Si deve iniziare a “disinvestire” per liberare risorse da dedicare all’innovazione costo-eficace! Un appello anche alle Società scientifiche italiane e alle associazioni dei pazienti!
Expert Interview With Christine K. Cassel, MD
Choosing Wisely, an initiative of the American Board of Internal Medicine (ABIM) Foundation, comprises evidence-based recommendations from 9 specialty organizations on questionable tests and procedures. The goal is to use these recommendations as the basis for discussions between clinicians and patients. Medscape interviewed Christine Cassel, MD, President of ABIM, on the history of this initiative and its importance to health professionals and their patients.
Medscape: Please describe the ABIM Foundation’s Choosing Wisely initiative, including its mission for both patients and physicians.
Dr. Cassel: To start, it is well recognized and well documented that a lot of waste exists in our healthcare system, and we believed that a discussion needed to occur between society experts, physicians, and patients to understand what are wasteful practices and what are not. This was stimulated by a discussion initiated by Howard Brody, who is a physician-ethicist. He wrote an article for the New England Journal of Medicine  a couple of years ago saying that physicians need to reduce waste and be stewards of medical resources. He also suggested that specialty groups should pick a few things in each of their specialties that are likely to be overused — not that they should never be done, but that they are likely to be overused. And they should communicate these to their members. So we gave a very small grant to the National Physicians Alliance, and, working with Stephen Smith, MD, from Brown University, they were able to get the primary care groups — internal medicine, family medicine, and pediatrics — to each develop a list. This was very successful, and [the recommendations were] published in Archives of Internal Medicine.
Medscape: What were the steps for expanding this initiative to specialty societies?
Dr. Cassel: The ABIM Foundation has good relationships with many specialties, so last September we began inviting them into the process. Nine societies initially stepped up to the plate. They went back to their own groups, looked at their research, and came up with 5 recommendations, which we launched last month.
We now have a dozen more societies lined up for the second wave, and they’re all working very hard to develop a list. We are also in discussions with several more societies. All of these societies are exercising very important professional leadership.
Medscape: What were the instructions to the societies?
Dr. Cassel: We asked them to identify 5 practices that are often susceptible to overuse and might be unnecessary. It’s important to point out, however, that no one is saying that these practices should never be used. The societies are where most specialists go for their information, and they are the most trusted source of practice guidelines and information in most specialties. So, we consider that educating the clinicians is the responsibility of the profession. We expect, just like with the American College of Physicians and the American College of Cardiology, that at their annual meetings and in their publications you’re going to see more and more discussion of these issues.
Medscape: Was a limitation of 5 recommendations difficult for the societies? It seems a little arbitrary. How did you come up with that number?
Dr. Cassel: We picked it because we were building on the idea that Howard Brody and the National Physicians Alliance had started, which used 5 practices. Every society that we’ve talked to, of course, said that there there’s more than 5. We see this as just the beginning of the campaign; for example, inAnnals of Internal Medicine the American College of Physicians published 37 questionable practices that should be discussed . The societies will do more on their own, and we encourage that. It would be great.
Medscape: Is there much push-back from society members who might feel that this is cutting into their income?
Dr. Cassel: Some of their members push back, but most are very supportive and are saying that it’s about time somebody did something. It’s true that many physicians who are still in a straight fee-for-service system actually stand to lose money if they order fewer of these tests and treatments. But they are the first to say that it’s unethical if a practice is not helping the patient. They shouldn’t order tests just to make money, and they know that. I think for most doctors it’s not that they’re consciously calculating the “ca-ching” every time they do an unnecessary ECG or some other common test, but they do it because it’s a ritual and an expectation. Also, the patient might say, “My neighbor had a routine stress test, so why shouldn’t I have it?” So, in addition to losing revenue from the test, it takes more time and effort for the physician to explain to the patient why they don’t need it. And the patient may doubt it anyway and think, “I’m not getting something I need.” No physician wants to say “no” to a patient in those circumstances. That’s why the real power of this campaign is getting the consumers into the same discussion with the doctors, with the same information.
Medscape: How are you reaching consumers?
Dr. Cassel. We began by talking with Consumer Reports, because they were interested in getting more evidence-based information out to consumers about overuse and the harm that can come from it.Consumer Reports is working with each society to “translate” the lists for patients and consumers — making the medical language more accessible. In addition, many consumers have high-deductible health plans and worry about spending money on things that don’t help.
Medscape: We just published a Physician Compensation Report, which included the question, “Will you reduce testing to contain costs?” The answers were discouraging, I thought: Nearly a quarter (24%) said that they would not reduce testing because they were still going to practice defensive medicine, and 43% said they wouldn’t because they felt that the guidelines are not in the patients’ best interests.
Dr. Cassel: I’m not surprised by your survey response. I think the wording of the question, however, makes the issue about costs, when the Choosing Wisely campaign instead is focused on the relationship between the physician and the patient, as well as about having conversations with and tailoring care to the patient’s medical needs and preferences.
But there is also a myriad of reasons why some physicians are uncomfortable making these recommendations or don’t have time or are worried about malpractice. I’m actually surprised that the ABIM Foundation hasn’t gotten more negative feedback. And, for the record, it’s not our first goal to contain costs by reducing tests of marginal value. We are viewing the issue from the patient’s perspective; we are saying that these practices — for example, routine chest x-rays — could potentially lead to situations that might be harmful. Therefore, much of the work by specialty societies is about putting the right evidence in front of the clinicians and the patients.
The American College of Cardiology and the American Society of Clinical Oncology have put on their blog some wonderful talking points to address the few negative responses from members. They pushed right back and said, “This is the reason why we’re doing this and here’s the evidence.” They are trying to convey the ethical framework as well as the scientific evidence behind these decisions.
Medscape: Is there anything else you’d like to add?
Dr. Cassel: For both physicians and consumers, it is very, very important to emphasize that these are not lists of things never to do. These are practices that are susceptible to overuse, and therefore both the doctor and patient ought to have a conversation about them. Patients should feel empowered to ask their doctors, “Do I really need this?” And the doctors should have at their fingertips the information from their societies to answer that question. Our goal is to have this initiative be about a conversation. I had a radio show interview in New York City. A man called in who was 41 years old and healthy and had no symptoms of heart disease. He said that every time he went to his PCP he got an ECG. And you know that there are millions of people who probably have that experience. I don’t think it’s necessarily about that doctor doing this test intentionally to make money, but it has become a ritual. Patients expect it, and they think it’s a routine. However, it is not only unnecessary, but it also can often lead to incidental findings that cause other expensive and perhaps more risky tests to be done unnecessarily. I believe it’s very important to make the point that this isn’t one-size-fits-all medicine. This is really about fashioning these options to fit a particular patient — not doing something routine just because the patient walked in the door.