A Few Nudges for the Choosing Wisely Campaign
As discussed by Christine Cassel of the American Board of Internal Medicine in an Institute of Medicine (IOM) commentary on June 14, 2013, the Choosing Wisely campaign unites more than 25 medical specialty societies, each agreeing to identify “Five Things Physicians and Patients Should Question.” It’s hard to imagine this in any other industry: leaders questioning even some of their most profitable practices. But physicians hold themselves to a higher standard, and Choosing Wisely proves it.
This leadership comes not a moment too soon. As the IOM reminds us, unnecessary services help drive more than $750 billion in wasted spending each year, and countless patients suffer unnecessary pain, distress, disability, and sometimes death.
Choosing Wisely is so extraordinary that it is hard to nudge for even more. But there is much more work ahead to achieve the brilliant and powerful vision for change outlined in this remarkable initiative. So here are some nudges for Choosing Wisely, plus a case study on why it’s all worth it.
Nudge 1: Complete the list of unnecessary procedures. Currently, almost all of the questionable procedures in Choosing Wisely are screenings or tests. But screenings rarely result in immediate death or disability, and that’s what consumers rightfully worry most about. To confront more injurious outcomes, Choosing Wisely should incorporate advice about when to question hysterectomies, back surgeries, surgeries to prevent stroke, heart surgeries, or ear tube surgeries, to name some of the most striking examples from The Treatment Trap, the landmark book by Rosemary Gibson and Jamardan Prasad Singh.
Nudge Two: Impose accountability for results. Unfortunately, this is not an easy task. There are few measures that would enable us to monitor progress toward achieving the goals of Choosing Wisely. Even after we establish measures, we need transparent internal intelligence and public reporting, and these are not well established for issues of overuse. But time is short, so we can’t wait for perfect measures and perfect reporting. Accountability is the key to whether this initiative goes down in history as the moment our nation turned the corner, or another much-hyped but failed attempt at change.
A case study for these nudges. Nowadays we have a shining case study that exemplifies the advantage of bold leadership and public accountability: the national effort to end early elective deliveries (EEDs).
The American College of Obstetrics and Gynecology (ACOG) admirably named EEDs on their Choosing Wisely list of questionable procedures. These unsafe deliveries put newborns at immediate risk for respiratory distress, other serious complications, and death. Women also endure the many increased risks of inductions and C-sections.
We’ve heard about this problem for a long time, not only from ACOG, but also from March of Dimes, most health plans, some major hospital systems like the Hospital Corporation of America, Childbirth Connection, and others. Yet, despite the leadership and educational campaigns of these influential players, after years of effort we had no evidence of progress.
Finally, however, using a Joint Commission measure endorsed by the National Quality Forum, the purchaser driven Leapfrog Group publicly reported in 2010 on the prevalence of EEDs in more than 750 hospitals in the United States. The results were dismaying: the national average rate of EEDs was 17 percent, and rates among hospitals varied enormously, sometimes within the same community.
Leapfrog members were astonished by the response that followed the first announcement of these results. It helped accelerate efforts already under way to address the high rate of EEDs, and engaged new stakeholders—in particular, Leapfrog’s audience of public- and private-sector purchasers. For instance, with the help of purchaser-led Catalyst for Payment Reform, in South Carolina, Governor Nikki Haley’s administration moved to change the
payment rules for EEDs. Other purchaser organizations like the National Business Group on Health launched educational campaigns. The National Priorities Partnership, a coalition of the nation’s leading health care stakeholders advising the Obama administration’s national strategy, made this issue a priority, as did the Department of Health and Human Services last year. Consumer media began to focus attention on the problem like never before.
The result has been major strides during the past 2 years. In January 2013, Leapfrog announced that nearly one-half of reporting hospitals report close to zero of these harmful deliveries (compared with one-third reporting zero 2 years ago); the national average rate of EEDs dropped significantly, from 17 percent in 2010 to 11.2 percent in 2012. Variability among and within states remains, with many hospitals still reporting rates much higher than the average. States with strong leadership show strong results; in South Carolina, for instance, rates dropped from 27.8 percent in 2010 to 10.4 percent in 2012. Rates also declined in Illinois, which had a multi-stakeholder campaign led by the Midwest Business Group on Health.
With EEDs, we see the powerful potential of the highest standards for ethics and leadership combined with tough public accountability. Now, we need to apply this model to other hazardous and overused procedures. Through the leadership of Choosing Wisely, we are halfway there; a few more nudges and success is within reach.
