Changing Patient Outcomes Using Choosing Wisely

Each year, an estimated 40 percent of older adults on Medicare receive a health service that is considered “low value,” which not only adversely affects their health but also contributes to an estimated $750 billion of wasteful spending on health care annually in the United States, according to Health Affairs.

the Choosing Wisely campaign. Led by the ABIM Foundation (American Board of Internal Medicine), Choosing Wisely aims to improve patient health and outcomes and reduce costs by preventing unnecessary treatments.

Traditional fee-for-service approaches to healthcare reward clinicians and healthcare institutions for running more tests and prescribing more treatments, while value-based care, the bedrock of the Choosing Wisely campaign, takes a different approach. Value-based care focuses on optimizing patient outcomes and public health overall while reducing the use of unneeded, costly — and potentially harmful — tests and procedures.

Importance of the Choosing Wisely campaign

“The Choosing Wisely campaign organizes many sets of guidelines from dozens of different organizations that support value-based care,” says Reyan Ghany, MD, the National Director for Cardiovascular Diseases and one of ChenMed’s Regional Chief Medical Officers. Launched in 2012, Choosing Wisely today includes input from more than 75 medical specialties, including the American College of Cardiology, the American College of Radiology, and the American Academy of Family Physicians.

“The Choosing Wisely guidelines help a busy physician make decisions that lead to better patient outcomes,” says Ghany, including reducing hospitalizations.

For example, in the past, many U.S. cardiologists would routinely have their patients undergo annual nuclear stress tests, which usually exposes them to very high levels of radiation. “With this increased level of radiation exposure each year, the test can be doing more harm than good,” says Ghany. Choosing Wisely guidelines recommend that people who are healthy and have no cardiac symptoms should “think twice” before having a nuclear stress test annually for heart disease detection.

Offering another example, Ghany explains that magnetic resonance imaging (MRI) should not be the first line of investigation for a patient with back pain. “Many clinicians jump quickly from taking a history and doing a physical exam to ordering an MRI, but this may be inappropriate,” he says. “The guidelines tell us not to jump.” Studies show that people who get imaging tests for back pain don’t get better faster. At least one study indicated that patients who have an MRI for back pain are more likely to land in the hospital to have surgery; however, the surgery doesn’t help them feel better faster, according to Choosing Wisely

Imaging tests such as CT scans, X-rays, and MRIs, do have a place in medicine. “But you have to push pause before you go straight to advanced imaging,” says Ghany.

Alternatives to MRIs, CT scans, and other testing

“Value-based guidelines really help us to avoid doing harm,” Ghany notes. At ChenMed, where many patients have complex chronic conditions, doctors consider each patient holistically, and act accordingly.

For instance, in the case of a patient with back pain, instead of rushing to do an MRI, a doctor can first prescribe simple but potentially valuable interventions including physical therapy, acupuncture, and the use of a non-steroidal anti-inflammatory drug (NSAID).

Then there are the patients with severe cases of heart failure or end-stage dementia who may also develop cancer. In such cases, doctors should seriously consider whether aggressive cancer treatment would improve mortality. The treatment may involve considerable suffering on the patient’s part and may impart little or no benefit. “The point of health care is not just to extend a patient’s life, but also to preserve quality of life,” says Ghany.

Most effective treatments

In the past, U.S. medical specialties with similar fields of interest have each offered their own sets of guidelines for testing, imaging, and other procedures, and these guidelines have often differed. Such differences have often been confusing for clinicians, but physicians can now turn to the Choosing Wisely website for evidence-based guidelines that represent a consensus of expert opinions aimed at improving patient outcomes.

In fact, both patients and providers can find helpful information, including a list of “Top 12 Recommendations That Are Reducing Overuse.” Among other things, the list includes discussions about the overuse of: imaging for uncomplicated or stable headaches, antibiotics in patients with upper respiratory infections, and benzodiazepines for adults 65 and older.

Looking ahead, a continued push toward greater adoption of value-based care is inevitable in light of actions taken by the Centers for Medicare & Medicaid Services to incentivize such patient-centered care.

“I fully support this shift to valued-based care,” says Ghany. “As providers we need to think carefully about each test or prescription and ask ourselves, ‘Is this really necessary? Is this right for this patient?”

Putting the brakes on unnecessary procedures and prescriptions, he says, will provide better health outcomes for patients, with fewer complications, and thus ultimately will reduce costs for the American taxpayer.

The success of the value-based movement rests on the brief, decision-making moments that physicians face daily. In the end, clinicians bear the final responsibility for doing the right things for each patient.

Choosing Wisely has downloadable resources you can place in exam rooms or give to patients to educate them about overuse of common medical procedures such as antibiotics, MRIs, and CT scans.

Value-based care is changing both outcomes for patients and how physicians practice medicine. At ChenMed, we make value-based care work, translating higher-quality patient care with real results. If you’re ready to practice medicine differently, view our open positions today.