Studying the Impact of Choosing Wisely Campaign - An Original investigation Santosh Bhaskarabhatla, Bhaskara Group, and Graduate School of Biomedical Sciences at Rutgers - Robert Wood Johnson Medical School J. Anna Looney, PhD, Department of Family Medicine at Rutgers - Robert Wood Johnson Medical School
Context: ple size of n=100 also will give us a very thorough sampling of the population of family physicians. overtreatment According to the Center for Medicare Services, American health care costs are rising from $2.6 trillion in 2010 to a projected $4.6 trillion by 2020, more Rashidian et al [8]: Physician understanding of the evidence behind the than twice that of other developed nations [1]. At least twenty percent of guidelines affected the implementation rates of the guidelines healthcare expenditures may classify as waste [2]. One of the six major com- Sirovich et al [9]: A 2011 study by Sirovich et al found that a high percentage ponents of this waste is overtreatment, which is defined as the excessive use of doctors overprescribed treatments because of “malpractice concerns of medications, testing, and procedures that have no clinical benefit for the (76%), clinical performance measures (52%), and inadequate time to spend patient [2, 3]. By reducing overtreatment, American physicians can reduce an with patients (40%)” estimated $150 billion dollars in waste annually [2, 4]. The Choosing Wisely Part II: Questionnaire Design campaign has been spearheaded by the American Board of Internal Medicine (ABIM) Foundation in collaboration with organizations such as Consumer The questionnaire has three parts. The first part collects basic demographics Reports to reduce overtreatment across the medical specialties. about the physician. The second part consists of several clinical vignettes based on the Choosing Wisely recommendations. The third part asks the The Problem: physician about the awareness and implementation of Choosing Wisely, and Unnecessary medical tests and treatments reduce the quality of medical care it also examines physician opinions and potential barriers to implementation. by wasting limited resources and potentially causing harm to patients. We have validated the questionnaire with several actively practicing physi- cians and statisticians. Assessment of The Problem and Analysis of Causes: Part III: Survey (in progress) In 2012 and 2013, the American Board of Internal Medicine (ABIM) released Given that our study is preliminary and cross-sectional, we have limited data lists of specific evidence-based recommendations. These Choosing Wisely on the expected outcomes of the study. We are measuring overtreatment recommendations aim to facilitate discussions between physicians and pa- based on three clinical scenario questions. Based on literature, we infer that tients about appropriate medical care. Our study examines the fifteen rec- 33% of doctors in the general population will overprescribe treatments [6]. ommendations released by the American Academy of Family Physicians We hypothesize that doctors who are aware of Choosing Wisely will overpre- (AAFP). scribe slightly less, at a rate of approximately 30%. We aim to have an alpha- In 2011, the National Physicians Alliance originally published “Top Five” lists value of 0.01 because we applied a Bonferroni correction of p= 0.05/5 for five to reduce overtreatment for family medicine, pediatrics, and internal medi- independent factors that we are measuring. We aim to have a beta-value cine [5]. In 2012, the ABIM Foundation partnered with Consumer Reports to (statistical power) of 0.8. Therefore, we need a sample size of at least 91 create the Choosing Wisely campaign to foster conversations about over- family physicians, and we are aiming to survey 125 family physicians. We treatment be-tween physicians and patients. Through the Choosing Wisely expect that 25% will be excluded from the survey. After collecting 100 valid initiative, five recommendations for Family Medicine were published by the responses, we will close the survey. Having a sample size of n=100 also will ABIM Foundation and the American Academy of Family Physicians. In 2013, give us a very thorough sampling of the population of family physicians. the American Academy of Family Physicians released ten new recommenda- tions to make a total of fifteen Choosing Wisely recommendations. The Discussion and Message for Others: Choosing Wisely Campaign also has published “top 5” lists of overused medi- We believe our study provides valuable information about the implementa- cal treatments for many other medical specialties [6]. In order to implement tion of Choosing Wisely. In addition, this questionnaire may become a learn- these Choosing Wisely recommendations, it is important to understand why ing tool to identify and reduce unnecessary medical tests and treatments. We overtreatment exists. Currently, there is little literature about the implemen- hope that it can advance the IHI Triple Aim. In addition, the electronic nature tation of Choosing Wisely. of our questionnaire makes a large-scale survey very cost-effective. Local Aims: researchers are much better equipped to study geographically proximate healthcare systems. There is an urgent need for enthusiastic researchers to I) Extensive literature review of historically significant clinical practice guide- study overtreatment and the implementation patterns of the Choosing Wise- lines and recommendations to develop an effective strategy to implement ly campaign. Therefore, we encourage other researchers in the United States the Choosing Wisely recommendations in the United States. to use our straightforward framework to: II) Design of survey instrument in the form of an electronic questionnaire. (1) measure overtreatment in Family Medicine in other states of the USA and This questionnaire will be distributed to family medicine physicians in order (2) expand this study of overtreatment in other medical specialties in the to measure: (1) treatment patterns in several clinical scenarios, (2) the extent United States. of physician awareness of the Choosing Wisely campaign, and (3) the barriers References: for implementation of these recommendations. III) Survey of family medicine physicians in New Jersey using the validated 1. Keehan SP, Sisko AM, Truffer CJ, et al. National health spending projections through 2020: economic recovery and reform drive faster spending growth. Health Aff. questionnaire (in progress). 2011;30(8):1594-1605. Results: 2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513-1516. Part I: Literature Review 3. Reilly BM and Evans AT. “Much Ado About (Doing) Nothing.” Ann Intern Med. 17 Kumar et al [7]: Physician awareness of clinical practice guidelines led to a February 2009;150(4):270-271. 4. "Estimated Waste in American Healthcare Spending." The Economist. 17 June 2011. statistically significant reduction in overtreatment. Accessed: 01 December 2012. Rashidian et al [8]: Physician understanding of the evidence behind the