Professionalism in Action



TMA Choosing Wisely Grant Ends, But Physicians Still Strive to Cut Overuse of Unnecessary and Possibly Harmful Tests and Procedures While Promoting Shared Decisionmaking

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Quality Feature — March 2015 

Tex Med. 2015;111(3): 51-57.

By Amy Lynn Sorrel
Associate Editor

Texas is Choosing Wisely, thanks to the Texas Medical Association's efforts to promote the national initiative, which aims to improve quality and reduce waste by encouraging physicians and patients to discuss medical tests and procedures that may be unnecessary and possibly harmful. 

March marks the conclusion of a $50,000 grant TMA and its philanthropic arm, the TMA Foundation, won to advance Choosing Wisely by raising awareness and helping physicians build its tenets into daily practice. The American Board of Internal Medicine (ABIM) Foundation, Choosing Wisely's creator, awarded the grant in 2013, with support from the Robert Wood Johnson Foundation (RWJF). 

Since its inception in 2012, more than 60 national specialty societies have joined Choosing Wisely to identify and develop evidence-based recommendations for the top five tests and procedures they say are overused and have not always demonstrated benefits to patients. 

With the grant, TMA mobilized a consortium of county and specialty medical societies across the state to call attention to what now add up to more than 300 recommendations. TMA's online Choosing Wisely resource center has a suite of tools to help physicians understand and implement relevant recommendations at the practice level. (See "Start Choosing Wisely.") 

Meanwhile, TMA partnerships have helped Choosing Wisely gain traction at the state level with adoption by the state Medicaid program and the Texas Institute of Health Care Quality and Efficiency, established to implement Texas' own version of health reform.

Although the grant is coming to an end, the work continues as physicians exercise what TMA Foundation Advisory Council member Nick Shroff, MD, describes as a less wasteful approach to improving the quality and efficiency of health care. "This is about delivering the right care at the right time to enhance the quality of care, and it's an ongoing partnership between the physician and the patient." 

His accountable care organization (ACO), Integrated ACO, strives to provide the right care at the right time by sharing the specialty societies' recommendations with the roughly 30 practices across the state that make up the organization. The physicians, care coordinators, and care teams, in turn, discuss the information with their patients, encouraging them to review patient-friendly Choosing Wisely resources accessible via the ACO's website

Dr. Shroff, a Plano urologist, says the initiative aligns with his ACO's goal of patient-centered, accountable care because it "centers care on patients' individual needs, and that's how we improve outcomes."

As more physicians and health care organizations adopt Choosing Wisely, the campaign is contributing to what ABIM Foundation Executive Vice President and Chief Operating Officer Daniel B. Wolfson describes as an overall shift in the culture of health care. "We are increasing awareness, and we are changing attitudes toward overuse. That has been the first order of business, and TMA has been an incredible leader."

TMA Takes Action

Thanks to TMA's and other grantees' efforts, the campaign, now in its third year, is off to a good start. Results from a May ABIM Foundation survey of 600 physicians nationwide show:  

  • One in five physicians say they are aware of Choosing Wisely;
  • Of those, 62 percent say they are more likely to have reduced the number of times they recommended a test or procedure, compared with 45 percent of those who are unaware of the effort; 
  • Two-thirds of physicians acknowledge responsibility to make sure their patients avoid unnecessary tests and procedures; and 
  • Nearly 60 percent of physicians say they are in the best position to address the problem. 

"We already have physicians motivated to move in the right direction," Temple nephrologist and past ABIM Foundation Chair Donald E. Wesson, MD, told a roomful of physicians at TMA's Fall Conference in September.

With the largest and most active physician medical association in the country, Texas is positioned to be a "vanguard state" for advancing the program and a strong partner moving forward, he added. "Physician leadership is key to improving the quality of health outcomes. I commend TMA for taking leadership in doing this because physician awareness [of Choosing Wisely] is key to making this happen."

TMA's involvement in Choosing Wisely began with the Council on Health Care Quality's endorsement of the initiative in 2012 as yet another vehicle to prepare physicians for upcoming quality improvement, patient safety, and performance measurement challenges. The TMA House of Delegates in 2013 voted for TMA to advocate the adoption of the campaign. At TexMed 2014, the Council on Health Care Quality led a continuing medical education (CME) track to educate physicians on the program. Choosing Wisely, TMA, the TMA Foundation, Blue Cross and Blue Shield of Texas, and TMF Health Quality Institute sponsored the CME.

In what is quickly evolving into a value-based care system, council member Cliff Fullerton, MD, says the campaign encourages physicians and patients to weigh various treatment options, not only to address escalating costs but also to ensure patients get high-quality care. He is chief medical officer for the Baylor Scott & White Quality Alliance, which incorporated Choosing Wisely into its quality improvement and population health management initiatives. 

"We know there are significant inefficiencies in the health care system, and we talk about physicians wanting to be in the middle of making these kinds of decisions. Here's an opportunity to do that," Dr. Fullerton said.  

Physician-driven

The Choosing Wisely campaign's physician-driven focus has attracted widespread participation, says Harris County Medical Society (HCMS) then-President Elizabeth Torres, MD, who authored an open letter to HCMS members and blog entry promoting the initiative in TMA's Me and My Doctor. HCMS is one of nine Texas county medical societies and six state medical specialty societies, along with the Texas Osteopathic Medical Association, participating in the program with TMA.

As an internist, Dr. Torres was readily familiar with Choosing Wisely because her specialty society, the American College of Physicians, was a founding member. She says the initiative is a chance for physicians to take the lead in promoting evidence-based quality initiatives, rather than having insurance companies or government agencies dictate those parameters. 

It's also a way for patients to get sound medical advice from a trusted source and for physicians to use these conversations to build the patient-physician relationship. In primary care, for example, Dr. Torres commonly gets requests for magnetic resonance imaging (MRI) scans, regardless of their necessity. 

"Everybody wants an MRI, and I have to explain that their history and physical do not indicate any of the worrisome signs we usually look for when deciding how to further evaluate their symptoms. I'm not a neurologist or an orthopedist, so Choosing Wisely provides me a guide or mini-consult before referring them to a specialist, and it gives me the scientific evidence to explain to the patient why we are taking certain actions," she said. "Our patients are trying to understand, and they are looking for this information somewhere. We [physicians] have to bring patients into our thinking, and we haven't always done that. This gives patients a baseline for why we are doing or not doing something. But it's the relationship and the time that we spend that makes the difference."   

Some of those conversations may seemingly take extra time on the front end. But Lubbock emergency medicine physician Gerad Troutman, MD, says the recommendations are not only practical but also reinforce good medicine. 

As a board member of the Texas chapter of the American College of Emergency Physicians (ACEP), Dr. Troutman introduced ACEP's Choosing Wisely recommendations to every emergency medicine residency program in the state and recently updated Texas members on the specialty society's latest list. 

One of those recommendations says to "avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma, and a normal neurological evaluation."

"These are topics that physicians already know. But it's one of those things that, as we get pushed to see more patients in less time, there is a potential to get lax because it's easier to click 'CT-head' on an EMR (electronic medical record), versus sitting on a stool and discussing it with the patient. By the time I order the CT and wait for the read, I could have spent two minutes talking to the patient, he or she could be back home, and we may not need to explain it next time," he said. "All doctors are pushed on time constraints. This actually helps save time and money, and it's better medicine."

Statewide Attention

TMA's work has caught the state's attention, too. 

James Cooley is a research specialist with the Health Policy & Clinical Services Quality Unit of the Texas Health and Human Services Commission (HHSC). The agency adopted Choosing Wisely after the 2011 legislature created and tasked the Physician Payment for Quality Committee with determining the 10 most overused services performed by Texas Medicaid physicians. During that process, he says, HHSC staff reached out to TMA, knowing it had a grant.

"The initiative greatly influenced recommendations by the Physician Payment for Quality Committee," he said. "The appeal of Choosing Wisely is that it came from doctors themselves as a quality and safety effort. It was physicians offering advice to their peers via respected specialty societies. HHSC staff welcomed the opportunity to work with the TMA on a project to improve patient care that was physician-led."

Mr. Cooley adds Choosing Wisely will be "a useful resource" in an upcoming analysis of potentially avoidable ancillary services. The initiative also prompted a look at the overuse of diagnostic imaging among what he described as emergency department "super-utilizers." Some patients, for example, received dozens of CT scans in a single year. 

At TMA's urging, the Texas Institute of Health Care Quality and Efficiency also adopted Choosing Wisely in its legislative recommendations for the state's version of health care reform. The campaign dovetails with the institute's task of identifying and promoting evidence-based approaches to improve health care quality, accountability, education, and cost containment in Texas. 

The institute also included Choosing Wisely in its strategic plan for improving health literacy among patients, which also could help identify and reduce variations in care utilization across the state, says Dr. Fullerton, a consultant to the board. 

Just Getting Started

Mr. Wolfson says TMA continues to be a key partner as the ABIM Foundation works to overcome challenges to furthering the program, such as a lack of health literacy. With medicine being a team sport, physicians also can help build other partnerships as nonphysician professions come into the fold, he adds. 

For example, physical therapists and dentists have joined Choosing Wisely. Also, the American Academy of Nursing chose Texas as the pilot state for its entry into the campaign. 

At press time in mid-December, the ABIM Foundation also announced a second round of grants to expand the "next generation" of Choosing Wisely "beyond educating and raising awareness of over-utilization of key tests and treatments to measuring and demonstrating reductions in inappropriate utilization for those services." Support for the seven $315,000 grants also comes from RWJF, and applications began in January. TMA shared the grant notice with members. 

Physician leaders agree: Education and awareness are one thing, but sustained change requires more. 

That means taking the Choosing Wisely recommendations from paper to practice, Dr. Torres says. "We're just scratching the surface." 

Dr. Fullerton agrees some form of measurement is important to advance the campaign's and physicians' success. Baylor Scott & White, for example, took a two-pronged approach to adopting Choosing Wisely: After endorsing and promoting the initiative among its specialty committees and choosing a handful of recommendations to focus on, "our intent is to try to pick a subset of those that fit to try to measure so we can report that information out to help our physicians improve."  

For example, the Baylor Scott & White quality committee can likely track how well doctors are abiding by the American College of Obstetricians and Gynecologists' recommendation against scheduling elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks gestational age. 

Mr. Wolfson says physicians can use many methods to put Choosing Wisely into action, and doctors can find examples in the ABIM Foundation's newsletter, Updates from the Field, available by email subscription or online. TMA and Texas Medicine also continue to collect reports from Texas physicians, available in TMA's online Choosing Wisely resource center,  

Now that physician practices and health systems are moving in that direction, Mr. Wolfson says Choosing Wisely can once again follow physicians' lead as it looks to collect data and offer feedback on physician performance and variations in care.  

"We thought that we needed carrots and sticks, but this is saying we need the medical profession to stand up and be the force," he said. "This is professionalism in action."

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

Start Choosing Wisely

TMA's Choosing Wisely resource center has a host of materials for Texas physicians to start discussions with patients and avoid unnecessary care. 

The resources include:  

  • Links to evidence-based recommendations created by leading medical specialty societies. These lists help physicians engage in important conversations with patients to do the right thing at the right time.
  • Videos featuring an overview of Choosing Wisely and more specific information for physicians and patients. 
  • Patient-friendly educational fact sheets and other resources developed by Consumer Reports and participating specialty societies.
  • Continuing medical education credit through TMA's bundle of five on-demand webinars. For a limited time, the Choosing Wisely bundle is available free through the TMA Education Center. Earn 3.75 AMA PRA Category 1 Credits™ and 3.75 ethics credits for watching all five webinars.
  • A bibliography of Choosing Wisely articles from the medical field. 
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