It's Monday afternoon and a mother brings her 2-year-old son to your office with low-grade fever, upper respiratory symptoms, and apparent ear discomfort. You have seen him regularly for well-child visits with no previous visits for illness. When you enter the exam room, he is playing and interacting appropriately with his mother. Your examination reveals redness and bulging of the right tympanic membrane with a poor light reflex and immobility on insufflation. He appears to be well-hydrated. You inform the mother that her son has an inner ear infection. Because they live nearby and he otherwise appears well, you recommend that she give him acetaminophen for pain and fever and observe him for two to three days to see if he feels better. Looking surprised, the mother asks, “If my child has an ear infection, doesn't he need a course of amoxicillin or some other antibiotic?”
In another room, you see a 55-year-old man for a routine health maintenance visit. The patient has no major past medical history other than being mildly overweight, and he denies any family history of cancer. During his physical exam, which includes a rectal exam after he describes occasional “hemorrhoid problems,” he asks what lab tests you plan to order. He specifically asks if you are going to order a test for prostate cancer screening, as he has a coworker in his early 60s who was recently diagnosed with prostate cancer after a prostate-specific antigen (PSA) test.
The last patient of the day is an 85-year-old woman with mild hypertension and osteoarthritis. She lives independently in a retirement community, adheres faithfully to a low-salt diet, and remains physically active, going on 30-minute walks several times a week with friends. Her blood pressure is well-controlled today. As you prepare to leave the exam room, she asks your opinion about health screening services being sold by a company at the local senior center, including a low-cost ultrasound scan of her carotid arteries to look for blockages that could lead to a stroke.
All of the interventions mentioned in these scenarios – antibiotics for uncomplicated otitis media, routine PSA screening for prostate cancer, and ultrasound screening for carotid artery stenosis – either do not provide net health benefits or provide no more benefits than less risky or less harmful alternatives. Nonetheless, physicians prescribe these services every day, increasing health care costs and exposing patients to unnecessary harm. In this article, we will discuss how family physicians can work with their patients to choose medical interventions more wisely.
Scope of the problem
Appropriate care has been defined as providing a net health benefit for the patient or providing the right intervention to the right patient in the right setting at the right time.1 Overuse refers to medical services that are unnecessary, likely to lead to more harms than benefits, or both; such services are responsible for an estimated $150 billion to $200 billion in wasted health care spending in the United States each year.2 Although overuse can involve specialist procedures such as coronary revascularization or colonoscopy, it also occurs in tests or treatments provided in primary care settings.3,4
A national survey found that men age 75 or older were more likely to receive screening for prostate cancer in 2009 than they were in 1999.5 About one in 10 dual-energy x-ray absorptiometry (DEXA) scans billed to Medicare between 2006 and 2011 were judged to be unnecessary because they were repeated in the same patients at intervals of less than two years.6 Overuse in primary care not only wastes money but also can harm patients. For example, broad-spectrum antibiotics for upper respiratory infections can cause severe allergic reactions or Clostridium difficile infections.7,8
The Choosing Wisely campaign
A call to arms to address the problem of medical overuse began in 2002 with the publication of “Medical Professionalism in the New Millennium: A Physician Charter.”9 While Congress debated the legislation that eventually became the Affordable Care Act, family physician and medical ethicist Howard Brody, MD, PhD, challenged physician groups to take the lead in creating “Top 5” lists to discourage routinely performed, high-cost medical services that lacked strong evidence-based support.10 The American Board of Internal Medicine Foundation's Choosing Wisely campaign answered this challenge and is designed to support physicians and patients in choosing care that is more beneficial than harmful, is not duplicative, and is truly necessary. Participating groups developed a list of potentially overused tests and treatments and encouraged physicians and patients to question them.
Since its launch in 2012, Choosing Wisely has grown to include more than 70 national organizations representing physicians and other health care professionals, as well as Consumer Reports and other organizations that represent employers and patients. The American Academy of Family Physicians (AAFP) has been involved in this effort since its inception and has provided 15 recommendations to date (see “AAFP's Choosing Wisely list”). The AAFP's initial “Top 5” list was developed through a working group with online voting and field testing; subsequent items were added by the AAFP Commission on Health of the Public and Science and reviewed and approved by the AAFP Board of Directors. American Family Physician (AFP) maintains a searchable online database of all primary care-relevant Choosing Wisely recommendations that is updated as new recommendations are released.
Although it isn't known how many family physicians are aware of Choosing Wisely, a 2013 survey of members of the Uniformed Services Academy of Family Physicians and the Council of Academic Family Medicine found that between 60 percent and 90 percent of respondents correctly answered questions about cases derived from the AAFP's original “Top 5” list.11
Choosing Wisely requires patients and physicians to accept that health does not always improve when more care is delivered.12 Furthermore, even if a test or treatment has been shown to benefit a particular group, using it as a universal standard or applying it to other groups, including those with less severe diseases or lower risks, can result in net harm.13 Challenged by this paradigm shift as well as the obligation to provide patient-centered, high-quality care, physicians must be equipped with tools and strategies to incorporate Choosing Wisely into practice.
AAFP'S CHOOSING WISELY LIST
Do not order annual ECGs or any other cardiac screening for low-risk patients without symptoms.
Do not prescribe antibiotics for otitis media in children ages 2 to 12 years with nonsevere symptoms where the observation option is reasonable.
Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days OR symptoms worsen after initial clinical improvement.
Do not use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or in men younger than 70 with no risk factors.
Do not schedule elective, nonmedically indicated inductions of labor between 39 weeks, 0 days, and 41 weeks, 0 days, gestational age unless the cervix is deemed favorable.
Do not schedule elective, nonmedically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days, gestational age.
Do not do imaging for low back pain within the first six weeks unless red flags are present.
Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications.
Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.
Do not screen adolescents for scoliosis.
Do not screen for carotid artery stenosis in asymptomatic adult patients.
Do not screen for cervical cancer in women older than 65 who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
Do not screen for cervical cancer with human papillomavirus testing, alone or in combination with cytology, in women younger than 30.
Do not perform Pap smears on women younger than 21 or women who have had a hysterectomy for noncancer disease.
Do not perform VCUG routinely in first febrile urinary tract infection in children ages 2 to 24 months.
Office and system strategies to aid decision making
Understanding the concept of Choosing Wisely and implementing it in daily practice are two different things. We recommend a few key strategies to improve your chances of success.
Know the evidence. Familiarize yourself with not only the recommendations but also the evidence behind them. Many Choosing Wisely lists developed by different specialties provide good recommendations that are applicable to your practice. In addition to its Choosing Wisely database, American Family Physician provides levels of evidence for key recommendations in clinical review articles. The Agency for Healthcare Research and Quality's Effective Health Care Program publishes concise, unbiased clinical summaries of the latest research that can help you quickly review the comparative effectiveness of treatment decisions, such as management options for gastroesophageal reflux disease.
Help patients make informed decisions. Family physicians can tap into a wealth of patient education materials (see “Choosing Wisely resources”), which can be provided during visits for relevant problems and displayed in waiting and examination rooms. However, patients may be reluctant to forego questionable tests or treatments for a variety of reasons, including past experiences of having been provided unnecessary interventions (e.g., antibiotics for the common cold) and believing them to have been beneficial (e.g., they got better after taking the antibiotic).
To help your patients make informed decisions and reinforce the therapeutic partnership, you can use motivational interviewing techniques such as asking open-ended questions, using statements of affirmation, practicing reflective listening, and summarizing salient elements of the discussion.14 When speaking with a patient who requests an unnecessary test, be sure to ask what concerns him or her the most and validate those concerns (e.g., “It's normal to feel this way in your situation”). Pay attention to nonverbal behaviors that could indicate distress or confusion. Avoid using medical jargon when discussing benefits and harms. Reference the relevant guidelines, but acknowledge the patient's unique situation. These skills and others are reviewed by an AAFP-developed communication module that is available for viewing on the Choosing Wisely website.
Build (and lead) the system. Electronic health records (EHR), order sets, and strong partnerships with subspecialist colleagues can all go a long way toward implementing a Choosing Wisely approach. Some medical groups hold monthly meetings with medical directors and practice leaders. Recognizing that unnecessary testing and treatment drive up costs for everyone, this setting is the perfect platform to “deploy” Choosing Wisely. Many of the recommendations can become the focus of quality improvement projects, performance metrics, and pay-for-performance measures. A great example of a system-wide adoption of Choosing Wisely is at Crystal Run Healthcare in New York, which used peer teaching, clinical decision support, and feedback to reduce overuse of imaging for acute low back pain, antibiotics for sinusitis, DEXA screening, and electrocardiograms (ECGs) in asymptomatic patients.
In addition to working with your local or state Quality Improvement Organization (QIO), state medical society, and local AAFP chapter, you can help community physicians raise awareness of the campaign through continuing medical education presentations that discourage unnecessary testing. For example in Delaware, the QIO, Medical Society of Delaware, and Delaware Academy of Family Physicians all encourage physicians to participate in state-wide learning and action networks that improve the quality of medical care in the community while fostering team-based practice improvement.
Family physicians are uniquely qualified to serve as quality leaders because of their system-wide perspectives. Actively seek representation on hospital and insurance company quality committees and make these committees aware of Choosing Wisely recommendations relevant to both inpatient and outpatient medicine.
Advocate for technology that can improve your ability to easily provide relevant, appropriate care, including EHR reminders and flags and evidence-based order sets that can facilitate enhanced communication with your specialist colleagues. For example, imaging order sets for a diagnosis of low back pain could include questions such as, “Are red flag symptoms present?” and “Has pain persisted for longer than six weeks?”
How can you help subspecialists choose wisely?
Choosing Wisely only works well if everyone is on board. Fortunately, most specialty societies have chosen to support the campaign, providing guidance to their members about ineffective but commonly used interventions. Ideally you will have strong, collegial relationships among your medical community, and specialties can align together to make Choosing Wisely the expectation. But how should you handle a situation where a specialist colleague is ordering unnecessary tests for your patient?
Use anticipatory guidance opportunities to teach your patients to be credible self-advocates and actively participate in creating their own care plans. Provide independent information about the benefits and risks of the tests, and point them toward additional educational and support resources.
Share your recommendations confidently with both your patient and subspecialty colleagues. When reviewing preventive care, tell the patient not only what is due now but also what is no longer due. Many women expect an annual Pap smear because that has been their experience for most of their adult lives. You can help female patients become more confident in declining unnecessary future tests by explaining up front what their recent results have been, why they no longer need this test every year, and that this evidence-based change is so new that they may still get out-of-date reminders from insurers and other doctors.
Sometimes potentially unnecessary testing may be ordered without a discussion with the patient, such as the routine ordering of labs or tests prior to surgery that don't change the outcome or decision about the patient's suitability for surgery. In these cases, use your opportunity as the consultant to educate your colleagues. Explain why you have opted not to perform the ECG due to the patient's low overall cardiovascular risk or recent normal cardiac evaluation. Your colleague may simply be using what has become his or her standard protocol without realizing that the guidelines have changed. To avoid miscommunication about the patient's suitability for the anticipated procedure, speak to the specialist directly about any potentially controversial recommendations.
Putting Choosing Wisely into practice
How can Choosing Wisely resources help you address the concerns of the three patients we discussed earlier? For the mom whose son has otitis media, confidently explain that antibiotics are not necessary unless her son's condition worsens over the next 48 to 72 hours, and could in fact be harmful if they cause diarrhea or an allergic reaction. Visit the Choosing Wisely page on FamilyDoctor.org to print her a patient-friendly handout to take home. Then, close the visit by confirming her contact information and reassuring her that you are confident she can care for him safely at home.
For the PSA conversation, begin by encouraging the patient to share his concerns about prostate cancer and his understanding of what screening and treatment options exist. Pull up the Consumer Reports resource “The PSA test for prostate cancer” and review the pros and cons of screening with him. Encourage him to take the educational handout home to discuss with his family, and agree to talk more at a future visit.
Finally, for your older patient wondering about the usefulness of carotid artery screening, assure her that screening in patients without symptoms causes more harm than good by leading to other potentially harmful diagnostic tests and interventions. Highlight her reassuring history and physical exam findings, and emphasize that through her hard work managing her blood pressure, following a good diet, and maintaining regular exercise habits, she is already lowering her risk of stroke.
The Choosing Wisely campaign challenges health care professionals and patients to take a closer look at our routines to improve the efficiency and safety of health care. Community expectations and care practices may not necessarily be based on the best available medical evidence and can vary widely from one community to the next, often swayed by anecdotal reports of bad outcomes. By embracing Choosing Wisely, family physicians can be leaders in a worldwide movement to reduce medical overuse and provide better quality care for all patients.