroupMidwest Business Group on HealthMinnesota Health Action GroupNational Business Coalition on HealthNational Business Group on HealthNational Center for Farmworker HealthNational Hospice andPalliative Care OrganizationNational Partnership for Women & FamiliesPacific Business Group on HealthPuget Sound Health AllianceSEIUUnion PlusUnivision (with HolaDoctor)Washington State Medical AssociationThe Wikipedia Community
21 Health System Network Participants Advocate Health CareAmerican College of Physician ExecutivesCatholic HealthCapital District Physicians’ Health PlanCedars-SinaiChristiana CareCleveland ClinicDignity HealthFranciscan Health SystemFred Hutchinson Cancer Research CenterGeisingerGroup Health CooperativeHospital Association of Southern CaliforniaIntermountain Health CareJohns HopkinsKaiser PermanenteLong Island Health NetworkMaine Medical CenterMercyOregon Health & Science UniversityNorthwest Physicians NetworkNYUPartners HealthCarePenobscot Community Health CarePremier
22 Health System Network Participants (Continued) Puget Sound Health AllianceSouth Nassau Communities HospitalSteward Healthcare SystemUC-IrvineUCLAUCSFUniversity of MichiganUniversity of TorontoUniversity of WashingtonUniversity of WisconsinWellStar Health System
23 Clinical Decision Support: Cedars-Sinai Cedars-Sinai has incorporated 120 CW recommendations into its EHR system (Epic)Physicians receive alert when they order test, procedure or medication questioned by CWAlert provides information on the CW recResponse from physicians has been positive, despite “alert fatigue” – Cedars leader credits this to respect for specialty societies
24 Patient Support: Anne Arundel Medical Center Anne Arundel Medical Center has embedded Consumer Reports’ translations into its EMR system so that physicians can provide them to patients to enhance their understanding and ability to make decisions about their careAAMC has also included numerous articles about CW in its newsletter and “enews” for staff, as well as on its website and other communications geared to the public
25 Data Feedback: Fred Hutchinson Fred Hutchinson Cancer Research Center benchmarked the CW recommendations from the American Society of Clinical Oncology among 14 group practices in Seattle areaFound wide variationPlanning joint quality improvement activities to implement the recommendations
26 QI in Hospital Medicine: UCSF UCSF had existing focus on overuse, and leaders there thought their use of procedures highlighted by CW would already be lowDiscovered that their utilization was lower than their peers for only one of five SHM adult medicine recsNow implementing a quality improvement plan focused on other four recs from SHM, covering medications for stress ulcer prophylaxis, blood transfusions, continuous telemetry monitoring outside of the ICU, and certain lab testsEffort is led by committee of physicians and finance administrators who are focused on increasing physician awareness of the costs of treatments they commonly order
27 System as Employer: Mercy Mercy, an integrated Catholic health system with 32 hospitals, has aggressively promoted CW to its own employeesEach month, one recommendation is highlighted through employee communications, and Mercy developed an internal website that directs employees to the CW site and to Consumer ReportsUsed flagship site (Springfield, MO) to implement on physician side – medical directors reviewed 45 initial recs and narrowed to 27 where Mercy was performing the proceduresMedical directors and other leaders addressed large sections about the recommendations, received little pushbackMercy now has 14 measures to review whether the recommendations are having an impact – also sharing comparative data with its physicians on utilization of procedures covered by CW (e.g., imaging for headache)Example of how dissemination through the health care system could be studied (beyond flagship site)
28 QI in Radiology: KP Colorado KP-Colorado worked with department heads to review all CW recs, focused on 20, mostly imagingThrough chart reviews, found that 25 percent of physician orders for imaging for headaches was inappropriateHas launched projects to reduce overuse of imaging in five specific areas (e.g., headache, low back pain) – more projects are in the pipelineConducting one-on-one conversations with physicians who are outliers in test ordering (i.e., academic detailing)CW is “the most welcome thing we’ve ever seen,” according to Margaret Ferguson, MD, associate medical director of affordability. It “gives us a whole new way of presenting affordability.”
29 Choosing Wisely Grantees Regional CollaborativesBetter Health Greater ClevelandHealthInsight UtahInstitute for Clinical Systems Improvement and the Minnesota Health Action GroupIowa Healthcare CollaborativeMaine Quality CountsMassachusetts Health Quality PartnersMichigan Health Information Alliance, Inc.Puget Sound Health AllianceWisconsin Collaborative for Healthcare QualitySocieties/State Medical AssociationsAmerican Academy of Hospice and Palliative MedicineAmerican Academy of OphthalmologyAmerican College of PhysiciansAmerican Society for Clinical PathologyAmerican Society of EchocardiographyAmerican Society of Nuclear CardiologyMinnesota Medical AssociationOregon Medical AssociationSociety of Hospital MedicineTennessee Medical AssociationTexas Medical AssociationWashington State Medical Association
30 RWJF Grantee: Iowa Healthcare Collaborative IHC has developed an “Iowa 5” set of recommendations unique to the state’s communities.IHC will work with Wellmark to track claims data across the state to measure the effect of implementing the campaign across these focus areas, and promote resources to improve.
31 Maine Quality CountsMaine Quality Counts (MQC) will work with four pilot sites to identify a set of specific measures to implement and to monitor progress, identify lessons learned, best practices, and barriers. Sites include:Penobscot Bay Medical Center (25,000 patients)Penobscot Community Health Center (14,950 patients)Winthrop Family Practice (6,700 patients)Oxford Hills Family Practice (2,700 patients)Interventions include modification of order sets and communications training.A pre and post web based survey will be conducted by GfK to assess attitudes and awareness of Choosing Wisely in both the physician and patient populations.
32 American Society of Echocardiography ASE has developed a smartphone app that allows physicians to access the ASE Choosing Wisely recommendations and appropriate use criteria to determine whether a cardiovascular ultrasound exam is appropriate.The app also includes Choosing Wisely recommendations from other societies.Measures of success for this project include: the number of downloads of the app and a survey to measure use of and satisfaction with the app. The survey would measure physicians’ understanding of the Choosing Wisely information and their’ self-reported impact of CW on their attitudes and practice. We estimate that through the app, ASE could reach over 200,000 physicians.
33 “We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what’s unnecessary.”
34 For more information Choosing Wisely: www.choosingwisely.org ABIM Foundation:The Medical Professionalism Blog: blog.abimfoundation.orgTwitter: @ABIMFoundation@wolfsond@richardbaron17Facebook:www.facebook.com/theabimfoundation