Choosing Wisely: Top Ways to Reduce Low-Value Care in Pulmonary and Critical Care

Scott Halpern, MD, PhD, discussed the Choosing Wisely campaign with his opening presentation on “The History of and Rationale for the Choosing Wisely Campaign.” As most healthcare providers know, healthcare spending per capita in the United States is significantly higher than most other countries. As well, physician decisions contribute to a large proportion of healthcare costs. This is why the American Board of Internal Medicine (ABIM) Foundation is campaigning Choosing Wisely in an effort to promote discussions between physicians and patients about healthcare costs. Dr Halpern says that at center of Choose Wisely is physician stewardship, or the ideal that physicians are held responsible for providing effective healthcare, and therefore should be at the center of driving cost control.

With the Choosing Wisely campaign, the ABIM Foundation hopes to reduce the overuse of tests and procedures, and motivate physicians in helping patients make better, cost-saving choices. Choosing Wisely was originally conceived by the National Physicians Alliance, alongside various other medical specialty groups, in order to identify tests or procedures they felt should be questioned or discussed.

Each participating specialty group was then asked to focus on a “Top 5” list for condition-specific recommendations. For instance, Dr Renda Wiener, MD, MPH, said in her presentation,

“Development of the Top 5 List in Pulmonary Medicine” that some recommendations for “choosing wisely” in pulmonary medicine include: “Do not perform CT surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines,” and, “Do not perform chest x-rays in patients without pulmonary symptoms as part of routine examinations.” Rob Fowler, MDCM, MS, in his presentation, “Development of the Top 5 List in Critical Care Medicine,” reported similar recommendations for critical care including: “Don’t continue life support for patients at high risk for death or impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.”

Jeremy Kahn, MD, MS, says Choose Wisely acts not only as a guideline , but an evidence-based tool in physician decision making. Despite traditional methods of setting strategies for evidence-based decision making, often there are barriers for physicians, including their knowledge, environment, or attitude towards adhering to existing guidelines. Dr Kahn says when traditional incentives do not work, we “need to create financial incentives to do the right thing.”

Dr Kahn further commented that the most valuable part of Choosing Wisely, is its simplicity. Physicians need to consider the overuse and cost associated with unnecessary tests or procedures. It is up to them to take control of costs, rather than leaving it up to policy makers. Choosing Wisely is a mindset—physicians should be engaged with patients in formulating better recommendations that will drive value-based care.