The top 10 lists from the American College of Emergency Physicians and the Right Care Alliance (RCA) have distinct differences but a common goal: providing the best and safest care for patients in the emergency department. The biggest question is whether the new RCA recommendations will be adopted and improve diagnostic practices like imaging stewardship and reduce low-value care in the emergency department. Preliminary data have shown some promising results, however.
ACEP's Choosing Wisely recommendations focus on reducing overuse of medical tests and treatments. (Choosing Wisely. https://bit.ly/3aenpH2.) The brainchild of the American Board of Internal Medicine, the Choosing Wisely campaign was embraced by many medical specialties and subspecialties, and is described as a starting place for physicians and patients when discussing care. The first five Choosing Wisely recommendations were chosen with input from ACEP members, an expert panel, and the ACEP board of directors. The Cost-Effective Care Task Force then surveyed all ACEP members for suggestions, evaluated the results, and presented a final list from which the ACEP board selected five. The second set came from a Delphi panel of emergency physicians who winnowed the results from an ACEP member survey.
But the Right Care Alliance authors noted that the emergency medicine Choosing Wisely list “reflected in part an attempt to avoid controversy and left some important items—indeed some critical ‘elephants in the room’—unmentioned.”
The RCA's 10 recommendations for emergency medicine published this past December attempt to dissuade the overuse and underuse of certain diagnostic tests and treatments in the ED. (Emerg Med J. 2020;37:240.) The list was born from a process that involved an emergency medicine council, a community engagement council and patient advocates, and a vote to rank individual items. The alliance, a U.S. collaborative of health care practitioners and patients to address systemic overuse and underuse in health care, was formed in 2015 by the Lown Institute, a health care think tank.
Those involving the social determinants of health scored the highest, said Maia Dorsett, MD, PhD, an assistant professor of emergency medicine at University of Rochester Medical Center and the corresponding author of the RCA report. “It wasn't just about examples of overuse but also underuse,” she said, adding that she agreed with much of what is in ACEP's Choosing Wisely list but thought it did not go far enough. In fact, the ACEP list specifically does not address things that are well covered in ABIM's Choosing Wisely campaign, she said, noting, “This list wanted to address issues that were not addressed by the ACEP list, often because there's a little more controversy around them.”
Testing for pulmonary embolism, for example, has been affected by indication creep, Dr. Dorsett said. “In initial studies of PE, 15 percent of the patients had a pulmonary embolism. In the most recent studies, only two percent of people in the low-risk group had a pulmonary embolism,” she said. “We feel compelled to catch every single case, but in reality, there is no test that is going to do that.”
Yet low-value testing incurs financial and potentially harmful costs. “If you have something that could be construed as acute coronary syndrome, you end up with multiple high-sensitivity tests for troponin or stress tests that the patients don't actually need. It is mostly to protect ourselves and not the patients,” Dr. Dorsett said.
It is too early to gauge the effect of the Right Care Alliance's recommendations, but preliminary results are out for the ACEP Choosing Wisely list. Arjun K. Venkatesh, MD, MBA, an associate professor of emergency medicine at the Yale School of Medicine, was the lead author of a report that evaluated early effects of the Choosing Wisely program and the activities in the ACEP emergency quality network. (Am J Emerg Med. 2020 Jan 17. doi: 10.1016/j.ajem.2020.01.029.) His ACEP quality network evaluated utilization rates and quality improvement practices for three Choosing Wisely targets: atraumatic low back pain, syncope, and minor head injury.
They found small but significant decreases from 2017 to 2018 in the use of CT scans for syncope and minor head injury but no significant change for atraumatic back pain at the 305 ED sites in the study. Wide variation was seen among the hospital EDs in the study. Dr. Venkatesh and his colleagues concluded that quality improvement intervention could potentially improve imaging stewardship. Benchmarking and learning collaboratives would be important in further practice improvement.
There is definitely acceptance of ideas backed by research data, but such efforts are sometimes seen by insurers as a way to reduce utilization, Dr. Venkatesh said. “If you focus on that too much, you forget about access,” he said. “People recognize that there is a balance between the two in emergency medicine.”
His network has promoted shared decision-making with patients or the parents of pediatric patients. “We don't want a world where the physicians make an a la carte decision for patients,” he said.
Things like asking why the patient is in the emergency department in the first place or about his ability to comply with recommendations and find follow-up are often overlooked, but they could have a major impact, Dr. Dorsett said. “We say the patient is noncompliant for not taking medications without ever questioning why they can't take their medications,” she said. “Can they afford their medications? Can they get to their doctor? Are they choosing food for their kids over medications? I think this not only makes us better doctors because we understand the issues we need to address to help the patient, but it makes us feel better about our jobs.”
The key is setting achievable goals, Dr. Dorsett said. “If we asked one more patient if they can afford their medication, talk to one more patient about their discharge instructions, ask one more patient about their lives,” she said. “There are so many encounters that the sum of all those incremental changes would be massive, right?”
The Choosing Wisely campaign triggered a lot of low-value items, Dr. Venkatesh said. “There was a massive public awareness and relations campaign. What you find today are few examples of what physician organizations have done to translate them into practice,” he said. “That's why I'm proud to be part of this ACEP work that directly takes on the topic. This should be a call to other medical specialties to do the same.”
The Right Care Alliance Top 10 for Emergency Medicine
- Avoid testing beyond history, physical exam, clinical gestalt, and ECG in patients at minimal risk of an acute coronary syndrome and expand the traditional classification system of risk beyond low, medium, and high to include those at minimal risk.
- Avoid testing beyond history, physical exam, and clinical gestalt in patients at minimal risk of PE.
- Be judicious with imaging, especially advanced imaging, in trauma patients.
- Avoid routine laboratory testing.
- Consider that a patient's presentation might be for nonmedical reasons—biomedical, psychological, or social.
- Tailor the intensity of care to the patient's goals.
- Employ shared decision-making where appropriate.
- Make an effort to ensure that the patient is capable of accomplishing what is recommended.
- Tailor discharge instructions and follow-up recommendations to the patient.
- Be an advocate.
Source: Emerg Med J. 2020;37(4):240.
ACEP's 10 Things Physicians and Patients Should Question
- Avoid head CT scans for patients with minor head injury at low risk based on validated decision rules.
- Avoid placing in-dwelling urinary catheters for patient or staff convenience or for urine output monitoring in stable patients who can void.
- Don't delay engaging palliative and hospice care for patients likely to benefit.
- Avoid wound cultures for patients with uncomplicated skin and soft tissue abscesses after successful I&D and with adequate medical follow-up.
- Avoid instituting IV fluids before oral rehydration therapy in uncomplicated cases of mild to moderate dehydration in children.
- Avoid head CT scans in asymptomatic adult patients with syncope, insignificant trauma, and a normal neurological evaluation.
- Avoid CT pulmonary angiography in patients with a low-pretest probability of PE and either negative PERC criteria or a negative D-dimer.
- Avoid lumbar spine imaging for adults with nontraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition.
- Avoid prescribing antibiotics for uncomplicated sinusitis.
- Avoid ordering abdomen and pelvis CT scans in healthy patients under 50 with a history of kidney stones or ureterolithiasis and symptoms consistent with uncomplicated renal colic.
Source: ChoosingWisely.org. June 18, 2018; https://bit.ly/3aenpH2.
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Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.