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The Choosing Wisely campaign to reduce harmful medical overuse: its close association with Patient Blood Management initiatives

2015; Wiley; Volume: 25; Issue: 5 Linguagem: Inglês

10.1111/tme.12256

1365-3148

Michael Murphy,

Clinical Reasoning and Diagnostic Skills

Eliminating unnecessary diagnostic procedure and treatments in medicine is a cornerstone of doing no harm, improving patient care and outcomes and allocating resources appropriately. A recent report by the Academy of Medical Royal Colleges argued that doctors have an ethical responsibility to reduce this wastage of clinical resource because, in a healthcare system with finite resources, one doctor's waste is another patient's delay (Academy of Royal Medical Colleges, 2014). It has always been difficult to engage clinicians in stopping familiar or ingrained practices and procedures as it requires a different approach to that for introducing new treatments. A new initiative developed in the United States and Canada called Choosing Wisely (www.choosingwisely.org) aims to change doctors' practice to align with best practice by getting them to stop using various interventions that are not supported by evidence, free from harm and truly necessary, including those that duplicate tests or procedures already received and it will soon be applied to transfusion medicine. The Choosing Wisely campaign was originally an initiative of the American Board of Internal Medicine (ABIM) Foundation designed to reduce overuse of tests and procedures because they are unnecessary and therefore wasteful and potentially harmful (Hurley, 2014; ABIM, 2015). The campaign engages with patients as well as doctors to help them choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary (Box 1) (Choosing Wisely, 2015). In response to this challenge, national medical organisations in the United States have agreed lists of common interventions in their field whose necessity should be questioned and discussed when possible with patients. Over 70 specialist societies have created such lists. Do I really need this test or procedure? Medical tests help you and your doctor or other healthcare provider decide how to treat a problem. And medical procedures help to actually treat it. What are the risks? Will there be side effects? What are the chances of getting results that are not accurate? Could that lead to more testing or another procedure? Are there simpler, safer options? Sometimes all you need to do is make lifestyle changes, such as eating healthier foods or exercising more. What happens if I do not do anything? Ask if your condition might get worse – or better – if you do not have the test or procedure right away. How much does it cost? Ask if there are less expensive tests, treatments or procedures, what your insurance may cover, and about generic drugs instead of brand-name drugs. Blood transfusion is described as the commonest procedure performed in the hospitalised patient in the United States (Pfunter & Stocks, 2010). Unnecessary use of blood transfusion is common worldwide; national audits of blood transfusion in England suggest that there is substantial inappropriate use of transfusions of all types of blood components (Murphy et al., 2013; NHS Blood and Transplant, 2015). Overuse of blood transfusion has been listed as a Choosing Wisely recommendation by the American Society of Hematology, the Society of Hospital Medicine and the Critical Care Societies Collaborative in the United States. To support this initiative, the AABB, formerly the American Association of Blood Banks, developed a set of 10 recommendations with input from their committees and Board of Directors. The top five recommendations were selected, and all started with ‘Don't’ as required by the ABIM (Box 2) (AABB, 2015). They are intended to prompt clinicians to rethink their engrained culture of liberal transfusion practice and prompt patients to question why they are being prescribed blood. A recent commentary provides background information and the evidence for each of the AABB's recommendations (Callum et al., 2014). The development of the AABB's recommendations and commentary were intended to assist with the promotion of better Patient Blood Management, which is an international initiative for an evidence-based, multidisciplinary approach to optimising the care of patients who might need transfusion. It encompasses measures to avoid transfusion, such as anaemia management without transfusion, cell salvage and the use of anti-fibrinolytic drugs to reduce bleeding, as well as restrictive transfusion. It ensures that patients receive the optimal treatment, and that avoidable, inappropriate use of blood and blood components is reduced. On 18 June 2012, the Patient Blood Management: The Future of Blood Transfusion conference was held at the Royal College of Pathologists in London. The event was jointly hosted by the National Blood Transfusion Committee (NBTC), NHS Blood and Transplant and the Department of Health; Professor Sir Bruce Keogh, NHS Medical Director, gave the introductory presentation. A. GENERAL CONSIDERATIONS B. SPECIFIC ASPECTS OF SURGICAL PBM C. SPECIFIC ASPECTS OF MEDICAL PBM D. IMPLEMENTATION OF PBM As with previous national recommendations promoting appropriate blood use, it will be a major task to disseminate them to the many staff prescribing blood in the NHS and implement them effectively. Their integration into general initiatives for reducing ‘Too Much Medicine’ and variation in clinical practice may increase the likelihood of success. In this respect, it is exciting to see that the Academy of Medical Royal Colleges is bringing the Choosing Wisely campaign to the UK (Malhotra et al., 2015). This campaign has also been adopted in many other countries including Australia, Canada, Germany, Italy, Japan, the Netherlands and Switzerland. The Academy of Medical Royal Colleges has invited participating organisations in the UK to develop a list of five tests or interventions with questionable value. The Academy, Royal Colleges and other partners will then promote dissemination of this information to encourage Choosing Wisely conversations between patients and clinicians (Malhotra et al., 2015). The selection of the five topics for transfusion medicine to be included in the UK Choosing Wisely campaign was led by the NBTC in England. Possible topics were selected by reviewing Choosing Wisely recommendations from other countries and developing new ones, and then put to a vote of the chairmen of the NBTC and the Regional Transfusion Committees in England, the membership of the NBTC PBM working group (which includes two patient representatives) and consultants in transfusion medicine. The five selected topics submitted to the Academy of Medical Royal Colleges for consideration are shown in Box 4. Additional credibility for the selection of the topics is that all five are included in recommendations of the forthcoming NICE guideline on blood transfusion which will be published in November 2015 (NICE, 2015). First, there is a need to ensure that the topics are selected according to rigorous criteria, such as the practice is not evidence-based, is frequent, measurable and wasteful of resources. Second, the topics need to have the support of clinicians and patients to maximise the chance of their implementation. The process for the selection of topics could be designed to optimise the likelihood of support, e.g. by soliciting suggestions from clinicians based on knowledge of practices associated with harm and unnecessary costs followed by a voting process. This is the approach we took to develop the list of transfusion topics presented here in addition to using topics developed by Choosing Wisely campaigns in the United States and Canada. A different approach was taken by the Swiss Society of General Internal Medicine who used literature review and expert opinion followed by multiple rounds of an electronic Delphi process (Clement & Charlton, 2015). A more robust methodology could also be developed by using systematic reviews and health technology assessments. There is no evidence as yet that the top five lists have produced a positive impact on reducing low-value healthcare in either the United States or elsewhere (Clement & Charlton, 2015). Indeed, a telephone survey of 600 physicians in the United States found that only 21% had even heard of the Choosing Wisely campaign (PerryUndem Research/Communication, 2014). Public awareness, which is an essential component of the campaign, has not yet been assessed (Malhotra et al., 2015). There is also a need to ensure that there are appropriate parameters to measure the effectiveness of each Choosing Wisely topic, and that a pre-implementation baseline measurement has been made. Greater consideration also needs to be given to implementation of the top five lists and how to support clinicians and their teams in doing so. Benchmarking, feedback of data including the use of dashboards are examples of tools needed to drive change and monitor progress. Formal implementation plans should be part of each Choosing Wisely list and their inclusion is very much a part of the campaign in the UK. Returning specifically to blood transfusion, how can the evidence supporting the UK Choosing Wisely recommendations for blood transfusion and Patient Blood Management be accelerated into routine transfusion practice, apart from continuing efforts to educate clinicians prescribing blood? Prospective monitoring of blood orders provides the opportunity for intervention to avoid unnecessary transfusion in addition to collecting data for audit of transfusion practice. However, it is labour intensive and risks delaying patient care. Retrospective review is easier to do, but the possibility of intervention to prevent inappropriate transfusion is missed. Both methods for review are hugely facilitated by the use of information technology, and particularly so through blood ordering using a computerised physician order entry (CPOE) process. In addition, warning screen ‘alerts’ can be triggered if the prescriber attempts to order a transfusion where the most recent laboratory tests are outside those recommended as triggers for transfusion, and the prescriber given the option of cancelling the order (‘decision support’) (Murphy & Yazer, 2013). A recent systematic review of relevant studies of this topic found that there was significant variation in study population, the type of CPOE/decision support used and outcome reporting (Hibbs et al., 2015). All but one study used a before-after design without any element of randomisation. Overall, there was good evidence that implementation of CPOE/decision support improved red cell usage, but the effect on plasma, platelets and cryoprecipitate usage was less clear probably because fewer studies have been conducted focusing on these products. In addition, the introduction of this process resulted in cost savings in the studies that reported financial outcomes. Patient outcomes were generally not studied in detail, and there were few data on the sustainability of the effect. The review concluded that further data are needed to assess the effect of CPOE/decision support on blood usage other than red cell transfusion and future studies should standardise reporting of the process itself, any ancillary efforts to influence transfusion practice such as education and training, and outcome measures. The current introduction of electronic patient record systems into many hospitals in the UK provides the opportunity to implement CPOE/decision support for blood ordering to reduce inappropriate transfusion with the dual benefit of improved patient outcomes and reduced hospital costs, and our own group in Oxford has demonstrated that this is feasible in routine practice in the NHS (Butler et al., 2015). This article is based on an article by the author of this review ‘The United States Choosing Wisely campaign and measures to implement good transfusion practice on both sides of the Atlantic’, published in The Bulletin of the Royal College of Pathologists (2014), 168, 226–229. The author thanks Odette Brownings for help in preparation of this article, and Kate Pendry, Shubha Allard, Lisa Estcourt, Dora Foukaneli, Graham Donald, Susan Robinson and Megan Rowley for their contribution to drafting the recommendations for the UK Choosing Wisely campaign.