1. The Choosing Wisely® Campaign

2. 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.

3. Stand-up if you have witnessed unnecessary care harming patients

4. 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

6. 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

7. 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. 

8. 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

9. 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

11. 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): doi: /jama

12. “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.”

13. 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.”

14. 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

15. 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):

16. 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

17. 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

18. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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.”

29. 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

30. 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.

31. 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.

32. 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.

33. “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.”

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

35. Thank you