The Choosing Wisely® Campaign www.choosingwisely.org

Disclosures Daniel Wolfson has no relevant financial relationships with commercial interests and will not be discussing non-FDA approved uses of any drugs nor has he received any financial compensation in connection with the initiative described in the following presentation.

Stand-up if you have witnessed unnecessary care harming patients

Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. 4

ABIM Foundation/ACP Foundation/EFIM Physician Charter A Commitment to Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities Fundamental Principles Primacy of patient welfare Patient autonomy Social justice 6 6

Motivating behavior change: Self-Determination Theory Autonomy “One form of autonomous motivation is identified regulation, in evidence when one personally endorses or identifies with the value or importance of a behaviour or health practice.” Competence “…support for competence is afforded when practitioners provide effectance relevant inputs and feedback.” Relatedness “In this process a sense of being respected, understood, and cared for is essential to forming the experiences of connection and trust that allow for internalization to occur.” Ryan, R. M., Patrick, H., Deci, E. L., & Williams, G. C. (2008). Facilitating health behaviour change and its maintenance: Interventions based on self-determination theory. The European Health Psychologist, 10, 2-5. 

Activating Professionalism Societies were free to determine the process for creating their lists with the following requirements: Each item was within the specialty’s purview and control Procedures should be used frequently and/or carry a significant cost Should be generally-accepted evidence to support each recommendation Process should be thoroughly documented and publicly available upon request 8

Choosing Wisely By The Numbers 60 specialty society partners 230 recommendations to date (will exceed 300 by mid 2014) 23 grantees (funded by Robert Wood Johnson Foundation) 163+ journal articles discussing CW 36 participants in CW Health System Leaders Network

From: Eliminating Waste in US Health Care The “wedges” model for US health care follows the approach based on the model by Pacala and Socolow. The solid black “business as usual” line depicts a current projection of health care spending, which is estimated to grow faster than the gross domestic product (GDP), increasing the percentage of GDP spent on health care; the dashed line depicts a more sustainable level of health care spending growth that matches GDP growth, fixing the percentage of GDP spent on health care at 2011 levels. Between these lines lies the “stabilization triangle”—the reduction in national health care expenditures needed to close the gap. The 6 colored regions filling the triangle show one possible set of spending reduction targets; each region represents health care expenditures as a percentage of GDP that could be eliminated by reduction of spending in that waste category over time. Donald M. Berwick, MD, MPP; Andrew D. Hackbarth, MPhil JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

“Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little.”

60% of surveyed physicians believe that trial lawyers do; According to the results of a survey of more than 2,400 physicians, when asked who has a “major responsibility” for controlling health care costs,   60% of surveyed physicians believe that trial lawyers do; 59% believe that health insurance companies do; 56% believe hospitals and health systems do; 56% also believe pharmaceutical and device manufacturers do; 52% believe patients do; and, 44% believe government does. 36% reported that practicing physicians have “major responsibility.”

Call to the Profession: Where are the Health Care Cost Savings? Deficit pressures are making cost control inevitable. It will only be successful if physicians stop looking to others to find solutions and focus on approaches that improve the care for patients with chronic illnesses. -Ezekiel J. Emanuel, MD, PhD

How do we reduce health care costs? Reduce waste Initiatives such as Choosing Wisely that identify areas of potential waste (unnecessary tests and procedures) and encourage physicians to openly discuss options with patients Physician decisions account for 80% of all health care expenditures Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 27 Apr 2009 One-third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessary Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802

Choosing Wisely Partners Societies That Announced Lists April 2012 American Academy of Allergy Asthma & Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology Societies That Announced Lists February 2013 American Academy of Family Physicians American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Otolaryngology-Head and Neck Surgery American Academy of Pediatrics American College of Obstetricians and Gynecologists American College of Rheumatology American Geriatrics Society American Society for Clinical Pathology American Society of Echocardiography American Urological Association Society of Cardiovascular Computed Tomography Society of Hospital Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Society of Vascular Medicine

Societies Announcing Lists in Late in 2013 and Early 2014 American Academy of Clinical Toxicology American Academy of Dermatology American Academy of Family Physicians American Academy of Neurosurgery American Academy of Orthopaedic Surgeons American Association of Blood Banks American Association of Clinical Endocrinologists American Association for Pediatric Ophthalmology and Strabismus American College of Chest Physicians American College of Emergency Physicians American College of Medical Toxicology American College of Occupational and Environmental Medicine American College of Rheumatology American College of Surgeons American Geriatrics Society American Headache Society AMDA—Dedicated to Long Term Care Medicine American Medical Society for Sports Medicine American Psychiatric Association American Society of Anesthesiologists American Society of Clinical Oncology American Society of Colon and Rectal Surgeons American Society of Hematology American Society of Plastic Surgeons American Society for Radiation Oncology American Society for Reproductive Medicine American Thoracic Society Commission on Cancer The Endocrine Society Heart Rhythm Society North American Spine Society Society for Cardiovascular Angiography and Interventions Society of Cardiovascular Magnetic Resonance Society of Critical Care Medicine Society of General Internal Medicine Society of Gynecologic Oncology Society for Maternal-Fetal Medicine

Through Partnership with Consumer Reports Consumer Groups Through Partnership with Consumer Reports AARP Alliance Health Networks Covered California Leapfrog Group Midwest Business Group on Health Minnesota Health Action Group National Business Coalition on Health National Business Group on Health National Center for Farmworker Health National Hospice and Palliative Care Organization National Partnership for Women & Families Pacific Business Group on Health Puget Sound Health Alliance SEIU Union Plus Univision (with HolaDoctor) Washington State Medical Association The Wikipedia Community

Health System Network Participants Advocate Health Care American College of Physician Executives Catholic Health Capital District Physicians’ Health Plan Cedars-Sinai Christiana Care Cleveland Clinic Dignity Health Franciscan Health System Fred Hutchinson Cancer Research Center Geisinger Group Health Cooperative Hospital Association of Southern California Intermountain Health Care Johns Hopkins Kaiser Permanente Long Island Health Network Maine Medical Center Mercy Oregon Health & Science University Northwest Physicians Network NYU Partners HealthCare Penobscot Community Health Care Premier

Health System Network Participants (Continued) Puget Sound Health Alliance South Nassau Communities Hospital Steward Healthcare System UC-Irvine UCLA UCSF University of Michigan University of Toronto University of Washington University of Wisconsin WellStar Health System

Clinical Decision Support: Cedars-Sinai Cedars-Sinai has incorporated 120 CW recommendations into its EHR system (Epic) Physicians receive alert when they order test, procedure or medication questioned by CW Alert provides information on the CW rec Response from physicians has been positive, despite “alert fatigue” – Cedars leader credits this to respect for specialty societies

Patient Support: Anne Arundel Medical Center Anne Arundel Medical Center has embedded Consumer Reports’ translations into its EMR system so that physicians can provide them to patients to enhance their understanding and ability to make decisions about their care AAMC has also included numerous articles about CW in its newsletter and “enews” for staff, as well as on its website and other communications geared to the public

Data Feedback: Fred Hutchinson Fred Hutchinson Cancer Research Center benchmarked the CW recommendations from the American Society of Clinical Oncology among 14 group practices in Seattle area Found wide variation Planning joint quality improvement activities to implement the recommendations

QI in Hospital Medicine: UCSF UCSF had existing focus on overuse, and leaders there thought their use of procedures highlighted by CW would already be low Discovered that their utilization was lower than their peers for only one of five SHM adult medicine recs Now implementing a quality improvement plan focused on other four recs from SHM, covering medications for stress ulcer prophylaxis, blood transfusions, continuous telemetry monitoring outside of the ICU, and certain lab tests Effort is led by committee of physicians and finance administrators who are focused on increasing physician awareness of the costs of treatments they commonly order

System as Employer: Mercy Mercy, an integrated Catholic health system with 32 hospitals, has aggressively promoted CW to its own employees Each month, one recommendation is highlighted through employee communications, and Mercy developed an internal website that directs employees to the CW site and to Consumer Reports Used flagship site (Springfield, MO) to implement on physician side – medical directors reviewed 45 initial recs and narrowed to 27 where Mercy was performing the procedures Medical directors and other leaders addressed large sections about the recommendations, received little pushback Mercy now has 14 measures to review whether the recommendations are having an impact – also sharing comparative data with its physicians on utilization of procedures covered by CW (e.g., imaging for headache) Example of how dissemination through the health care system could be studied (beyond flagship site)

QI in Radiology: KP Colorado KP-Colorado worked with department heads to review all CW recs, focused on 20, mostly imaging Through chart reviews, found that 25 percent of physician orders for imaging for headaches was inappropriate Has launched projects to reduce overuse of imaging in five specific areas (e.g., headache, low back pain) – more projects are in the pipeline Conducting one-on-one conversations with physicians who are outliers in test ordering (i.e., academic detailing) CW is “the most welcome thing we’ve ever seen,” according to Margaret Ferguson, MD, associate medical director of affordability. It “gives us a whole new way of presenting affordability.”

Choosing Wisely Grantees Regional Collaboratives Better Health Greater Cleveland HealthInsight Utah Institute for Clinical Systems Improvement and the Minnesota Health Action Group Iowa Healthcare Collaborative Maine Quality Counts Massachusetts Health Quality Partners Michigan Health Information Alliance, Inc. Puget Sound Health Alliance Wisconsin Collaborative for Healthcare Quality Societies/State Medical Associations American Academy of Hospice and Palliative Medicine American Academy of Ophthalmology American College of Physicians American Society for Clinical Pathology American Society of Echocardiography American Society of Nuclear Cardiology Minnesota Medical Association Oregon Medical Association Society of Hospital Medicine Tennessee Medical Association Texas Medical Association Washington State Medical Association

RWJF Grantee: Iowa Healthcare Collaborative IHC has developed an “Iowa 5” set of recommendations unique to the state’s communities. IHC will work with Wellmark to track claims data across the state to measure the effect of implementing the campaign across these focus areas, and promote resources to improve.

Maine Quality Counts Maine Quality Counts (MQC) will work with four pilot sites to identify a set of specific measures to implement and to monitor progress, identify lessons learned, best practices, and barriers. Sites include: Penobscot Bay Medical Center (25,000 patients) Penobscot Community Health Center (14,950 patients) Winthrop Family Practice (6,700 patients) Oxford Hills Family Practice (2,700 patients) Interventions include modification of order sets and communications training. A pre and post web based survey will be conducted by GfK to assess attitudes and awareness of Choosing Wisely in both the physician and patient populations.

American Society of Echocardiography ASE has developed a smartphone app that allows physicians to access the ASE Choosing Wisely recommendations and appropriate use criteria to determine whether a cardiovascular ultrasound exam is appropriate. The app also includes Choosing Wisely recommendations from other societies. Measures of success for this project include: the number of downloads of the app and a survey to measure use of and satisfaction with the app. The survey would measure physicians’ understanding of the Choosing Wisely information and their’ self-reported impact of CW on their attitudes and practice. We estimate that through the app, ASE could reach over 200,000 physicians.

“We have created a medical ecology based on overprescription and overconsumption on the part of both physicians and patients,” Erb said. “What Choosing Wisely has done is legitimize our ability to cut back on what’s unnecessary.”

For more information Choosing Wisely: www.choosingwisely.org ABIM Foundation: www.abimfoundation.org The Medical Professionalism Blog: blog.abimfoundation.org Twitter: @ABIMFoundation @wolfsond @richardbaron17 Facebook:www.facebook.com/theabimfoundation

Thank you