Thursday, January 30, 2014

Will Choosing Wisely change the way family physicians practice?

- Kenny Lin, MD, MPH

As phase 3 of the Choosing Wisely campaign draws to a close, it's time to start assessing its impact. Family physicians have been at the forefront of this clinician-led movement to reduce waste and prevent harm from unnecessary medical interventions, beginning with Dr. Howard Brody's call for organized medicine to develop "Top Five" lists of such services:

I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's “Top Five” list. ... The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.

The American Academy of Family Physicians responded to the Choosing Wisely campaign by participating in all three phases, ultimately contributing 15 clinical recommendations that span the full scope of the specialty of family medicine. However, Dr. Nancy Morden and colleagues observed in a recent New England Journal of Medicine editorial that some societies avoided selecting services that are major contributors to their incomes:

The American Academy of Orthopaedic Surgeons, for example, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.

Although patient advocacy groups such as Consumer Reports are also participating in Choosing Wisely, the ultimate success or failure of the campaign will depend on how well physician societies can convince their members to curtail commonly accepted but nonbeneficial services, such as the annual physical examination in healthy adults. Earlier this month, American Family Physician unveiled an online tool that allows readers to search for primary care-relevant recommendations by keyword and topic area. We hope that you will bookmark this tool and use it often to Choose Wisely in your practice.