January 1, 2014
Volume 78, Number 1
Quality and Regulatory Affairs
Onyi C. Onuoha, M.D., M.P.H., B.S.N.
Valerie Arkoosh, M.D., M.P.H.
Lee A. Fleisher, M.D.
‘Choosing Wisely’ in Anesthesiology: Top-5 List – Addressing the Gap Between Evidence and Practice
The “Choosing Wisely” campaign is an ongoing initiative by the American Board of Internal Medicine (ABIM) to help physicians become better stewards of finite health resources by encouraging conversations between physicians and their patients to ensure the right care is delivered at the right time.1 Interestingly, patients believe that the world of medicine should be a place where evidence-based findings roll out into practice with ease and finesse. The reality, however, remains that despite the breadth of evidence and knowledge necessitating the practice of validated evidence-based guidelines, the translation of evidence to clinical practice still remains patchy at best. With the current economic climate advocating for improving quality of care, patient satisfaction and outcomes measures while decreasing unnecessary cost, the adherence to evidence-based guidelines that improve these measures will become important for the sustenance of health care facilities in the near future. In 2009, the cost of unnecessary health spending was estimated at $765 billion, a quarter of which ($210 billion) was spent on the overuse of services, including services that are provided more frequently than necessary or services that are at higher cost, but no more beneficial than lower-cost alternatives.2 The use of unnecessary diagnostic tests and treatments is hardly a novel issue. Compared to 10 years ago, physicians today are equally likely to perform a complete blood count, electrocardiography and chest radiography as part of routine health maintenance examinations even when these tests offer no additional health information or benefits and expose these patients to harm.3
The primary aim of the Choosing Wisely campaign is to promote “wise choices” by creating evidence-based lists of “five things physicians and patients should question” thatconsequently spark conversations with all stakeholders involved in the care of the patient. It is the first collective effort of many professional medical societies to identify common practices for which current evidence suggests little to no benefit. To date, more than 50 specialty and subspecialty societies have joined the campaign and have developed top-5 lists identifying common ineffective practices to question in their fields of expertise.1,4 More than 30 societies are expected to announce new lists in late 2013 and early 2014. Additionally, Consumer Reports, a magazine published by Consumer Union, is partnering with Choosing Wisely to ensure that patients are informed appropriately about medical tests and procedures that may be unnecessary, and in some instances can cause harm.5,6 This initiative represents an important first step toward the identification of low-value services, recognized jointly by consumer groups and professional specialties.6 In the past, anesthesiologists have pioneered the initial reductions in unnecessary testing with the development of preoperative screening clinics.7-9
To join this campaign and promote the practice of high-quality and safe patient care within the field of anesthesi-ology, a review of the literature and practice guidelines as approved by ASA was performed to identify an evidence-based list of activities to question within the field of anesthesiology. Criteria for inclusion as a candidate item included: 1) common clinical practices for which there is 2) little or no evidence of benefit to patients, 3) avoidance would lead to improved quality of care and/or 4) reduced costs. Postoperative and pain services were excluded for simplicity of analysis, interpretation and application.
In order to identify the anesthesiology “Top 5” items, we performed a two-step process. The first step involved surveying anesthesiologists in predominantly academic settings. The avoidance of an activity was considered well supported if a majority of the respondents rated it as being a frequent practice, with a weak impact on quality of care, a strong impact on cost of care, and weak evidence for its recommendation in clinical practice. Subsequently, an iterative process involving several ASA committees (committees on Surgical Anesthesia, Blood Management, and Cardiovascular and Thoracic Anesthesia) discussing the generated “Top-5 list” of preoperative and intraoperative activities was performed to establish the final list, which was endorsed by ASA and accepted for the “Choosing Wisely” campaign. They include:
1. Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA Physical Status I or II) undergoing low-risk surgery; specifically, complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
2. Don’t obtain baseline diagnostic cardiac testing (transthoracic/esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low- or moderate-risk non-cardiac surgery.
3. Don’t use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools, e.g., TEE).
4. Don’t administer packed red blood cells (PRBCs) in a young, healthy patient without ongoing blood loss and hemoglobin of ≥6 g/dL unless symptomatic or hemodynamically unstable.
5. Don’t routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications. Refer to current data for its use in specific populations.
With the involvement of multiple specialties in the perioperative care of a patient, a multidisciplinary approach involving the primary care physician, surgeon and anesthesiologist is needed to ensure the implementation of this list and evidence-based recommendations. We believe that developing strategies whereby all stakeholders in the perioperative team are involved is a means by which anesthesiologists could be engaged in the efforts to reduce overutilization of low-value, non-indicated medical services evident in the U.S. health system today. We may be far away from a utopian world of medicine, but we can begin to pave the pathway to ensuring that implementation from all those involved begins in the perioperative setting.
Onyi C. Onuoha M.D., M.P.H., B.S.N. is Assistant Professor of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania; Attending Anesthesiologist, Hospital of the University of Pennsylvania; Instructor, Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia.
Valerie Arkoosh M.D., M.P.H. is Professor of Clinical Anesthesiology and Critical Care, Professor of Clinical Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia.
Lee A. Fleisher, M.D. is Robert D. Dripps Professor and Chair, Department of Anesthesiology and Critical Care, and Professor of Medicine, Perelman School of Medicine, Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
1. Choosing Wisely: an initiative of the ABIM Foundation website. http://www.choosingwisely.org. Accessed November 20, 2013.
2. Berenson RA, Docteur E. Doing better by doing less: approaches to tackle overuse of services. RWJF website. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403697. Published January, 2013. Accessed November 20, 2013.
3. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148.
4. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802.
5. Volpp KG, Loewenstein G, Asch DA. Choosing wisely: low-value services, utilization, and patient cost sharing. JAMA. 2012;308(16):1635-1636.
6. Kuehn BM. Movement to promote good stewardship of medical resources gains momentum. JAMA. 2012;307(9):895, 902-903.
7. Pollard JB. Economic aspects of an anesthesia preoperative evaluation clinic. Curr Opin Anaesthesiol. 2002;15(2):257-261.
8. Foss JF, Apfelbaum J. Economics of preoperative evaluation clinics. Curr Opin Anaesthesiol. 2001;14(5):559-562.
9. Katz RI, Dexter F, Rosenfeld K, et al. Survey study of anesthesiologists’ and surgeons’ ordering of unnecessary preoperative laboratory tests. Anesth Analg. 2011;112(1):207-212.