Cardiac Critical Care: Limiting Unnecessary Treatment

Sunil V. Mankad, MD; Gregory W. Barsness, MD


July 10, 2015

Editorial Collaboration

Medscape &

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Sunil V. Mankad, MD: Greetings. I'm Sunil Mankad, associate professor of medicine at Mayo Clinic. During today's commentary, we'll be discussing Choosing Wisely®.[1] I'm joined by my colleague, Dr Greg Barsness, who is director of our cardiac intensive care unit here at Mayo Clinic. Greg, tell us a little bit about the Choosing Wisely campaign. What exactly is it and why is it important?

Gregory W. Barsness, MD: The Choosing Wisely campaign is something that was envisioned in 2010 and started up as a real campaign in 2012. It involves a variety of professional societies who have gotten together to distribute lists of five things that are less meaningful or less important to practice and, perhaps, even harmful. About 30% of current medical practice patterns in the United States are either not helpful or even potentially harmful. That's a huge amount of our scarce healthcare resources that are put forth toward something that really has no benefit and may even harm patient care. It's in that context that a collaborative group of various critical care societies got together and put together, from a vast list of potential candidate options, a list of five items that you should probably avoid doing routinely in critical care medicine.

Dr Mankad: What are some of the specific goals of this initiative?

Dr Barsness: The stated goal of the Choosing Wisely campaign is to spark a conversation between providers and among providers, patients, and their families to give a framework so that we can discuss what is appropriate and what might not be appropriate in the care of these patients.

Dr Mankad: How widely recognized or utilized is this campaign?

Dr Barsness: In talking about this for the past several years, I've taken informal polls in a variety of settings, from primary care to critical care clinicians; the awareness is growing, but it's certainly not at 100%. Back in 2012, there was just a smattering of people who had any idea that there was such a program. Now a good half of the audience often knows about the program.

Dr Mankad: You mentioned that some larger organizations are taking part in Choosing Wisely. What are some of the specific ones that people might know?

Dr Barsness: The American College of Cardiology has a list.[2] Virtually all of the major medical societies have gotten together, and there are now almost 70 of these lists that have been put together by different organizations.

Dr Mankad: I am an imager, and the American Society of Echocardiography has certainly become involved to make sure that the echocardiograms we order are appropriate. Have we been able to impact quality and make an actual difference in patient satisfaction?

Dr Barsness: That would be the goal—to decrease costs, improve quality, and improve outcomes. I would have to say that although this has engendered some discussion, data about the actual impact of this program are less clear. We don't have data about specific outcome measures, but I would say that awareness is increasing. These are practices that large groups of experts have agreed are not necessarily appropriate as part of routine care. In that way, I think it's had an impact, and it's actually had a global impact. All of this started with the ABIM Foundation in a US-centered effort. Now there are European and Canadian societies that are also doing the same sort of campaign.

Dr Mankad: You mentioned that the Choosing Wisely campaign targets practices that are to be avoided, for the most part. Does it also encourage certain practices that have been established to improve quality?

Dr Barsness: I can't speak to all of the lists, but these are generally lists of five things to be avoided in practice. However, I think that that's a natural next step. We already have guidelines that suggest that you should do this or that, but this is meant to fill the gap, where you might think about doing something. But there is no list anywhere that says you probably shouldn't do it. Now we have that, but incorporating some additional practices that are a good idea, or that you might consider, would also be important.

Dr Mankad: I think that's great because, ultimately, it's about quality and value, and respecting both the patient and the institutions' practices. Thanks, Greg, for these very important insights, and thanks to our viewers for tuning in to Mayo Clinic's commentary at on Medscape.


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