Patient Care

Ten Clinical Decisions to Eliminate Wasteful Healthcare Spending


 

Choosing Wisely

Who: Sponsored by the ABIM Foundation, the campaign includes 25 medical specialty societies.

What: A national quality campaign to educate physicians and patients about wasteful medical tests, procedures, and treatments.

When: Launched April 4, 2012.

Why: Treatments that are commonly ordered but not supported by medical research are not only potentially wasteful of finite healthcare resources, but they also could harm patients.

More info: www.hospitalmedicine.org/choosingwisely

Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?

If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.

Dr. Wolfson

Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”

SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.

“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.

Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.

“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.

Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.

“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”

Dr. Quinonez

Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.

Dr. Bulger

Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”

A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).

“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”

Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”


Larry Beresford is a freelance writer in Oakland, Calif.

Society of Hospital Medicine’s Choosing Wisely Recommendations

Adult Hospital Medicine

  1. Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis).
  2. Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
  3. Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
  4. Do not order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
  5. Do not perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

Pediatric Hospital Medicine

  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.

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