Choosing Wisely® and its impact on low-value care

By: Moises Auron, MD, SFHM

It is a well-known fact that healthcare expenditure in the United States occupies a large proportion of its gross domestic product, being 17.8% in 2016, which was almost twice to what is expended in other advanced countries; however, this expenditure does not necessarily translate into optimal patient outcomes. In 2012, the Institute of Medicine reported that the US healthcare system expends 750 billion dollars a year in waste that does not provide any meaningful outcome to patients or the system. Patients can suffer a financial impact from the delivery low value care; a study found that one of every 10 children receive low-value care, and even more,

In 2013, the Pediatrics Committee of the Society of Hospital Medicine (SHM) published 5 recommendations through the Choosing Wisely® campaign aimed to decrease the use of low-value interventions. These recommendations were:

1. Do not order chest radiographs (CXR) in children with asthma or bronchiolitis.
2. Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection.
3. Do not use bronchodilators in children with bronchiolitis.
4. Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.
5. Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

This publication led to the implementation of quality improvement initiatives across different hospitals and institutions nationally. Eventually, a team of hospitalists developed a report card that could help measure the utilization of these interventions in hospitals that were part of the Children’s Hospital Association (CHA). The data stemming from the report card analysis would allow to benchmark and compare performance as well as the secular trend in utilization of these procedures across the different institutions of the CHA.

Reyes, et al, recently published the impact of utilization of these scorecards among all hospitals members of the CHA in the Journal of Hospital Medicine, noting a positive impact of the SHM Choosing Wisely® recommendation in decreasing the utilization of low-value interventions. They compared the performance before and after to the publication of the Choosing Wisely® recommendations for a 9-year period (2008-2017). The most relevant impact occurred in children with bronchiolitis, with a decrease of 36% of bronchodilator use and of 31% in CXR utilization. In children with asthma, CXR utilization decreased by 20.8%. The authors found that although there is a steady decrease in the utilization of low value services, this is still limited.

What factors could impact the effectiveness of high-value quality initiatives? First of all, quality improvement requires a substantial investment of collective effort and time. It requires a change in culture that often involves changing long-standing paradigms. The Choosing Wisely® recommendations target a very specific, low clinical severity population – the focus is on “uncomplicated” disease. This is important as you don’t want to pursue aggressive unnecessary intervention in children and potentially cause harm – for example, unnecessary use of steroid in a child with uncomplicated bronchiolitis who may improve with nasal suctioning alone. There is a need to appraise that patients with more complex presentation of these diseases (e.g., patients that require escalation of care to ICU), and this is beyond the scope of Choosing Wisely®. Further research is needed to see if higher value care interventions can be implemented among these high acuity and severity patients.

In our institution, we have created specific care paths that facilitate following these recommendations. Essentially, we have leveraged the electronic health record order sets to avoid the inclusion of low-value interventions; all stakeholders (respiratory therapy, nursing, etc.) are aware of the care path and ensure compliance. Even further, as a consequence of the change in culture toward high-value care, we have identified low-value interventions in settings where high-value quality improvement can be implemented – for example, we found that at least 20% of non-critically ill children undergoing an appendectomy receive unnecessary antacid prophylaxis treatment.

Changes always start small; quality improvement requires a lot of effort, and we must focus our energy on “low-hanging fruit” and also begin tackling higher complexity tasks. In this Choosing Wisely® manuscript, the authors found that there was a change in performance with tendency toward higher value care, yet the change was not as substantial as originally thought.

How can we tackle higher complexity tasks if we find it difficult to implement solutions for those of lower complexity? My answer is simple. Maintain a consistent and continuous focus on high value and ensure the message is iterative and redundant with feedback on performance, decrease in costs and enhanced patient outcomes.