Partisan and government agencies alike agree that waste accounts for a significant portion of unsustainable U.S. healthcare costs. Experts estimate up to one-third of healthcare treatments and procedures have no benefit and 20% to 50% of imaging studies produce no actionable data. Cost estimates are all over the map, but most point to a striking $700 billion. This means one-third of the $2.2 trillion total U.S. healthcare expenditures are wasted on unnecessary, harmful, futile, or at best ineffective care. Here’s the dilemma: The money being spent is sustaining our outdated fee-for-service, volume-driven healthcare system. In this scenario, healthcare organizations continue to try to maximize their traditional means of income from hospital admissions, procedures, tests, and therapies as they wait for the axe to fall and instill a new reimbursement ethic of paying the appropriate provider for care that has value.
We’ve witnessed the rancor and politicization of issues when evidence-based guidelines that restrict testing and treatments call for more judicious use of resources. In 2009, the U.S. Preventive Services Task Force recommendations that increased the age for routine mammography screening from 40 to 50 led to death threats and were rejected for changes in policy. Proliferation of hyperbole on contrived “death panels” insulted healthcare professionals and seniors who sought a serious conversation on informed end-of-life choices.
A coalition of physician groups is trying to put the brakes on overuse of care by ensuring more prudent decision making as a way to achieve health care that’s both appropriate and cost effective. In a remarkable move, nine medical societies joined together to form the Choosing Wisely® initiative spearheaded by the American Board of Internal Medicine (ABIM) Foundation. The societies include the American Academy of Allergy, Asthma, and Immunology; American Academy of Family Physicians; American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology; American Society of Nephrology; and American Society of Nuclear Cardiology. (See http://choosingwisely.org.) In April, eight additional specialty societies joined. These groups are demonstrating extraordinary leadership by rejecting the traditional "more is better" pattern in favor of creating a new set-point for appropriate evidence-based care. Each society has created a list of five tests and procedures that providers, patients, and other stakeholders should question and discuss to determine why it is or isn’t necessary (or could even be harmful). The idea is to start a conversation with the patient, a key foundation of person-centered care.
Consumer Reports and a growing list of communication collaborators from the healthcare, consumer advocacy, and business communities will help educate and encourage consumers to take an active role in these conversations. The Choosing Wisely campaign envisions a more informed public that benefits from learning about unnecessary tests and treatments, coupled with questioning a physician’s recommendation for any test or procedure on the lists created by the nine professional societies.
Several societies recommended eliminating imaging for initial evaluation of adults with low back pain, as well as for syncope. They also recommend skipping certain diagnostic tests for asymptomatic adults at low risk for cardiac disease. Other recommendations aim to counter consumer demands for indiscriminate antibiotic use for such conditions as sinusitis. In short, if a diagnostic test or imaging procedure doesn’t contribute information that will improve an outcome, it shouldn’t be done. Asymptomatic patients shouldn’t be subjected to potential harm from unnecessary tests, and treatments with no efficacy should be avoided. Some of the practices in question are highly disease specific, such as those for oncology and digestive diseases; these are an initial step in moving away from "doing everything" simply because the drugs and technology are available. Another recommendation calls for a shared decision among patient, family, and provider before the start of chronic dialysis.
I’m not sure if the ABIM reached out formally to the nursing community as it initiated its work, but we should applaud this major step forward and join in advocating evidence-based, cost-effective care decisions. Nurse practitioners can embrace the recommendations in their own practices. Nurses in any practice area should be familiar with these recommendations and the associated evidence so they can respond to patients’ questions or requests from patients or their caregivers. More importantly, we should exercise our responsibility to question any potentially unnecessary test or care.
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN