Choosing Wisely: American College of Physicians

JHC_Sept14-484469357A Quest to Deliver High Value Care

“Choosing Wisely encourages physicians and patients to question the routine use of tests and treatments that are unlikely to help and may actually harm patients,” says Daisy Smith, MD, FACP, senior physician educator, American College of Physicians. As such, it fits with ACP’s mission, that is, “to enhance the quality and effectiveness of healthcare by fostering excellence and professionalism in the practice of medicine,” she says. “ACP members are dedicated to improving patient outcomes, and this is the goal of Choosing Wisely and the ACP’s High Value Care Campaign.”

The barriers to change are formidable.

“We have surveyed a subset of our membership who spend over 50 percent of their time in practice on reasons why they ordered additional unnecessary tests, and were a bit surprised with what we found,” says Smith. “The No. 1 reason physicians over-ordered tests was because of their discomfort with diagnostic uncertainty. The second most commonly cited reason was fear of malpractice. The third was concern for inadequate patient follow up/access (more prominent for hospitalists). The fourth was time pressure, and the fifth was patient requests.

“These data showed us that the major focus or concern driving physician behavior is a desire to do the best for their patients, and so we used the frame of avoiding the harms of unnecessary testing (this may include financial harm to the patient) in our education to providers around this issue. This resonates much more with providers than saving money.”

The ACP has integrated its own Choosing Wisely recommendations and those of other specialty societies, as well as the tools of its High Value Care program, into its education programs, products and services, says Smith.

“This includes High Value Care learning objectives and programming at our live meetings; High Value Care recommendations in our popular medical knowledge self-assessment program (MKSAP); a High Value Care sub-score on our internal medicine in-training examination; and High Value Care callouts in our new evidence-based point-of-care resource, SmartMedicine,” she says. In addition, ACP has collaborated with the Alliance for Academic Internal Medicine and MedU to create free curricula on High Value Care for medical students, residents, and practicing clinicians. These curricula have been accessed over 30,000 times since they were developed and have expanded the reach of the initiative and the discussion beyond isolated lists.

Payers are excited about Choosing Wisely as well as the ACP’s High Value Care initiative and have expressed an interest in supporting this work, says Smith. That said, “the ACP has been very cautious about accepting any support from payers for this work, as this may be perceived as a conflict of interest and focus unnecessarily on saving money, when our real focus is on improving outcomes,” she says. “In addition, we aim to promote and protect the healing relationship between a patient and their provider.

“A key step in our High Value Care framework involves customizing a care plan that incorporates the patient’s values and addresses their concerns. We do not believe that one-size-fits-all care is high value care.”

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American College of Physicians: Five Things Physicians and Patients Should Question

  1. Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
  2. Don’t obtain imaging studies in patients with non-specific low back pain.
  3. In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
  4. 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.
  5. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

Source: Choosing Wisely, an initiative of the ABIM Foundation,
http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf