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Choosing Wisely - A Campaign for Better Care

Posted on Feb 26, 2013 by Ailee Slater ()

Starting at age 21, you need a Pap exam every year. Chronic hives and itching? Better get an allergy test. Chest pain might mean heart disease, so take an imaging stress test to be on the safe side. If you're familiar with these guidelines, congratulations! You've been keeping up with the norms of the health care industry. Unfortunately, you now have to forget everything you think you know about these and other common tests - according to over 500,000 physicians and 25 medical organizations around the country, annual Pap smears, allergy tests, imaging stress exams and many other procedures are both needless and potentially dangerous. This revision of medical guidelines is part of a campaign known as Choosing Wisely. As the name implies, Choosing Wisely was designed to help doctors and patients decide which medical treatments are smart, and which are unnecessary.

For doctors, the goal of Choosing Wisely is to create a discussion in the medical community as to which standard tests are not actually producing a better quality of care. For patients, Choosing Wisely wants to publicize easy to understand information about why a procedure that seems like common practice may produce more harm than good. At first glance it might seem that fewer tests and reduced treatment will lead to worse medical care, but in fact this is not the case. The Choosing Wisely campaign believes quality is better than quantity, and that redundant and unnecessary tests can lead to delayed treatment, bodily stress, and harmful procedures following false positives. Therefore, the campaign is helping medical organizations to create new sets of guidelines for reducing superfluous testing and treatment.

The American Academy of Pediatrics (AAP), for example, is one medical group that has worked with Choosing Wisely to develop a list of unnecessary procedures. Entitled "Five Things Physicians and Patients Should Question," The AAP list encourages doctors and patients to avoid using antibiotics to treat viral respiratory infections; to not prescribe cough medicine to children under four; and to not use CT scans as a first response to minor head injuries, seizures as a result of fever, or routine abdominal pain. As per the principles of Choosing Wisely, the AAP has noted reasons why these procedures are unnecessary and potentially dangerous to the patient. Excessive use of antibiotics, for example, can lead to harmful side effects and drug resistance. CT, or computed tomography scans increase a child's risk of radiation exposure, and for a health ailment such as routine abdominal pain, these scans are less useful than other methods of determining the cause of the pain. Along with the American Academy for Pediatrics, many other groups have joined the Choose Wisely campaign and developed their own advisory lists of treatments to avoid.

The American Geriatrics Society recommends against prescribing older insomnia patients heavy sedatives, as these drugs may cause car accidents or falls; the American College of Obstetricians now says that annual Pap tests for women 30-65 offer no advantage over testing at 3-year intervals; and according to the American Academy of Allergy, Asthma & Immunology, unproven diagnostic tests should never be used to assess allergies, because such tests can lead to misdiagnosis and inappropriate treatment. To make the campaign valuable for patients as well as physicians, many of the organizations participating in Choosing Wisely have created separate lists of recommendations; one for the doctors, and one for the patients. The Society of Vascular Medicine, for example, has published a physician's list of problematic procedures using industry appropriate acronyms and technical vocabulary - resistant hypertension, VLT, atherosclerosis and more.

Patients, however, can look at a Choosing Wisely document entitled Heart Tests Before Surgery, and read an easy to understand report on why doctors may forgo a CT scan prior to minor surgery. The Choosing Wisely campaign was founded by the American Board of Internal Medicine, as part of the Board's mission to advance health care practices through collaborations in the industry. Overall, Choosing Wisely has been lauded by health care groups for its efforts to protect patients, create discussion and save money. However, not every medical organization has been eager to get on board. When Choosing Wisely was first announced, the American College of Emergency Practitioners (ACEP) voiced strong reservations about the campaign.

The ACEP explained that unlike normal physicians, Emergency Room doctors often do not have access to prior information about a patient, therefore tests that might seem excessive are actually extremely important in providing the ER patient with rapid and effective treatment. What's more, the ACEP feared that less testing and treatment in the Emergency Room could lead to more litigation - a patient might come to the ER, not receive a heart screening prior to surgery, develop complications and sue the hospital for failing to conduct the proper, pre-surgery tests. Add to this the fact that ER workers cannot legally refuse a patient care and are statistically more at risk for costly litigation, and it's no surprise that the ACEP was nervous about joining a pledge to provide less treatment. Still, the American College of Emergency Practitioners did eventually join the Choosing Wisely campaign.

They have announced their participation this year, due to membership surveys which indicate that many ACEP groups around the country are in favor of working with Choosing Wisely by developing a list of unnecessary tests and procedures in order to work more efficiently and save money. The ACEP has now been able to recommend a few treatments and screenings which are unnecessary, and can be avoided by doctors without risking litigation or patient safety. Along with the American College of Emergency Practitioners and numerous other medical organizations, Choosing Wisely has also seen support from partners like the AARP, which supports Americans over the age of 50, and the independent buyer advising group Consumer Reports. Indeed, Consumer Reports and their health subgroup Consumer Health Choices have done much for the Choose Wisely campaign in disseminating easy to understand facts to keep patients informed about new testing and treatment guidelines. With this sort of partner support, and more medical societies looking to join, it seems the Choosing Wisely campaign can be called a success.  

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