This decade of US health care is all about choosing wisely: that is, choosing the best interventions to use (and not to use) when diagnosing and treating patients through a careful weighing of the costs, risks, and benefits of each intervention.
The Choosing Wisely campaign, a nationwide initiative developed by the American Board of Internal Medicine (ABIM) Foundation, encourages doctors and patients to do just that when faced with the myriad tests, procedures, and treatments that are readily available in this current era of medicine. Since 2011, Choosing Wisely has published “top 5 lists” of common practices that both physicians and patients should question in terms of their true medical necessity for more than 40 subspecialties of medicine.
They unveiled the top 5 list for adult pulmonary medicine, which includes the following 5 recommendations:
- Do not perform computed tomography (CT) scans to evaluate indeterminate lung nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.
- Do not routinely offer advanced vasoactive agents (which allow for improved blood flow through the lungs) that are only approved for treatment of pulmonary arterial hypertension (a specific type of high blood pressure in the lung circulation) to patients with other types of pulmonary hypertension.
- Do not renew a prescription of supplemental home oxygen for patients recently discharged after hospitalization for an acute illness without assessing whether there is an ongoing need for home oxygen.
- Do not perform CT angiography to evaluate for a pulmonary embolism (blood clot in the lung) in patients with a low clinical probability of this problem.
- Do not perform CT screening for lung cancer in patients at low risk for lung cancer.
Scott Halpern, MD, PhD, of the University of Pennsylvania, who led the session, noted that the United States spent $2.87 trillion on health care in 2012, and of that, critical care spending accounted for $103 billion. Given the steady increase of this number out of proportion with the increase in US gross domestic product, the ABIM Foundation added a clause reflecting concerns about costs to its charter of professionalism for physicians in 2002, stating that “physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.… The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures.”
This idea that cost-conscious and cost-effective medicine is an ethical responsibility of physicians on par with other Hippocratic commitments laid the foundation for the ABIM Foundation’s launch of the Choosing Wisely campaign in 2011. Each top 5 list is developed through an extensive and careful review of evidence of effectiveness, cost, relevance, and potential to change practice by members of the professional societies of each medical specialty.
The list for pulmonary medicine was developed by the American College of Chest Physicians and the American Thoracic Society. A full manuscript discussing the evidence supporting the recommendations is slated for publication in the journal CHEST in upcoming months.
The CHEST 2013 session also featured a preliminary glimpse of the upcoming top 5 list for adult critical care medicine, developed by the American College of Chest Physicians, the American Thoracic Society, the Society of Critical Care Medicine, and, importantly, the American Association of Critical-Care Nurses, making it the only list to date that includes input from a nonphysician society. Seven potential topics were addressed, 5 of which will ultimately make the final list, which will be published in conjunction with its presentation at the Society of Critical Care Medicine meeting in January 2014.
These current 7 items of importance in critical care medicine include:
- The appropriate use of routine lab tests
- The appropriate use of broad-spectrum antimicrobial agents
- The optimal level and duration of sedation for patients receiving mechanical ventilation
- The optimal threshold for blood transfusion
- The optimal timing of initiation of intravenous nutrition
- The optimal timing of central venous catheter and arterial line insertion
- The optimal approach to discussing life-sustaining vs comfort care measures for end-of-life care in the intensive care unit
The Choosing Wisely top 5 lists are intended to stimulate conversation between physicians and patients; they should not be viewed as a rigid set of guidelines or rules that must be followed, cautioned Halpern.