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Early Trends among Seven Recommendations from the Choosing Wisely Campaign
The Journal of Emergency Medicine, Vol. 50, No. 3, pp. 543–550, 2016 0736-4679/$ - see front matter
Abstracts , EARLY TRENDS AMONG SEVEN RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN. Rosenberg A, Agiro A, Gottlieb M, et al. JAMA Intern Med. 2015;175:1913-1920. Nearly one of every five dollars in the United States is spent on health care and it has been estimated that as many as onethird of those dollars are spent on interventions and diagnostic tests with marginal clinical benefit–or worse–may result in harm by triggering an avalanche of unnecessary procedures. In 2009, the American Board of Internal Medicine (ABIM) Foundation piloted the Choosing Wisely campaign, a physician-led effort to address overuse and waste, which has since expanded to include more than 400 proposed recommendations across multiple specialties. The goal of this study was to evaluate changes in physician behavior in response to these identified opportunities for improvement. This study retrospectively analyzed population-level claims data for approximately 25 million Blue Cross and Blue Shield members in the United States. Adherence to seven Choosing Wisely recommendations from April 2012 were selected for monitoring. Utilization of these low-value practices was calculated quarterly for the 15 months before and after addition to the Choosing Wisely campaign. The seven recommendations included: 1) do not obtain brain imaging for patients with uncomplicated headache, 2) do not obtain cardiac imaging for patients without a concerning history or physical, 3) do not obtain imaging for low back pain without red-flags, 4) do not obtain routine preoperative chest x-rays for patients with unremarkable history and physical examination results, 5) do not screen for cervical cancer by human papillomavirus (HPV) testing for women younger than 30 years, 6) do not prescribe antibiotics for patients with acute sinusitis, and 7) do not prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to patients with hypertension, heart failure, or chronic kidney disease. Of the seven low-value practices analyzed, two experienced decreased utilization, three remained unchanged, and two experienced increased utilization. The two recommendations with decreased utilization included imaging for uncomplicated headaches and cardiac imaging without a history of cardiac conditions, each with a relative 10% decrease over the period analyzed. Utilization of routine preoperative chest x-rays, imaging of low-back pain without red-flag symptoms, and antibiotic prescriptions for acute sinusitis did not change over the three year period. Finally, there was a 12.5% increase in the use of NSAIDs for patients with hypertension, heart failure, or chronic kidney disease and a 25% increase in HPV testing for women younger than 30 years old.
Overall, the authors conclude that the clinical significance of the observed trends is uncertain, and that the mixed results may indicate a need for increased physician intervention to achieve widespread adoption of the Choosing Wisely recommendations. Several limitations to the study were acknowledged, including the limitation of administrative claims data not adequately capturing the clinical context in which services are ordered. [Zachary J. Jarou, MD Denver Health Medical Center, Denver, CO] Comment: This study shows that physician adherence to the recommendations of the Choosing Wisely campaign was mixed for seven low-value services in the 15 months following their initial adoption. Emergency physicians are most likely aware of the ten Choosing Wisely recommendations endorsed by the American College of Emergency Physicians but may be less knowledgeable of their recommendations of other specialty societies, even though they may apply to interventions and diagnostics ordered in the emergency department. Future study is needed to examine adherence to guidelines proposed by each physician’s own specialty society, with a methodology to include the clinical context in which services are ordered, as well as to identify limitations to implementation, such as lack of safe harbor protections for physicians fearful of medical malpractice litigation despite following guidelines. , CONTAMINATION OF HEALTH CARE PERSONNEL DURING REMOVAL OF PERSONAL PROTECTIVE EQUIPMENT. Tomas ME, Kundrapu S, Thota P, et al. JAMA Intern Med. 2015;175:1904-1910. Proper use of personal protective equipment (PPE) is crucial to reducing the transmission of pathogens between patients and healthcare personnel. Previous studies have shown high rates of health provider contamination even when wearing PPE and that the PPE removal process may be a high-risk step for inadvertent contamination if appropriate strategies are not in place. The goal of this study was to analyze the frequency and sites of contamination during PPE removal and also to test the effect of an educational intervention on reducing inadvertent contamination. This study contained two parts, a point-prevalence study at four hospitals serving diverse patient populations in the Cleveland area, as well as a quasi-experimental intervention at one of the hospitals. Physicians, nurses, and allied health care personnel were included. Participants completed two simulations with either gloves or gowns smeared with fluorescent
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Abstracts , EARLY TRENDS AMONG SEVEN RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN. Rosenberg A, Agiro A, Gottlieb M, et al. JAMA Intern Med. 2015;175:1913-1920. Nearly one of every five dollars in the United States is spent on health care and it has been estimated that as many as onethird of those dollars are spent on interventions and diagnostic tests with marginal clinical benefit–or worse–may result in harm by triggering an avalanche of unnecessary procedures. In 2009, the American Board of Internal Medicine (ABIM) Foundation piloted the Choosing Wisely campaign, a physician-led effort to address overuse and waste, which has since expanded to include more than 400 proposed recommendations across multiple specialties. The goal of this study was to evaluate changes in physician behavior in response to these identified opportunities for improvement. This study retrospectively analyzed population-level claims data for approximately 25 million Blue Cross and Blue Shield members in the United States. Adherence to seven Choosing Wisely recommendations from April 2012 were selected for monitoring. Utilization of these low-value practices was calculated quarterly for the 15 months before and after addition to the Choosing Wisely campaign. The seven recommendations included: 1) do not obtain brain imaging for patients with uncomplicated headache, 2) do not obtain cardiac imaging for patients without a concerning history or physical, 3) do not obtain imaging for low back pain without red-flags, 4) do not obtain routine preoperative chest x-rays for patients with unremarkable history and physical examination results, 5) do not screen for cervical cancer by human papillomavirus (HPV) testing for women younger than 30 years, 6) do not prescribe antibiotics for patients with acute sinusitis, and 7) do not prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to patients with hypertension, heart failure, or chronic kidney disease. Of the seven low-value practices analyzed, two experienced decreased utilization, three remained unchanged, and two experienced increased utilization. The two recommendations with decreased utilization included imaging for uncomplicated headaches and cardiac imaging without a history of cardiac conditions, each with a relative 10% decrease over the period analyzed. Utilization of routine preoperative chest x-rays, imaging of low-back pain without red-flag symptoms, and antibiotic prescriptions for acute sinusitis did not change over the three year period. Finally, there was a 12.5% increase in the use of NSAIDs for patients with hypertension, heart failure, or chronic kidney disease and a 25% increase in HPV testing for women younger than 30 years old.
Overall, the authors conclude that the clinical significance of the observed trends is uncertain, and that the mixed results may indicate a need for increased physician intervention to achieve widespread adoption of the Choosing Wisely recommendations. Several limitations to the study were acknowledged, including the limitation of administrative claims data not adequately capturing the clinical context in which services are ordered. [Zachary J. Jarou, MD Denver Health Medical Center, Denver, CO] Comment: This study shows that physician adherence to the recommendations of the Choosing Wisely campaign was mixed for seven low-value services in the 15 months following their initial adoption. Emergency physicians are most likely aware of the ten Choosing Wisely recommendations endorsed by the American College of Emergency Physicians but may be less knowledgeable of their recommendations of other specialty societies, even though they may apply to interventions and diagnostics ordered in the emergency department. Future study is needed to examine adherence to guidelines proposed by each physician’s own specialty society, with a methodology to include the clinical context in which services are ordered, as well as to identify limitations to implementation, such as lack of safe harbor protections for physicians fearful of medical malpractice litigation despite following guidelines. , CONTAMINATION OF HEALTH CARE PERSONNEL DURING REMOVAL OF PERSONAL PROTECTIVE EQUIPMENT. Tomas ME, Kundrapu S, Thota P, et al. JAMA Intern Med. 2015;175:1904-1910. Proper use of personal protective equipment (PPE) is crucial to reducing the transmission of pathogens between patients and healthcare personnel. Previous studies have shown high rates of health provider contamination even when wearing PPE and that the PPE removal process may be a high-risk step for inadvertent contamination if appropriate strategies are not in place. The goal of this study was to analyze the frequency and sites of contamination during PPE removal and also to test the effect of an educational intervention on reducing inadvertent contamination. This study contained two parts, a point-prevalence study at four hospitals serving diverse patient populations in the Cleveland area, as well as a quasi-experimental intervention at one of the hospitals. Physicians, nurses, and allied health care personnel were included. Participants completed two simulations with either gloves or gowns smeared with fluorescent
543