The Choosing Wisely initiative, which was started in 2012 and led by the American Board of Internal Medicine, spurred 70 medical societies, including the Society of Hospital Medicine, to create lists of practices within their field that are likely performed more often than necessary.
The campaign was so expansive that it inspired regular journal features that kept the Choosing Wisely theme in mind, focusing on things physicians and other health professionals could do differently in the name of value and optimal outcomes. One of those has been the “Next Steps” column in the Journal of Hospital Medicine.
Since it was introduced in 2014, the column has been called “Choosing Wisely: Next Steps in Improving Healthcare Value,” with forward-looking, big-picture pieces on ways to improve healthcare systems—in the vein of Choosing Wisely, but with somewhat broader themes and aims.
The Choosing Wisely campaign officially ended in 2023, and now the Next Steps column is evolving as well. It will be re-titled “Next Steps: Improving Healthcare Value” or “Next Steps: Policy in Clinical Practice,” depending on the subject matter. The change made sense because it allows for topics beyond the scope of Choosing Wisely to be considered and makes for a more streamlined title, said Michael Tchou, MD, the column’s editor and an assistant professor of pediatrics at the University of Colorado, where he is a pediatric hospitalist at The Children’s Hospital Colorado in Aurora, Colo.
Dr. Tchou
Dr. Tchou, who has been the column’s editor since 2021 and works alongside Oanh Nguyen, MD, MAS, associate professor of medicine at the University of California, San Francisco, said the Choosing Wisely campaign “has really helped increase awareness of the things we do that are probably low-value to patients in the healthcare system” and has inspired a lot of quality improvement work. But he said the time had come to shift the focus of the column, while keeping the roots in mind.
Dr. Nguyen
“We didn’t want to limit it just to Choosing Wisely-related things,” he said. “It’s kind of an expanded view of the same topic area that Choosing Wisely was focused on, but really thinking about how to maximize that impact, whether it’s policy change or changing the systems of care on a broader scope.”
Dr. Tchou said he was drawn to the concept of Next Steps largely because he has had a professional interest in quality improvement. During his pediatric hospitalist fellowship at Cincinnati Children’s Hospital, his research focused on the overuse of medical resources, mostly from laboratory testing.
He led a project that looked at electrolyte testing, which is a basic test that many pediatric patients routinely get but that usually doesn’t change their management very much. While he was at Cincinnati, he and his team were able to reduce this electrolyte testing by about 30%, a reduction maintained for at least the next two years until he moved to the Children’s Hospital Colorado.
Despite the substantial reduction in testing, there was no worsening of outcomes, such as length of stay, he said. But the change significantly decreased the number of overnight awakenings for the pediatric patients—a notable development considering that it can be difficult for the children to fall back to sleep—as well as early-morning awakenings, while also decreasing the anxiety of the children who dread the blood draws. The change also reduced demand on nursing resources.
“We were really proud of that work, and I think it was a model for thinking about how do we think about this concept of diagnostic stewardship—doing the right test at the right time that we think will be most beneficial for patients in making decisions,” he said.
Much of Dr. Nguyen’s research has focused on how social and structural determinants of health affect outcomes for people who have been underserved and historically marginalized, and on interventions to overcome these factors.
The editors have brought that eye toward improvement to the Next Steps series, with the choice of topics and thorough exploration of those topics.
One piece looked at changes needed in the era of prescribing the opioid partial agonist buprenorphine in the context of no longer needing an X waiver, with writers suggesting developing order sets for easier prescribing and reducing errors, as well as educational interventions to decrease bias and increase confidence in prescribing appropriately.1
In another piece, writers described an “innovation center” around COVID-19 policies, with staff members at the center invited to propose ideas, and seed funding going to ideas that were chosen. The innovation center produced nearly 200 ideas covering personal protective equipment, testing, and data analytics.2
In perhaps one of the biggest-picture pieces in the series, authors in 2022 examined the limitations of the Choosing Wisely campaign itself, arguing that the grassroots, “bottom-up” nature of the campaign had possibly maxed out on the impact it could have. Authors pointed to hindrances for making change leading to value, including that wasteful practices are often intertwined with high-value practices, and that some interventions, such as automated alerts, have simply led to “clinicians overriding such alerts virtually all of the time.”3
Endorsing a strategy of both physician-led and system-wide approaches, they pointed to a Canadian initiative to reduce unnecessary red-blood-cell transfusions that outlined benchmarks for appropriate use and offered quality-improvement credit in the accreditation process to participating hospitals.
“More substantive reductions in low-value care will depend on a new approach—one that tackles broader system-wide targets through an approach that combines grassroots efforts with health policy changes to healthcare delivery,” the authors wrote.
Dr. Tchou said he is hoping to raise the profile of the series and said he would welcome article proposals.
“Our goal moving forward is to try to garner more interest in this series,” he said, adding that potential writers can get in touch “if people have a topic that they’re passionate about or an area of interest.” The email for suggested columns is [email protected].
“We would invite them to email us even if it’s just a really short bullet-point summary,” Dr. Tchou said.
He also would like to interact with readers more and hopes to draw more ideas from them, as well.
“It would be great to get ideas from readers, too, because our goal with the series is really to bring people with the experience in these topic areas, policy, or system-wide improvement, and write articles that help the readers in their daily practice and help them understand these higher, bigger issues and these next steps.”
Tom Collins is a medical writer based in South Florida.
References
- Haber LA, et al. Policy in clinical practice: elimination of the buprenorphine “X-waiver”. J Hosp Med. 2023;18(10):931-933. doi:10.1002/jhm.13176.
- Shumacher ME, et al. Use of an innovation center to foster high-value COVID-19 care at an academic healthcare system. J Hosp Med. 2022;17(5):384-388. doi:10.1002/jhm.12824.
- Levinson W, Leis JA. Improving healthcare value: Lessons learned from the first decade of Choosing Wisely®. J Hosp Med. 2023;18(1):78-81. doi:10.1002/jhm.12969.