Has the Choosing Wisely Campaign Affected Clinical Oncology Practice?

Victoria Stern, MA

Disclosures

August 19, 2015

The aim of the Choosing Wisely initiative, launched in 2012 by the ABIM Foundation, is to encourage providers and patients to follow evidence-based treatment regimens and to cease performing tests and procedures that probably provide no benefit and contribute to healthcare spending in the United States.

Although most oncologists agree about the importance of the Choosing Wisely campaign, it is unclear whether they are actually incorporating the 10 Choosing Wisely recommendations issued by the American Society of Clinical Oncology (ASCO), into practice.

Dean Gesme, MD, an oncologist at the Minneapolis Clinic, part of the US Oncology Network, has observed the Choosing Wisely recommendations begin to drive patient care in his group of 60 oncologists. "The recommendations help us provide valuable care and subtract out-of-date practices that do not contribute to a patient's physical, mental, and financial health," said Dr Gesme. "We distribute Choosing Wisely guidelines to physicians in our group as well as work with health systems and the media to publicize and highlight evidence-based oncology care. Although Choosing Wisely recommendations are not enforced throughout the US Oncology Network, they are widely publicized and encouraged."

Dr Gesme acknowledges that in his group, there are several areas that still need work, such as scaling back on antinausea drugs in situations when they're not called for or using a cheaper drug in lieu of a more expensive product, but overall, "the Choosing Wisely recommendations have been very effective in our practice."

Jeffrey Ward, MD, a hematologist/oncologist at the Swedish Cancer Institute in Edmonds, Washington, also believes that the initiative has been persuasive and that it may be motivating some oncologists to change practice. "If you were already inclined to practice in a Choosing Wisely way, this makes it easier for you and for your patients to make the right decisions. What better way to defend your choices and recommendations than with the full backing of ASCO?"

Both David Levin, MD, professor and chairman emeritus in the Department of Radiology at Jefferson Medical College and Thomas Jefferson University Hospital in Philadelphia, and Dhruv Khullar, MD, MPP, a resident in internal medicine at Massachusetts General Hospital and Harvard Medical School, say there's a big push at their institutions to keep the Choosing Wisely guidelines in mind, but they are uncertain of the broader impact of the campaign.

"In my radiology department, we try to do only tests that are necessary and eliminate those that aren't, according to the recommendations," Dr Levin said. "But I'm not convinced adherence is happening on a wider scale in the United States."

Dr Khullar agreed that "although there's a lot of hype around [Choosing Wisely]—and physicians are definitely talking about it—I'm not sure I've seen data suggesting it's changed tests ordered or procedures done yet."

Indeed, initial efforts to track adherence show that the initiative may not be having a significant impact on practice. Scott Ramsey, MD, PhD, an oncologist at the Fred Hutchinson Cancer Research Center in Seattle, has been involved in a large-scale effort to monitor whether oncologists are adhering to Choosing Wisely recommendations in Washington State. The Washington State Choosing Wisely Task Force, which includes representatives from almost two dozen of the largest healthcare organizations in the state, has looked at adherence to the first five metrics.

To accomplish this, Dr Ramsey and his colleagues identified oncology clinics and doctors in those clinics, and then examined their use of particular services, such as high-cost imaging for local-stage breast cancer. The investigators also linked their data from cancer registries with insurance claims from Premera Blue Cross between 2007 and 2014.[1]

"When I first talked to oncologists in the community about measuring adherence to Choosing Wisely, some said, 'Well, that's all nice, but what are you going to do when you find out that our clinic is 100% adherent?'" Dr Ramsey recalled. "It turned out, however, that 100% adherence to Choosing Wisely is simply not happening. We found huge variations from clinic to clinic—as much as five- to eightfold between the most adherent and least adherent clinics."

Part of the problem, according to Dr Ramsey, is a discrepancy between how well oncologists think they are following the guidelines and how well they actually are.

In addition, no particular patterns emerged within or across the clinics. "There weren't any all-star clinics," he said. "Some clinics were above average in certain areas and below average in others, but no one was doing above average across the board and no single recommendation stood out as particularly easy or difficult to follow."

"It seems that doctors don't really know how they're doing on a lot of performance measures," Dr Ramsey said. "It is hard to look back objectively at your experience of practice and come away with an accurate estimate."

Other evaluations of the impact of Choosing Wisely have uncovered similar results. A study[2] published in 2014 attempted to assess opinions of the Choosing Wisely breast cancer imaging guidelines amongst Canadian breast cancer specialists. Of 173 physicians who responded to an email survey, 60% said they had read the recommendations of the first top-5 list in oncology, and of those, 81% agreed with the guidelines.

But lead author Demetrios Simos, MD, found that most respondents had not changed their imaging practices. More than 95% of doctors identified a range of factors they felt indicated a need for imaging, including suspicious history, physical examination findings, and inflammatory breast cancer. The authors concluded that despite generally agreeing with the recommendations, "adherence is variable and factors such as local practice patterns and disease biology may play a role."

This pattern was echoed in another study performed by Dr Simos and colleagues. The authors collected retrospective data from a single Canadian academic cancer center and found no change in imaging practices in early-stage breast cancer. Almost 90% of women diagnosed with early-stage breast cancer underwent imaging, and more than one half received clarification imaging. After comparing imaging practices before and after the Choosing Wisely list became public, the authors found no change in the proportion of women who had at least one such imaging test.

One important caveat to the study, however, is that the measurements took place just 4 months after the first Choosing Wisely list was published and only examined practice patterns for several months. Although this may have been sufficient time for oncologists to become aware of the guidelines, it may not have been enough time for oncologists to change their habits.

"Our habits often become standard practice and are especially hard to break after years or decades of caring for patients," Dr Gesme said.

Still, even before the launch of Choosing Wisely, ASCO has periodically issued guidelines that reiterate those set forth by Choosing Wisely. In particular, ASCO published guidelines from 1996 up until 2007 that do not recommend using specific tumor marker tests for screening, diagnosing, or staging breast cancer, nor as surveillance tests for detecting recurrence after treating breast cancer.

"These Choosing Wisely recommendations are not new," saidDr Ramsey. "Some of the recommendations have been around for almost 20 years. The Choosing Wisely campaign has merely repackaged old guidelines."

In an earlier investigation, Dr Ramsey explored whether tumor marker tests were routinely overused in 39,650 women diagnosed with breast cancer from 2001 and 2007.[3] Dr Ramsey and colleagues found that almost 50% of patients on Medicare had at least one tumor marker test in the 2 years following their diagnosis and that the frequency of tests actually increased between 2001 and 2007. Although the study didn't assess the impact of Choosing Wisely, it did uncover widespread use of tests that ASCO had routinely deemed unnecessary or inappropriate.

One major barrier to changing practice patterns has been an underlying revenue issue. In a fee-for-service system, performing fewer tests can affect the bottom line for physicians. "Ultimately, real change in practice will require changes in reimbursement schemes," Dr Khullar said.

To this end, the Obama administration has recently announced a new goal to change the way in which doctors are paid, focusing on value-based rather than fee-for-service payments. The goal would be to focus fees to Medicare doctors on the quality, not the volume, of care—by examining, for instance, a patient's overall health. Still, determining how best to design and implement such a performance-based payment program remains a difficult venture.

Patient expectations and demand also represent a barrier to adopting Choosing Wisely. "Some patients want high-tech services," Dr Ramsey noted. "As a doctor who runs a business, if a patient thinks she needs an MRI and her doctor says she doesn't, it might not go down so well."

Doctors often worry about backlash from patients if they don't appear to be as thorough as possible. "Many doctors fear malpractice litigation if they don't order that extra test, even if the test is not recommended," said Dr Levin. "Hopefully, given the fact that Choosing Wisely represents widely respected and well-supported opinions and recommendations, the initiative will help doctors worry less about malpractice."

Part of the solution may lie in promoting adherence to the guidelines early in a doctor's career. "At Massachusetts General Hospital (MGH), I am involved in a group working to start our own MGH residency Choosing Wisely campaign, in which we identify tests that are low-value or often inappropriately ordered specifically by residents," Dr Khullar said.

Dr Gesme proposes initiating end-of-life discussions early in a diagnosis, instead of putting them off until patients and families are faced with imminent decisions. "We know from studies that having those end-of-life discussions earlier can spare patients treatments they may not really want or need," Dr Gesme said. "Having these conversations sooner may help alleviate a lot of the anxiety and emotional anguish, as well as additional tests and treatment costs, that patients encounter toward the end of life."

Dr Levin believes that increasing oversight from such organizations as radiology benefit managers (RBMs), which have tried to eliminate unnecessary imaging tests, may also help adherence.

"RBMs have had a huge impact," Dr Levin said. "When RBMs came on the scene in 2007, we went from seeing rapid growth in the use of imaging in the United States to a leveling off, and now the rates are beginning to drop."

Perhaps, Dr Ramsey suggested, even showing doctors how they rank relative to their colleagues can motivate adherence.

"But we haven't even got to the first step of measuring how well we're doing," Dr Ramsey said. "After that, we will need to implement incentives to change behaviors."

Dr Ward believes that we will start to see greater compliance over time. "Some doctors will slowly change their practice habits toward Choosing Wisely as they see colleagues change their habits, but won't necessarily be early enthusiastic adopters of the recommendations," he noted.

Dr Ramsey is more cautious, however. "The problem we've seen over years of trying to change behaviors of physicians is that we tend to go back to our old patterns. It is hard to extinguish habits in general and in the practice of medicine. We may see some behavior change in the short run, but maintaining that change will be difficult."

But, Dr Ramsey added, "if the campaign can serve as a launch pad for establishing unique partnerships and getting people together to solve the problem, it may have a greater impact in the long term."

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