Five Things Physicians and Patients Should Question

2014 - 1 February – Critical Care in Underserved Areas
The Critical Care Societies Collaborative (CCSC), together with the ABIM Foundation and the Choosing Wisely® campaign, released the list, “Five Things Physicians and Patients Should Question,” during the 43rd Critical Care Congress.

 

The Critical Care Societies Collaborative (CCSC), together with the ABIM Foundation and the Choosing Wisely® campaign, released the list, “Five Things Physicians and Patients Should Question,” during the 43rd Critical Care Congress. Since Choosing Wisely was launched in April 2012, more than 80 national, regional and state medical specialty societies, health collaboratives and consumer groups have joined as partners. The campaign has released more than 60 lists covering more than 300 tests and procedures that the specialty society partners say are overused or inappropriate, and that clinicians and patients should discuss. The CCSC, which includes the Society of Critical Care Medicine, the American College of Chest Physicians, the American Thoracic Society, and the American Association of Critical-Care Nurses, is proud to have contributed to a list specific to the critical care community.

“‘Five Things Physicians and Patients Should Question’ is the only list representing a collaborative effort among four professional societies and the only list including a professional nursing association,” noted Scott D. Halpern, MD, PhD, during his presentation of the list during the Critical Care Congress. The Choosing Wisely campaign maintains that healthcare delivery contains too many tests or procedures that may not necessarily provide benefit.

The ABIM Foundation offered guidelines to representatives working on the list, noting that: items should fall within the specialty’s purview and control; procedures and tests should be used frequently and/or carry a significant itemized cost; generally accepted evidence should exist to support each recommendation; and the list development process should be thoroughly documented and publically available upon request.

Hannah Wunsch, MD, MSc, noted during her Congress presentation that the group also formulated its own criteria, including:

• Strength of evidence: How sure are we that our suggestion is correct?
• Prevalence: How commonly do we think the issue arises?
• Aggregate cost: How large are the anticipated cost savings if clinicians adhere to the suggestion?
• Relevance: To what extent is the recommendation a “core” or “unique” part of the practice of critical care medicine?
• Innovation: How much does the suggestion represent an advance, rather than recapitulate known best practices or previously published clinical guidelines?

“We wanted to focus on things that we owned as a specialty and could stand behind, and wouldn’t overlap too much with things that were recommended by other societies,” she said.

When asked about how the CCSC representatives dealt with consideration of items that do not harm patients versus those that primarily restrain costs, and the different viewpoints related to that controversy, Wunsch acknowledged this as a large challenge.

 “We looked for a balance. There’s no simple list of the key things that you should not be doing because they are done to every patient, cost a lot of money and cause harm. So, the list ends up being a compromise at different levels and across not just the issue of cost and harm, but across all five domains described. Each one had its benefits in some of these realms and not others. There was acknowledgment of the pros and cons of each item and recognition that this is a starting point. The idea is to generate discussion and to teach others to think about these topics while caring for patients.”