What Are the Barriers to Choosing Wisely in Hematology Care?

Barriers to adopting hematology-specific recommendations to reduce low-value care can be separated into 2 buckets, those that are practitioner-related and those that are system-related, according to a recent review of the Choosing Wisely initiative.

Recommendations from Choosing Wisely, the campaign from the ABIM Foundation, were adopted by the American Society of Hematology (ASH) in 2013 and 2014.

Choosing Wisely was instigated by a 2012 report from the Institute of Medicine, which estimated that more than $200 billion is spent annually on unnecessary medical care. The campaign marked 5 years in 2017, but a survey then found that most physicians were still unaware of the program.

Besides encouraging harm avoidance, the campaign also stresses the importance of high-value health care and aims to start a conversation between patients and physicians about the costs and benefits of medical care.

ASH now has a list of 10 items that should be questioned in hematology care. For instance, it warns against baseline or routine surveillance CT scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia. In sickle cell disease, it notes that these patients are vulnerable to possible harm from unnecessary blood transfusion and recommends not to use transfusions for chronic anemia or uncomplicated pain without an appropriate clinical indication.

But as with other reports about the Choosing Wisely campaign, the authors noted that shifting away from using every possible resource is a cultural change for both physicians and patients. In addition, a fear of lawsuits historically have worried practitioners about missing early signs of a disease.

Education can help physicians become more familiar with choosing wisely recommendations, and knowledge about the evidence behind the recommendations, such as through references, can help overcome barriers, the authors said.

To overcome concerns about malpractice lawsuits, the Choosing Wisely recommendations should be considered as “standard of care approaches,” the researchers wrote.

Another barrier to the adoption of the recommendations is the fixed limits of time in the exam room. Practitioners don’t have time to explain all of the factors that went into their decision making when they are not with the patient, the authors noted.

The authors also recommend value-based care using fixed payment bundles rather than fee-for-service models in order to dissuade any financial incentives from ordering more tests and treatments.

Some institutions have implemented methods to alert doctors to think about and discuss the Choosing Wisely recommendations adopted by ASH. For instance, Stanford University Hospital created an electronic alert to reduce unnecessary thrombophilia testing in outpatients.

Banner Health also implemented an alert, as well as patient education, to limit PET or CT scans in asymptomatic patients after curative treatment for lymphoma. In the 8 months prior to the alert system, the number of imaging studies was 387, for an average of 48.3 scans per month across Banner facilities. In the 3 months afterwards, the number of imaging studies fell to 76 overall, or an average of 25.3 scans per month.

Measuring any long-lasting impact from Choosing Wisely is difficult, but adoption is more important than ever because of the coronavirus disease 2019 (COVID-19) pandemic, the authors said.

The fragmented system of US health care makes it difficult to measure adherence to the campaign recommendations beyond a single institution.

“It goes without saying that we should avoid bringing a patient from home to an overwhelmed healthcare system, with potential unintended exposure to COVID-19 while in the hospital, for an unnecessary test. Furthermore, ordering unnecessary tests in a patient hospitalized with confirmed COVID-19 exposes technicians, nurses, and practitioners to potentially acquire the disease themselves,” they noted.

Reference

Hilal T, Munoz J. Choosing Wisely® in Hematology: Have we made a difference? Curr Hematol Malig Rep. Published online June 12, 2020. doi:10.1007/s11899-020-00593-2