Creating a List of Low-Value Health Care Activities in Swiss Primary Care

ArticleinJAMA Internal Medicine 175(4) · February 2015with 39 Reads
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Abstract
In 2010, the idea emerged of creating lists of low-value health care activities as a way to confront rising medical costs and encourage cost-conscious care. The Good Stewardship Working Group¹ and Brody² pioneered the idea of “top 5” lists, leading to the Choosing Wisely campaign.³ Building on this momentum, there has been widespread interest in proposing additional lists.⁴ In 2012, the Swiss Society of General Internal Medicine committed to creating a list for Swiss ambulatory internal medicine.

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    Background: In 2014, the 'Smarter Medicine' campaign released a top five list of unnecessary tests and treatments in Swiss primary care, such as imaging for acute low-back pain and long-term prescribing of proton pump inhibitors. Objectives: Measure general practitioners' (GPs) agreement with the recommendations and self-reported adherence. Methods: Cross-sectional, online survey of GPs in the 'Swiss primary care active monitoring' (SPAM) network, which assessed awareness of 'Smarter Medicine' and views on each recommendation. Questions included whether the clinical situation is common, whether the recommendation is followed, whether GPs agree with the recommendation and reasons why the recommendation would not be followed. Results: One-hundred-and-sixty-seven of 277 GPs from the SPAM network participated (60%), of which 104 (62%) knew of 'Smarter Medicine', including 79% in German areas, 49% in French areas and 38% in Italian areas (P < 0.001). Agreement with the five recommendations was high, with scores around nine out of 10. The proportion saying they typically follow each recommendation was 68 to 74%, except not continuing long-term PPI prescriptions without attempting dose reduction, with only 34%. Common reasons for not following the recommendations were patient or other provider requests and situations that might suggest the need for more aggressive care. Conclusion: Two years after the launch of the campaign, awareness and acceptance of 'Smarter Medicine' appear to be high among Swiss GPs. By self-report, the recommendations are adhered to by most of the respondents but there may be room for improvement, especially for long-term PPI prescriptions.
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    As part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign,¹ more than 60 specialty societies have published lists of 5 tests, procedures, or treatments that physicians and patients should question. Recognizing the opportunity for the provision of higher-value care in our own setting, we developed a Choosing Wisely list for the inpatient General Internal Medicine service at Mount Sinai Hospital (MSH), one of the affiliated teaching hospitals at University of Toronto.
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  • Article
    Zusammenfassung Ziel Im Rahmen der „Choosing wisely“-Kampgagne werden Empfehlungen von Experten zu diagnostischen oder therapeutischen Interventionen publiziert, die unangemessen sind und zu Überdiagnose oder Überbehandlung führen. Ziel unserer Arbeit war, eine innovative Methode darzustellen, wie Empfehlungen mit praktizierenden Hausärzten entwickelt werden können, und die Resultate mit den Listen der „Choosing wisely“-Kampgagne und mit der Schweizerischen „Smarter medicine“-Kurzliste zu vergleichen. Methoden 109 niedergelassene Hausärzte, die an einer Kongress-Fortbildung teilnahmen, wurden gebeten, in Gruppen (zu 5-7 Ärzten pro Gruppe) drei für ihre Arbeit relevante Interventionen zu entwickeln, die zu vermeiden seien. Die am häufigsten genannten Interventionen verglichen wir mit denjenigen der publizierten Listen der „Choosing wisely“-Kampagne und der Kurzliste der „Smarter Medicine“-Kampagne. Die Themenliste wurde ergänzt mit Vorschlägen, die von Mitgliedern des Verbandes Junger Hausärzte Schweiz (JHaS) erfragt wurden. Resultate Fünf Gruppen schlugen Check-up-Untersuchungen als verzichtbare Intervention vor, vor allem bei jüngeren oder asymptomatischen Individuen. Die Durchführung von Ruhe- oder Belastungs-Elektrokardiogrammen bei asymptomatischen Individuen und die Cholesterinmessung bei Individuen älter als 75 Jahre, oder die Statintherapie in der Primärprävention und/oder hohem Alter, waren ebenso häufig genannte verzichtbare Interventionen. Vier bzw. drei Gruppen nannten die Arthroskopie oder ein MRI des Kniegelenks nach Distorsion (in Abwesenheit von Gelenksinstabilität oder -blockade) bzw. die bildgebende Diagnostik bei Kopfweh (ohne Alarmzeichen) als verzichtbare Interventionen. Zwischen den Interventionen, die von Hausärzten vorgeschlagen wurde, und denjenigen auf der Liste der „Smarter medicine“-Kampagne bestand keinerlei Übereinstimmung. Hingegen fanden wir bei den am häufigsten vorgeschlagenen Interventionen Entsprechungen auf den Listen der „Choosing wisely“ Partnergesellschaften. Die Rücklaufquote der JHaS-Mitglieder war eindrücklich niedrig. Konklusion Für die Entwicklung von Listen mit potentiell unangemessenen Interventionen ist die Perspektive der Anwender (praktizierende Ärztinnen und Ärzte) wichtig. Dadurch kann ein höherer Identifikationsgrad und Adhärenz der Anwender mit den Empfehlungen erwartet werden. Die in unserer Studie vorgeschlagenen Interventionen könnten, optimalerweise in Zusammenarbeit mit der „Smarter medicine“-Kampagne, zu weiteren Empfehlungen führen, was in der Grundversorgung besser zu unterlassen sei. Entscheidend für die Umsetzung ist eine einfühlsame Kommunikation mit dem Patienten zu Nutzen und Schaden von potentiell unangemessenen Interventionen.
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    Switzerland with its decentralized, liberal health system and its tradition of direct democracy may be an ideal place for shared decision making (SDM) to take root organically, rather than using top-down regulations seen in other countries. There are now multiple directives and programmes in place to encourage SDM, with the creation of several decision aids and specific training programs in the five Swiss medical schools. There has been an emphasis on preventive care, with the integration of patient preference into an organized colorectal cancer screening program, clear recommendations for prostate cancer screening, and inroads into the primary prevention of cardiovascular disease. Focusing on the experience of the University of Lausanne, we describe multiple approaches being taken to teaching SDM and the local development of decision aids, drawing on international experience but tailored to local needs. Efforts are being made to further involve patients in not only SDM, but also associated research and quality improvement projects.
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    Background: Launched in the US in 2012, Choosing Wisely(®) is a campaign promoted by the American Board of Internal Medicine (ABIM) Foundation with the goal of improving healthcare effectiveness by avoiding wasteful or unnecessary medical tests, treatments and procedures. It uses concise recommendations produced by national medical societies to start discussions between physicians and patients on the relevance of these services as part of a shared decision-making process. The Multiple Sclerosis Focus Group (Groupe de Reflexion Autour de la Sclérose en Plaques; GRESEP) undertook a pilot study to assess the relevance and feasibility of this approach in the management of multiple sclerosis (MS) in France. Methods: Recommendations were developed using the formal consensus method from the guidelines of the French National Health Authority (HAS). A steering committee selected the themes and drafted concise evidence reviews. An independent rating group then assessed these recommendations for clarity, relevance and feasibility. Results: Seven recommendations were accepted: (1) avoid systematic ordering of multimodal evoked potential studies for diagnosing MS; (2) do not treat MS relapses with low-dose oral corticosteroids; (3) when treating MS relapse with high-dose corticosteroids, the systematic use of the intravenous route is unnecessary if the oral route can be used; (4) systematic hospitalization is not necessary for treating MS relapse with high-dose corticosteroid therapy, particularly if the oral route is used, except for the first treated relapse and the presence of exclusion or non-eligibility criteria; (5) in the absence of clinical signs or symptoms of urinary infection, avoid systematic screening with urine microscopy and culture before the administration of corticosteroid therapy for MS relapse in patients using intermittent self-catheterization; (6) avoid antibiotic treatment of clinically asymptomatic MS patients using intermittent self-catheterization, even if urine microscopy and culture reveal the presence of microorganisms; and (7) avoid introducing symptomatic drug treatment for MS-related fatigue. Conclusion: This pilot study, the first of its kind in France, has demonstrated the relevance and feasibility of adapting the Choosing Wisely(®) model to MS by practitioners specializing in the disorder. However, the acceptability of these recommendations by other practitioners in other specialist fields as well as their impact on everyday clinical practices now need to be studied.
  • Article
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    Background Inspired by the US Choosing Wisely®, in 2016 the Swiss Society of General Internal Medicine released a list of five treatments or diagnostic tests used in the hospital and considered unnecessary based on not improving patient care and adding to health care costs. These “Smarter Medicine” recommendations were implemented in the Department of Internal Medicine, Uster Hospital, in August 2016. They were supported by lectures and weekly email communications. We analyzed the number of blood draws before and after implementation of the recommendation aimed at reducing blood tests. Methods This retrospective analysis was conducted in the Department of Internal Medicine, Uster Hospital, Canton of Zurich, Switzerland. Patients hospitalized in the 3 months before and after implementation were analyzed. Results A total of 2023 hospitalizations were analyzed. There was a significant decrease in the number of blood draws after introduction of the recommendation: before implementation, the median number of blood draws per patient was 4 (interquartile range [IQR], 2–7); after implementation, the median was 4 (IQR, 2–6; P = 0.002). Indeed, since 46% of the patients in the first group had more than four blood tests, this ratio decreased to 39% after implementation. Discussion Inappropriate blood draws may lead to anemia, patient discomfort and false-positive results. The simple and low-cost interventions used to implement “Smarter Medicine” have changed physician behavior by reducing the number of blood orders. These results are promising. Whether such recommendations will impact patient and clinical outcomes remains unknown; hence, further studies are needed to clarify this issue.
  • Article
    In the short time since its April 2012 launch by the American Board of Internal Medicine Foundation, the Choosing Wisely campaign has affected more than 60 US specialty societies. Now the campaign is becoming an international phenomenon, as evidenced by Selby et al¹ and Gupta and Detsky² in this issue. These publications should be considered in the context of other national efforts, the most prominent being Choosing Wisely Canada,³ which identifies itself as being modeled after its American counterpart and having “spread to Australia, Germany, Italy, Japan, Netherlands, Switzerland and elsewhere.” This rapid expansion is a heartening sign that there is increasing international sentiment against wasteful medical practices. However, actually decreasing wasteful and harmful health care will require both patient and physician commitment as well as objective evidence of effectiveness. If either is found wanting, the results will be underwhelming.
  • Article
    Background: Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled "Promoting Good Stewardship in Clinical Practice" that aimed to develop a list of the top 5 activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved. Methods: Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities. A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians. Results: The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities that could improve clinical care. Conclusions: Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities that could lead to higher quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the activities, the potential positive impact on medical care quality and cost, and the ease with which the activities could be performed. We recommend that these "Top 5" lists of activities be implemented in primary care practice across the United States.
  • Article
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    To develop and apply a novel method for scanning a range of sources to identify existing health care services (excluding pharmaceuticals) that have questionable benefit, and produce a list of services that warrant further investigation. A multiplatform approach to identifying services listed on the Australian Medicare Benefits Schedule (MBS; fee-for-service) that comprised: (i) a broad search of peer-reviewed literature on the PubMed search platform; (ii) a targeted analysis of databases such as the Cochrane Library and National Institute for Health and Clinical Excellence (NICE) "do not do" recommendations; and (iii) opportunistic sampling, drawing on our previous and ongoing work in this area, and including nominations from clinical and non-clinical stakeholder groups. Non-pharmaceutical, MBS-listed health care services that were flagged as potentially unsafe, ineffective or otherwise inappropriately applied. A total of 5209 articles were screened for eligibility, resulting in 156 potentially ineffective and/or unsafe services being identified for consideration. The list includes examples where practice optimisation (ie, assessing relative value of a service against comparators) might be required. The list of health care services produced provides a launchpad for expert clinical detailing. Exploring the dimensions of how, and under what circumstances, the appropriateness of certain services has fallen into question, will allow prioritisation within health technology reassessment initiatives.