Changing long-standing habits can be challenging, but several well-established axioms in medicine have fallen in the last couple of years. How are we doing with changing our practice to eliminate these unhelpful and/or possibly harmful interventions?
AFP recently published the "Top POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign" which includes the following evidence-based findings:
- Meniscectomy does not improve long-term outcomes for patients with meniscal tears.
- Pregabalin (Lyrica) is ineffective for spinal stenosis neuropathic pain.
- Platelet-rich plasma injections for knee degenerative joint disease are no better than hyaluronic acid (and hyaluronic acid probably isn't that effective to begin with).
- The benefits of beta-blockers in CAD are limited to the first 30 days after a myocardial infarction.
- Continuing dual antiplatelet therapy 1 year after drug-eluting stent placement confers no additional benefit and can cause serious bleeding.
- Bridging anticoagulation for patients with atrial fibrillation undergoing surgery doesn't prevent venous thromboembolism and increases the risk of bleeding and cardiovascular events.
- Vitamin D doesn't reduce falls in community-dwelling postmenopausal women.
Last fall, Dr. Lin commented on the early uptake of 7 of the Choosing Wisely recommendations; the study found decreased use of imaging in line with 2 recommendations, but, unfortunately, use of the other 5 "Things Providers and Patients Should Question" either did not change or increased.
More recent studies have examined physician behavior regarding several of the Choosing Wisely initiatives. The number of inappropriate DEXA scans ordered in women under age 65 in a large ambulatory care network in the DC area did not change with the Choosing Wisely recommendation to not "use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors." A broader study created a composite score of adherence to 11 Choosing Wisely recommendations and examined national patterns; the researchers found preoperative cardiac testing for low-risk procedures to be the most prevalent low-value service performed (46.5%), followed by prescribing antipsychotics to dementia patients (31.0%), prescribing opioids for migraines (23.6%), and early imaging of acute low back pain (22.5%). The study found wide geographic variation in adherence and also found that:
[T]otal Medicare spending per capita was associated with low-value care utilization, in addition to a higher ratio of specialist to primary care physicians, a higher proportion of minority beneficiaries and a higher proportion of residents with poor or fair health.Primary care physicians have higher awareness of Choosing Wisely than do other specialties, but we have room for improvement in implementation. A national survey of 2000 primary care physicians' attitudes about Choosing Wisely found that "[t]he most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists." Awareness of Choosing Wisely is an important first step, but we still have work to do regarding how we put it into practice.
The Choosing Wisely campaign's mission to reduce unnecessary medical care aligns well with the Right Care Alliance's mission "to restore trust, balance, professional ethics and principles of justice and equality to healthcare in the United States." This week is Right Care Action Week, where "thousands will be participating in radical actions that reimagine health care as listening, hearing, sharing, partnering, caring... and sanity." Ensuring that the care we deliver is "effective, affordable, and needed," the Right Care Alliance provides many opportunities to get involved, both in small and big ways. You can start by signing up to learn more about them here.