Choosing Wisely®: From Engagement to Implementation

A recent article challenged the Choosing Wisely recommendations around routine stress testing before low-risk surgeries. The article, “Stress Testing Before Low-Risk Surgery: So Many Recommendations, So Little Overuse” suggested the campaign’s partners focus on services with “high baseline rates of inappropriate care.” In her Editor’s Note in the same issue, Rita Redberg, MD, called for the specialty societies to create bolder recommendations about tests and procedures that patients and physicians should question. Both articles agreed that societies should adhere to the campaign’s charge to reduce unnecessary care.

While Choosing Wisely attempts to address the issue of overuse and waste in our health care system, I would like to remind my colleagues that its primary focus is—and has always been—sparking conversations between patients and physicians about appropriate care. In this regard, I believe Choosing Wisely has had a profound effect. The number of these conversations around the country has increased dramatically, and the work of our twenty-one grantees over the past two years has brought even more attention to the issue that sometimes less care is better care.

As we head into Choosing Wisely’s fourth year, we are shifting away from generating campaign awareness, its philosophy and recommendations to hopefully changing the way clinicians practice. The opportunity now lies in learning how best to implement these recommendations in practice and creating deployment strategies aimed around decreasing utilization of specific services per the recommendations. Several delivery systems across the country are already implementing meaningful utilization decreases for their system and their patients.

A new grant program funded by the Robert Wood Johnson Foundation also marks this shift. The program aims to reduce utilization of tests and/or procedures highlighted in at least three Choosing Wisely recommendations through a community partnership of patients/consumers, delivery systems, physician organizations and other interested parties. It is built on the premise that both the “supply” and “demand” sides must be involved and patient and providers need to work in partnership for this to provide meaningful and lasting impact.

Another prime example of how the campaign has transitioned is the recent announcement of the winners of the Society of Hospital Medicine’s competition (a current grantee). The competition’s aim was to encourage and recognize hospitalists who are implementing one of the ten SHM Choosing Wisely recommendations. Winner Hyung (“Harry”) Cho, MD and his colleagues from New York’s Mount Sinai Hospital focused on the use of urinary catheters and decreasing catheter-associated urinary tract infection (CAUTI).  Their initiative, called the “Lose the Tube,” had attendees and residents ask the simple question, “Does the patient need the Foley?” Learnings from the initiative are consistent with the campaign’s culture – permitting ownership and responsibility by the clinicians, avoiding mandated, top-down stewardship and putting the efforts within the context of doing no harm rather than money saved. Data showed the initiative decreased urinary tract infections almost to zero.

The Choosing Wisely campaign continues with great vigor. I have the deepest respect for the specialty societies who continue to advance this campaign with challenging recommendations that will improve quality, safety, patient experience and reduction of harm. The success of the Mount Sinai initiative proves the tremendous power of physician engagement in this implementation. It’s time to put words into action.

Daniel B. Wolfson
EVP and COO, ABIM Foundation