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Choosing Wisely: avoiding bad care and maximizing the chance of getting good care

By Myra Gerson Gilfix

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports (begun in 2012), is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.

From their website:
 
“In 2012 the ABIM Foundation launched Choosing Wisely® with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.abimfoundation.org/About-Us.aspx
 
“Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of ‘Things Providers and Patients Should Question.’ More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patient’s individual situation.
 
“Consumer Reports is a partner in this effort and works with specialty societies to create patient-friendly materials to educate patients about what care is best for them and the right questions to ask their physicians. Through a coalition of consumer groups like AARP and the National Partnership for Women and Families, Consumer Reports is ensuring patients get the information they need just when they need it.”

Virtually every specialty has lists of procedures or tests to avoid doing
 
The collection of Choosing Wisely Lists can help a patient or patient advocate to resist recommendations of physicians — and nursing homes — which they are wary about, and allow them to make proactive choices. It’s nice to have the power of a major medical group to back up your concerns!
 
Working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”
 
The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest. Needless to say, there are likely more tests and procedures that are not “wise,” but this is a great start. It also means that you should use our handout, “Suggested Questions to Ask Your Doctor” when any treatment or procedure is proposed … not just those on these lists.

For the elderly in particular to avoid

Although virtually every specialty has released lists, the recommendations from geriatricians and palliative care specialists may be of particular interest to you, since many are grappling with such issues in their own families.
 
Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for dementia patients. This is something most of you have already specified in your Advance Health Care Directive that you don’t want. This is important because many patients are still being tube fed by default — even without a conversation that would engender a good decision.
 
Feeding tubes
 
Research has shown that feeding tubes do not prevent aspiration pneumonia or prolong dementia patients’ lives, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.
 
Antipsychotic medications

The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.
 
Meds to achieve ‘tight glycemic control’ for type 2 diabetes
 
Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics who need to control their blood sugar, but not as strictly as younger patients.
 
Avoid prescribing sleeping pills when possible. Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five, pointed out that doctors should not turn to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien and Lunesta “. . . don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies, such as cognitive therapy, are preferable.

Avoid prescribing antibiotics for many urinary tract infections (UTIs)
 
An informative case study:
 
Avoid prescribing antibiotics when tests indicate a urinary tract infection (the most common infection among nursing home residents) but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.
 
Brown University geriatrician Dr. David Dosa observes, “As people get more frail and old, physicians tend to do more, when often we should do less.” This observation is so important that it should be a guiding principle in hospitals and nursing homes. DO MORE BY DOING LESS.
 
While younger people who get a positive test result almost always need antibiotics since it’s not normal for them to have bacteria in their urine, many older people are “colonized” with bacteria and thus don’t necessarily need treatment. Often they live in environments with more germs, and they’re subject to procedures — like catheterization — that can lead to infection. Yet even though they may have a positive urinalysis indicating the presence of bacteria, they’re not sick. “This is normal for them,” Dr. Dosa said. “Just because they’re colonized doesn’t mean they need to be treated.”
 
The McGeer criteria (named for the infectious disease specialist who published them) call for antibiotics only if an older patient has three of these five symptoms: a fever; increased frequency or urgency of urination, or burning associated with it; pain behind or near the bladder; a change in the smell or appearance of urine; or deteriorating function or mental state.
 
But in two Rhode Island nursing homes where Dr. Dosa and his colleagues reviewed the medical records of 172 residents with urinary tract infections, physicians routinely ignored those guidelines. As the researchers recently reported in The Archives of Internal Medicine, more than 40 percent of patients got antibiotics when the guidelines suggested no treatment was necessary. Even worse, not only are we treating people with antibiotics when they don’t need them,” Dr. Dosa said, “but we’re using the wrong drugs.” 

In the Rhode Island sample, 56 percent of patients who received antibiotics got the inappropriate medications, and almost half were taking the wrong doses. They were also taking the drugs for far too long. Women generally only need three days to treat a UTI, according to medical guidelines. Men, who get far fewer infections, need to take them for seven to 14 days. But in this Rhode Island sample, where the average age was 83, more than two-thirds of patients took antibiotics for far longer. And these are high-quality nursing homes.
 
Uncomplicated urinary tract infections should be treated first with narrow-spectrum drugs (Bactrim is an example), the guidelines say, rather than broad-spectrum ones like Cipro or Levaquin. Broad-spectrum antibiotics tend to wipe out all the bacteria in the gastrointestinal tract, including the helpful ones that help people digest food and ward off infection. “It’s like a nuclear bomb that takes out everything, as opposed to a sniper’s bullet that targets one bug,” Dr. Dosa said.
 
Some of us who have experienced uncomfortable UTIs may think, “Better safe than sorry.” But that really doesn’t apply here. It just isn’t safe for elderly folk to take unnecessary, unfocused antibiotics or to take them for longer than needed when they are actually appropriate.
 
“One of the most important findings, and other studies show similar results, is that under- treatment didn’t hurt anybody,” Dr. Dosa said. “Nobody in our sample who didn’t get an antibiotic had a bad outcome,” like a kidney infection, hospitalization or death.  But those patients who were over-treated — that is, given antibiotics when their symptoms didn’t fit the criteria — were far more likely to be struck by the virulent and dangerous C. difficile bacterium, which flourishes in the gut when patients’ own competing bacteria have been eliminated by potent drugs.
 
Palliative care
 
The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.
 
Other specifics:
 
Implantable defibrillators
 
It also urges discussion about deactivating implantable cardioverter defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco VA Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.” Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.
 
Topical anti-nausea gels
 
The palliative care list also warned that topical gels to control nausea don’t work because they aren’t absorbed through the skin. Dr. Widera noted, “We have lots of other ways to give anti-nausea drugs.”  Evidence also shows patients suffering pain as cancer spreads to their bones get as much relief from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.
 
Ways of applying ‘Choosing Wisely’
 
My hope is that this initiative will have far-reaching positive effects the more it is discovered and embraced by patients and professionals alike. I found an interesting example of how this might look from an article from “Choosing Wisely – Canada” written by medical students. By seeing their list, we can tailor our own questions of medical professionals. Here are their six ways “medical students and trainees can avoid unnecessary or inappropriate tests, treatments and procedures . . .” My comments follow the quotes.
 

• “Do not suggest ordering the most invasive test before considering other less invasive options.” 
A good rule in any situation. Always start with the least invasive, most helpful intervention or test possible to get what is needed for the patient.

• “Do not suggest a test, treatment or procedure that will not change the patient’s clinical course.”
Fundamental. In other words, if it won’t make a difference to the patient’s treatment plan, don’t do it!

• “Do not hesitate to ask for clarification on tests, treatments or procedures that you believe may be ordered inappropriately.”
SPEAK UP — whether you’re a medical student, trainee or an “advocate” for the patient.

• “Do not miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary.”
This is a nice corollary to my admonition in our handout, “Suggested Questions to Ask Your Doctor,” always to ask these questions.

• “Do not suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want.”
Don’t do what may be unnecessary and counterproductive with the hope of sucking up to your supervisor.

• “Do not suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.”

IMPORTANT. Many will justify that in a teaching hospital, this is appropriate. However, a teaching hospital should emphasize teaching that the patient comes first. Students should be learning that it is the patient’s welfare that trumps their learning how to do something that their own patient doesn’t need. That is the most important learning for medical students and trainees. No rationalization about training being important should trump the welfare of the patient first.

Stay well, people. But if you need medical help, do what you need to do to ensure it is best for you or your loved ones. 

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