ANN ARBOR, MI - Five years ago, a group of medical organizations did something they'd never done before: give doctors a list of things they shouldn't do for their patients. Their goal: to empower doctors and patients to start a conversation about avoiding unnecessary care.
Now, the momentum behind this campaign, called "Choosing Wisely", has snowballed. The list of things doctors shouldn't do has grown to more than 500 items - from specific uses of blood tests and scans, to particular prescription drugs and medical devices. Behind each one lies a body of evidence showing that it's not necessary for specific patients - or that it may even harm them.
But if the world wants to eliminate unnecessary care, the Choosing Wisely movement needs to evolve, say a trio of University of Michigan and VA researchers in a new analysis published in Health Affairs and discussed at a briefing in Washington, D.C. today.
Even after a Choosing Wisely recommendation comes out, the actual use of that type of care may go down only slightly, according to several studies. This shows how hard it is to help doctors stop doing things they may have done for years, for patients with particular symptoms or health risks.
The campaign has succeeded tremendously in starting the conversation about low value care, say the authors of the new paper. But it does need to take specific next steps to continue to move forward.
"We need to get more rigorous, and more innovative," says Eve Kerr, M.D., M.P.H., lead author of the paper and a longtime researcher on appropriate and low-value care. "The recommendations so far are a great start and laid the foundation, but we need to focus on using strong methods to identify ones that will make the most difference in quality and value in healthcare, and innovate in the way we change clinical practice and culture."
Some specific recommendations that Kerr and her colleagues make include:
- Prioritize recommendations: New recommendations should focus on the most-overused practices, based on actual clinical data, so as to make the biggest impact on care
- Consolidate recommendations: Groups of professional societies should work together to create recommendations for the care of patients seeking care for the same complaint. For instance, many current recommendations address back pain.
- Evaluate efforts: Researchers should evaluate the impact of recommendations more rigorously, using methods that can truly let them see if the recommendations are making a difference and if any they led to any unintended consequences. They should also try to identify barriers to success. While this kind of evaluation should include cost-related impacts, cost reduction is not the key goal of Choosing Wisely.
- Consider patient preferences: Recommendations should take into account patient priorities, and preferred outcomes, front and center with guidelines and in evaluations, and make sure they can understand the recommendations that affect them.
- Share best practices: Health care and government organizations should partner with institutions that are making serious efforts to help their providers follow Choosing Wisely recommendations, and with researchers who can help enhance the innovation and rigor of interventions and evaluations.
"Choosing Wisely has changed the game in terms of getting people to think about healthcare services that don't help people, could hurt them and add excess cost to our health system," says Jeff Kullgren, M.D., M.S., M.P.H., a co-author of the new paper and an assistant professor of internal medicine at U-M. "We hope that this synthesis of the evidence will point us in a clear direction for how to make our health care system more efficient."
The authors note that Choosing Wisely has made great inroads in awareness and provider buy-in over a short period. It represents an evolution in medical thinking, because just 20 years ago, the medical community was most focused on making sure that more patients got more of the types of care they needed the most, such as as regular blood sugar tests for people with diabetes.
That's still important, says Kerr, but now "we need to also focus on making sure patients don't get care they don't need. This is about patients and physicians having conversations to help them make the right decisions."
Says co-author Sameer Saini, M.D., M.S., "The key is to get the right care to the right patient at the right time. But changing the behavior of patients, providers, and health systems is not easy. We need to be more thoughtful about how we design programs and interventions to reduce the use of low-value care and be more rigorous and complete in how we assess whether these programs actually worked. At the same time, we need to think about how we will sustain what has been achieved once a program ends. Doing this well is going to require that clinicians, health system leaders, and researchers work together."
Kerr, a professor of internal medicine at U-M and director of the VA Center for Clinical Management Research, heads an effort called the Michigan Program on Value Enhancement that's working to do many of the things the team recommends in the new paper. MPrOVE brings researchers and clinicians together to identify, implement and evaluate specific projects focused on improving quality and demonstrating the value of care at Michigan Medicine, U-M's academic medical center.
Kullgren, who specializes in studying consumer behavior around use of health services, notes that Consumer Reports has done a good job of creating materials aimed at patients for each of the Choosing Wisely recommendations.
He has even used them in his own research, which is funded by the Donaghue Foundation and seeks to assess the impact of having providers make specific commitments to applying Choosing Wisely guidelines for diabetes care, sleep medication and prostate cancer screening in their own practice. He is also holds a Career Development Award from the VA to bring behavioral economics approaches to clinical care practice.
"How we go about changing the hearts and minds of patients, as well as doctors, still holds a lot of unknowns," he says. "We have an opportunity to move things forward."
The authors had funding from the VA. Kerr serves on the steering committee for Choosing Wisely International, which is bringing the Choosing Wisely approach to many countries. Reference: Health Affairs, web first: doi: 10.1377/hlthaff.2017.0953