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Posts made in April 2015

Good Medicine: Choosing What to Do, Choosing What Not to Do


ChoosingWisely-CMYK-taglineRThe Choosing Wisely® campaign was launched in 2012 by the ABIM Foundation to encourage patients and clinicians to think about the tests and treatment choices they are implementing or requesting, and to avoid those tests that have proven to be overused and inappropriate.

Over the past three years, this initiative has engaged nearly 100 national and state medical specialty societies, regional health collaborative and consumer organizations. These organizations have identified more than 300 tests and procedures that must be scrutinized for their efficacy and efficiency before they are ordered.

In the Commonwealth of MA, Massachusetts Health Quality Partners (MHQP) is leading a multi-stakeholder effort to advance the Choosing Wisely campaign.
“The Massachusetts health care environment provides a fertile ground for Choosing Wisely to take hold,” said Barbra G. Rabson, executive director of MHQP. ” As a Commonwealth, we have made it a priority to find ways to achieve high quality and affordable care  Choosing Wisely is another step in that direction.”

The Choosing Wisely Massachusetts Campaign:
• Engages providers to integrate Choosing Wisely recommendations and materials in their practice.
• Engages patients and families to use Choosing Wisely consumer materials to become better informed about the decisions and choices they need to make about their health and health care.
• Identifies ways to engage providers and patients to better communicate in using Choosing Wisely materials.

Dr. Paul Hattis, Massachusetts Health Policy Commissioner and public health professor at Tufts University Medical School stated in an interview that patients typically do not challenge their doctors. “They usually accept the advice that their clinicians offer.  So empowering and engaging patients to filter their choices takes education to help them better understand the consequences of their decisions,” he said.

There are five key questions developed by Consumer Reports Health, a partner in the Choosing Wisely campaign, that patients and clinicians need to answer before tests and procedures that have become automatic and standard are ordered. These questions include:

1. Do I really need this test or procedure?
2. What are the risks?
3. Are there simple safer options?
4. What happens if I don’t do anything? Will my condition get worse or better if I wait?
5. How much does it cost? Are there less expensive equally effective ways to treat this problem?

The following are examples of common health problems where there has been a tendency to rush to tests, when studies and data indicate there are other considerations to be taken into account.

Low Back Pain

It has long been thought that the treatment of low back pain should begin with life-style modification, with imaging deployed when other avenues of treatment have been exhausted. In 2012, Atrius Health, one of the MHQP partners formally began studying practice data on the use of imaging tests for acute low back pain. They conducted site-by-site clinical meetings to review guidelines on imaging use; and shared the findings from the analysis.

Based on the Choosing Wisely recommendations from the  American College of Physicians (ACP) and American Academy of Family Physicians (AAFP), Atrius health distributed patient materials developed by Consumer Reports Health to educate patients and to open up a dialogue between patients and their clinicians regarding low back pain and the use of imaging tests. The Atrius Health approach helps to guide conversations with patients in productive ways – to reassure them that their pain is not concerning and to allow adequate time to discuss at-home and other treatments that help the patient make a safe recovery.

Atrius Health consists of four leading community-based groups who joined together to form a non-profit alliance, for the delivery of health care in Eastern Massachusetts. These medical groups serve 675,000 adult and pediatric patients in over 2.2 million visits annually to 42 practice locations and include more than 750 physicians and a total of almost 6,800 employees.

Pap Tests

New guidelines released just one month ago from The American College of Obstetricians and Gynecologists (ACOG) – and supported by The American Cancer Society – indicate that most women only need a Pap test, which screens for cervical cancer, every 3 to 5 years, rather than annually.   Two decades of research with conclusive proof that certain high-risk strains of HPV cause cervical cancer has reinforced how this disease is transmitted; how few infected women actually develop cancer; and how slowly this cancer progresses. Additionally, the technique for collecting and analyzing cervical cells for the Pap test has improved.  As a result of this new knowledge, it is advised that a safe option for women is to get regular, but less frequent, Pap tests, unless they have certain risk factors and health issues, regardless of age.  These risk factors include women who have HIV/AIDS, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, or have been treated for cervical intraepithelial neoplasia (CIN) or cervical cancer.

The American Academy of Nursing (AAN), an organization dedicated to advancing health policy and practice, has also adopted the Choosing Wisely mantra. In most settings, nurses spend more time with patients than other clinicians. This positions nurses to have conversations with the patients about the best practices that promote health and healing. The AAN has issued several cautions that nurses routinely encounter that are often avoidable and unnecessary.  Among these are:

• Don’t automatically initiate electronic fetal heart rate monitoring for low-risk women during labor.  Evidence does not support routine use of continuous monitoring among women with low-risk pregnancies.  Such monitoring has been associated with an increase in cesarean and instrumental births, without an associated improvement in perinatal outcomes.

• Don’t let older adults lie in bed or only get up into a chair during their hospital stay.  Walking while in the hospital is critical for maintaining functional ability. Evidence shows a lack of walking increases the length of hospital stays and the need for rehabilitation services while elevating the risk of falling after being discharged.

• Don’t wake patients from sleep for routine care unless the patient’s condition or care specifically requires it.  There is a long-standing perception that patient safety requires patient assessment and monitoring at pre-determined intervals around the clock.  Studies, however, show that sleep deprivation negatively affects cognitive function, the ability to perform physical activities and ventilator, circulatory, immunologic, hormonal and metabolic stability.

• Don’t place or maintain a urinary catheter in a patient unless there is a specific reason for doing so.  Catheter-associated urinary tract infections are among the most common healthcare-associated infections in the U.S. and most are related to the use of urinary catheters.

There are United States health care provider organizations representing more than one million providers who have developed lists of Things Physicians and Providers Should Question in recognition of the importance of conversations to improve care and eliminate unnecessary tests and procedures.
These lists represent specific, evidence-based recommendations providers and patients should discuss together in order to make wise decisions about the most appropriate care, based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.For a comprehensive list of these recommendations check the Choosing Wisely website,

Many challenges lie ahead for the Choosing Wisely agenda, not the least of which is convincing all stakeholders that reducing unnecessary tests frees up needed health resources without compromising patient outcomes. Additionally, making the leap from publication to practice and turning these recommendations into action will involve the collective support of patients, clinicians, payers and other healthcare professionals. MHQP and Choosing Wisely Massachusetts have aggressively taken this to the next level.

Short Message Systems, Formula for Improving Health Literacy

short message systems - Copy

Nearly 9 out of 10 adults have difficulty understanding and using the everyday health information that is routinely available in our health care facilities, retail outlets, media, and communities. Studies show that today’s health information is presented in a way that isn’t usable by most Americans, with the result that people are more likely to skip necessary medical tests, end up in the emergency room more often, and have a hard time managing chronic diseases, such as diabetes and hypertension.

In 2003 the U.S. Department of Education, Institute of Education Sciences, did an extensive assessment of the health literacy of American adults.  The study revealed that only 12 percent of U.S. adults had proficient health literacy. Over a third of U.S. adults—77 million people— had difficulty with common health tasks, such as following directions on a prescription drug label or adhering to a childhood immunization schedule, using a standard chart.

The study also revealed that limited health literacy affects adults in all racial and ethnic groups, and that all adults, regardless of their health literacy skills, got their health information from radio/television, friends/family, and health professionals. Not much has changed in over a decade, except that there is a growing number of individuals who now get much of their health information from the Internet.  This does not make them more or less health literate.

Health literacy affects people’s ability to:
Navigate the healthcare system, including filling out complex forms and locating providers and services
Share personal information, such as health history, with providers
Engage in self-care and chronic-disease management
Understand mathematical concepts such as dosing instructions.

Unfortunately, even people with strong literacy skills can face health literacy challenges, including:
Difficulty with medical terms
Interpreting numbers or risks to make a health care decision.
Confusion about a diagnosis
Inability to carry out complicated self-care associated with complicated chronic conditions.

There are many ways to foster health literacy including public health forums, public television programming, better information coming from healthcare professionals and clinicians. However the reach with these approaches is minimal. There is also a way, using a standard cellphone or a  smartphone that health literacy can improve.

Over 98% of the world’s population, including many in developing nations have a cellphone available to them. There are more than 5.3 billion mobile phone users globally. By 2012, more than 50% of these mobile phones were equipped with global positioning systems (GPS) and web-connectivity (i.e., “smartphones”). Smart- phones allow information to be delivered by voice, texts, pictures, and videos as well as to be triggered by location and date.

Using mobile phone technology to send short messages (SMS short message systems) to people, in the form of prompts and reminders, has proven to  improve patients’ access, quality, and utilization of care, and  helps patients  receive health information, skills, support, and crisis services directly for a specific health condition.

SMS technology is cost efficient, easy to set up and maintain and has the broadest possible reach.  It is a way to get out messages to the general population and  to encourage people to be more engaged and proactive in their health

Short messages offer advice on nutrition, alcohol, tobacco and drug use; early warnings about potential epidemics; instructions on how to monitor chronic conditions and reminders to take medications and get immunizations. With more than 50% of people not adhering to the drugs that their primary care givers prescribe it is kind of obvious that SMS has value in so many ways. So how do patients benefit from the increased use of mobile health technology?

1. Communication

Better communication reduces the risk of serious medical errors. For example, the Joint Commission estimates that 80 percent of medical mishaps occur due to poor communication. One example of this includes when patients are handed off to a new physician or specialist. For clinicians, the ability to send a secure text message facilitates a real-time exchange of health information and removes the need for pagers, email and voice mail, which are not timely and often not secure.

2. Compliance

Secure text messaging can be used to remind patients to take prescribed medicines and to comply with recommended care practices, such as pre-surgical procedures designed to reduce infections. A study published in the Journal of the American College of Surgeons found that patients prefer text messaging when partnering with their physicians on the specifics of their health management. Researchers at the Medical College of Wisconsin, Milwaukee, used texts, emails and voice mails to remind patients to take antiseptic showers 24 to 48 hours before a scheduled surgery. Text messages were the most popular electronic communication method (80 percent) among the patients. Those who received the texts were significantly more compliant with the pre-admission orders.

Other examples include the numerous Text4Health projects recognized by the U.S. Department of Health and Human Services. These initiatives show the immense opportunities to engage under-served groups and improve health. For example, the National Cancer Institute’s SmokeFreeTXT effort more than doubled the smoking quit rate among teens by texting smoking cessation messages to them.

A series of studies  looked at how providing diabetic patients with health information using their cellphone  improved their health status. In 9 out of 10 studies that measured hemoglobin A1c patients and clinicians reported significant improvement among those receiving education and care support. Cell phone and text message interventions increased patient–provider and parent–child communication and satisfaction as well.

SMS has been around for several years.  As the use of smartphones proliferate and people become more accustomed to sending and  receiving  short messages, understanding  basic health information will become more widespread.  This should insure a more health literate population.