The American Society of Nephrology (ASN) joined the American Board of Internal Medicine (ABIM) Foundation's effort to identify tests and procedures that are commonly ordered but not always necessary to improve patient care.
“The ABIM Foundation, together with colleagues in other organizations, is realizing there is a very important physician responsibility to address problems of health care costs,” said Christine Cassel, MD, President and CEO of ABIM and the ABIM Foundation.
“The Institute of Medicine estimates that 30 percent of health care cost is waste. Some come from discretionary interventions—both diagnostic and therapeutic—and in every specialty there are times where the patient and physician together might question if it is needed.”
As part of the campaign, called Choosing Wisely, each participating specialty society is to develop an evidence-based list of five common tests or procedures that should prompt these types of patient-physician discussions. The lists are to be released in April.
The ASN assigned its Quality and Patient Safety Task Force to lead the society's participation in the campaign.
“The task force represents each of ASN's 10 advisory groups,” said Rachel Shaffer, Manager of Policy and Government Affairs for ASN. “This is important because each advisory group represents a special niche area of nephrology, so it confirms that everyone thinking about this represented a facet of nephrology.”
After initial internal discussions, members of the task force went to their respective advisory groups and made a list of around 10 tests, procedures, and therapies for consideration. The task force whittled this number down from around 100 to seven, sending the list to the ASN Public Policy Board, which shortened it to five.
“When the task force was narrowing it down, they tried to focus on what would have a meaningful effect on patient outcomes,” Ms. Shaffer said. “It was very much a patient-centered approach. The second most important component was what evidence can support this recommendation.”
The campaign focuses on an important topic, noted Paul Palevsky, MD, Chair of the Quality, Safety, & Accountability Committee of the Renal Physicians Association, Chief of the Renal Section at VA Pittsburgh Healthcare System, and Professor of Medicine at the University of Pittsburgh School of Medicine.
“Overuse of testing and even of interventional procedures is a major concern in modern medicine, and nephrology is not exempt from this, so I think it is very appropriate for nephrology organizations to take leadership in trying to address this issue,” he said. “I would think there is significant potential, and we will have to see what the work group puts together.”
Discussions like this do come with potential pitfalls, Dr. Palevsky added.
“Whenever you try developing guidelines or performance measures, there is always a risk of unintended consequences,” he said. “There will potentially be accusations of rationing, which always come up when there are attempts to limit overuse.
“We need to be careful and consider how these recommendations about overuse are applied but make sure that we are being equitable and honoring patients.”
Also, while the focus has been on unnecessary interventions, underused procedures also should be considered, noted Tom Parker III, MD, Chief Medical Officer of Renal Ventures Management.
“I think there is as much risk with underutilizing practices that have been shown to be highly effective as there is with overutilization, and this really begs an issue of whether we are also underutilizing certain things that the science and best practices tell us we should be doing,” Dr. Parker said.
“I think it is a mistake just to look at overutilization. It could be that underutilization is costing as much money as overutilization. I think there are a lot of examples of that.”
‘Widely Engaged Public Discussion’
The eight other medical specialty societies participating in the ABIM campaign are the American Academy of Allergy, Asthma and 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; and the American Society of Nuclear Cardiology.
Around 10 societies are in discussions about participating in a second wave of the campaign, Dr. Cassel said.
“After the results are revealed, the next steps are to expand the specialties,” she said. “Our staff will begin to work with the other groups to develop the same kind of rigorous, meaningful lists that the first group had.
“If you think about the context of debates about health care reform, there is rhetoric about rationing and death panels, and we all know there are a lot of avoidable costs in health care.
“We need to have a rational discussion about this if we are ever going to reduce costs and be able to expand access to care. I think that is what is so powerful about this campaign. It's not just professionals or politicians talking among themselves, but it a widely engaged public discussion.”