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Q&A: What can we learn from the US Choosing Wisely campaign to cut down unnecessary tests, treatment?

 

Below is the second in a series of posts that Croakey is running on the ground-breaking Choosing Wisely campaign, which will launch in Australia on 29 April. The campaign focuses on cutting down the numbers of unnecessary medical tests and treatment and has been successful in the USA and Canada in reducing non-evidenced based interventions.

This article – submitted by the campaign – features a Q&A with Daniel Wolfson, who has been instrumental in the campaign in the US. He looks back on its role, on what makes the campaign unique and why and how it works.

Listen also to this Radio National Health Report feature on the campaign.

***

When it launches next month, Choosing Wisely Australia® will start an important national conversation about reducing the many low value and often potentially harmful tests, treatments and procedures that have become entrenched in healthcare.

It follows on from the highly successful Choosing Wisely campaign initiated in the US in 2012 by the ABIM Foundation.What started modestly with nine organisations is now a collaboration of more than 70 medical speciality societies, as well as consumer organisations that  collectively represent almost a million members. Medical specialty societies have identified lists of “Things Physicians and Patients Should Question.” The evidence-based recommendations are used to inform consumer-friendly materials, created jointly by US consumer watchdog, Consumer Reports and the societies themselves. Designed to spark conversations between clinicians and patients, they provide consumers with the sound science and evidence they need to make informed decisions. This is central to the initiative.

Here in Australia, six founding members – the Royal Australian College of General Practitioners, the Royal College of Pathologists of Australasia, the Royal Australasian College of Physicians, the Australian College of Emergency Medicine, the Royal Australian and New Zealand College of Radiologists and the Australasian Society of Clinical Immunology & Allergy – will release the first lists of Choosing Wisely recommendations in late April. NPS MedicineWise will use the very positive influence it has built within the medical community to facilitate.

What can Australia learn from the US experience? Daniel Wolfson, Executive Vice President and Chief Operating Officer of the ABIM Foundation, responds in the Q&A below.

Question: While there has for some years been a growing international recognition of the need to tackle obsolete, unsafe or evidence-lacking interventions, and many studies have sought  to identify them, translation into changes to medical practice has been slow. Now into its third year, is Choosing Wisely able to show that it is making a difference? 

Daniel Wolfson:Three years into Choosing Wisely we can point to a number of ways the campaign is making a difference. For example, more than 70 medical specialty societies have shown tremendous leadership by joining Choosing Wisely and publishing lists of tests, treatments and procedures they say are being overused or wasteful. That is unprecedented in our country and it took a lot of courage for the societies to undertake this important work.

The goal of the lists was always to inspire conversations between clinicians and patients about what care they really need, and we’re beginning to see uptake by many organisations that are putting frameworks around those conversations to ensure they happen consistently in practice. One great example is the work of Cedars-Sinai, where they’ve embedded 180 of the Choosing Wisely recommendations in their EHRs (electronic health records). When a physician orders something on one of the lists they are prompted with information from the campaign to help them think about if this particular test or treatment is really necessary for that patient. We have many more examples like this on the ChoosingWisely.org website.

Q: Why is a hands-off approach important?

Wolfson: The society recommendations are just that – recommendations based on science and evidence, but each clinician knows his or her patients best and is in the best position to decide what care is right for them. Recommendations were created by physicians themselves in a way that respects their unique knowledge and mastery of their particular specialty areas and the guidelines we’ve created empower them to develop their own credible processes for creating their lists.

We gave societies four simple rules to guide them through the creation of their lists of tests and procedures. The recommendations needed to be: frequently done or costly; evidence-based; within the control of the specialty; and created using a transparent process.

Q:There were criticisms in the early days that some societies weren’t being transparent enough in their decision-making and they were playing safe by recommending interventions that weren’t commonly done. Has this been addressed?

Wolfson: Through the campaign societies have identified more than 350 tests and procedures that may not be necessary and could cause harm.Those criticisms overlooked one important fact: Choosing Wisely is more than the sum of its individual recommendations.We set out to effect change in medical practice on a broad scale – to engender a cultural shift.  We knew this would take time. I believe we are achieving this with our approach of minimal rules/principles and maximum flexibility in how the lists are created.

Q:Given that Choosing Wisely has eschewed the typical hierarchical/top-down form of governance for a non-hierarchical, bottom-up one, how is it managed? How is the information shared?

Wolfson: Choosing Wisely is pursuing change from the bottom up, acting collectively and collaboratively. In the absence of a centralised authority or bureaucracy, more than 70 societies have joined the campaign. They, in turn, solicit the opinions of many physicians in their specialty, getting them to understand the goals and ideals of the campaign during the process.

The Choosing Wisely website contains the lists of recommendations and resources as well as patient-friendly materials from our partner, Consumer Reports. More than 100,000 people visit our website each month. All parties, including regional health collaboratives, medical associations and health care delivery systems,use these to help them develop their own local strategies for implementing the recommendations and changing attitudes.

We’ve actively engaged with our partners and created tools and resources they can use to communicate with their members—and many of the societies have written about their recommendations and list creation process in their journals and member publications. A number of the societies developed suites of communications skills modules to help clinicians learn how to have these important conversations with patients within the time constraints of a typical office visit. We’ve also been active in social media and use it as a tool to announce new lists and spotlight media coverage. About a year and a half ago we launched a monthly e-newsletter “Updates from the Field” highlighting how Choosing Wisely is being implemented by clinicians, hospitals, health systems and others across the country.

Q:  Choosing Wisely is as much about consumers as it is practitioners. What has changed in the way you communicate since it was first launched?

Wolfson:Choosing Wisely has empowered patients to talk to their doctors about the care they receive through an easy-to-access website, brochures, videos, etc. Consumer Reports has been a critical partner in this effort and,working with the societies, leads the creation of easy-to-understand materials for patients. They’ve also grown their coalition of consumer partners to include groups like AARP and the National Partnership for Women and Families to ensure the campaign information is reaching patients when they need them.

Q:Do you think the model you have developed for Choosing Wisely can work elsewhere?

Wolfson:The conversation about the quality and value of frequently ordered tests and treatments has grown into a global movement.The ABIM Foundation’s Choosing Wisely campaign in the United States has inspired other countries, including Canada,Netherlands, Italy and many others, to initiate their own efforts to address overuse in their countries. We’re proud Choosing Wisely is making a difference on a global scale and we wish all the best for the Choosing Wisely Australia campaign.

Corrected: this post is updated with the correct image of Daniel Wolfson, after a wrong one was inadvertently used in the original article.