As part of an effort to address the overuse of medical resources, the American Society of Nephrology (ASN) has pinpointed five commonly ordered but not always necessary tests, services, and treatments that should prompt a discussion between physician and patient.
The initiative, called Choosing Wisely, is led by the American Board of Internal Medicine (ABIM) Foundation. Eight other medical societies also participated in the campaign, each releasing its own five-item list. (To read the initial Nephrology Times coverage of the Choosing Wisely campaign, please see pages 10-11 of the February 2012 issue.)
“I think this is so important because the campaign is not just about physicians, but the entire health care team,” said Amy Williams, MD, Chair of the ASN Quality and Patient Safety Task Force and a nephrologist at the Mayo Clinic in Rochester, MN.
“It is about having honest discussions about tests and procedures. Conversations about these recommendations are needed in order for this campaign to work.”
The Quality and Patient Safety Task Force, which was responsible for creating the “Five Things Physicians and Patients Should Question,” includes representatives from all 10 ASN Advisory Groups.
To develop the list, members of the Task Force worked with their respective Advisory Groups to come up with entries for consideration. The list was whittled down from about 100 possibilities to the final five, which were unanimously approved by the ASN's eight-member Public Policy Board:
1. Don't perform routine cancer screening for dialysis patients who have limited life expectancies and do not have signs or symptoms.
2. Don't administer erythropoiesis-stimulating agents to patients with chronic kidney disease (CKD) who have hemoglobin levels of 10 g/dL or higher and do not have anemia symptoms.
3. Avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension or heart failure or CKD of all causes, including diabetes.
4. Don't place peripherally inserted central catheters (PICC) in Stage 3-5 CKD patients without consulting nephrology.
5. Don't initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.
“Every one, if not implemented or if it doesn't become part of routine practice, can cause further unnecessary health care spending and possibly harm for the patient,” Dr. Williams said.
More Information, Transparency
The item on cancer screening is one of the entries that particularly stood out to Paul Palevsky, MD, Professor of Medicine at the University of Pittsburgh School of Medicine and Chief of the Renal Section at Veterans Affairs Pittsburgh Healthcare System, he said.
“The caveat is that it has great logical value, but has it ever been directly tested in clinical trials looking at a strategy of screening versus not screening? The answer is, no.”
The recommendation on shared decision making, which represents a consistent theme across the specialty societies, also caught Dr. Palevsky's attention, he noted.
Referring to the entire list, he said, “One of the problems is these are sound bite-type items, and the thought process behind them and rationale of the data aren't provided. The longest of the explanations is not even five lines long.
“It's hard to know what the thinking of the work group that put this together really was, and I'm hoping that this is only a starting point and that they will publish a more complete description of the processes that they followed and the rationale.”
One as yet unanswered question is, what other interventions were considered for inclusion on the list?
“I'd love to know what items six through 10 were,” Dr. Palevsky said. “There are some that I would have loved to have seen considered. One of them is evaluation for renovascular disease in patients with resistant hypertension given data that in many patients, intervention is not associated with benefits. This is just one of a variety of potential areas that could have been included on the list.
“I think they had a very tough job of finding only five things on the list. To the extent that I know how this process worked, I think the work group is to be commended, but I think we need more information and more transparency.”
Dr. Williams, too, would like to see the list extended, she said.
“We have many more.”
‘Listen to the Patient’
Theodore Steinman, MD, Professor of Medicine at Harvard Medical School, also recognized the members of the Task Force behind the list.
“They are very thoughtful people,” Dr. Steinman said. “Everyone can come up with their own little tweak, but I think they did a good job.”
Overuse of medical interventions is widespread, he added.
“Many things that we order are unnecessary, and half of what we do is kind of a reflex response,” Dr. Steinman said. “Part is driven by patient demand.”
Medical training also plays a role.
“We do not train our house officers, medical students, or fellows well about selective use of testing,” Dr. Steinman said. “This is a fault mea culpa. Part of it is driven by ‘can't afford to miss anything.’”
More effective communication could go a long way toward correcting the problem of over-testing.
“We order entirely too many tests because we do not listen to the patient,” Dr. Steinman said. “That is a fault in medicine in general.
“What I would emphasize the most—what you can't afford to miss—is listening to the patient. If you listen to the patient, he will tell you the diagnosis. Emphasizing improvement and change is emphasizing the interview technique.
“We are focusing too far down the line. I appreciate what has been done, and I really understand the basis and drive behind this, but can we do a better job?”
Spreading the Word
In addition to the ASN, eight other societies released lists of “Five Things Physicians and Patients Should Question” in their fields: 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 American Society of Nuclear Cardiology.
A new round of lists is to be released in fall 2012 from another eight societies: the American Academy of Hospice and Palliative Medicine, American Academy of Otolaryngology–Head and Neck Surgery, American College of Rheumatology, American Geriatrics Society, American Society for Clinical Pathology, American Society of Echocardiography, Society of Hospital Medicine, and Society of Nuclear Medicine.
Consumer Reports and eleven consumer-oriented organizations, including AARP, The Leapfrog Group, and Service Employees International Union (SEIU), are working with the ABIM Foundation to help disseminate information from the initiative.
“I think the biggest thing is getting the word out,” Dr. Williams said. “This is the nice thing about the Choosing Wisely campaign.”
Patient education is key, Dr. Steinman agreed.
“The more informed the patient, the better off we will be,” he said. “An informed consumer will drive change more quickly than anything else.”