Choosing wisely for health.

Abstract

Many midwives may remember widespread media coverage in 2012 of recommendations from a group of 9 medical specialty boards that clinicians perform 45 common tests and procedures less often. These recommendations went on to urge patients to question these services if they were offered.1 Other medical specialty organizations followed suit, with additional lists of procedures their members should perform far less often.2 The goal of creating these lists of questionable tests or procedures is to promote conversations between providers and patients about the too common occurrence of patients receiving unnecessary health treatment, as well as to assist consumers to make effective health care choices. This campaign, called Choosing Wisely, was launched by the not-for-profit American Board of Internal Medicine (ABIM) Foundation, in conjunction with the National Physicians Alliance and supported by patient education materials from Consumer Reports.3 Recommending or ordering a test, as described in Choosing Wisely, must be 1) supported by evidence, 2) not duplicative of other tests or procedures already received, 3) free from harm, and 4) truly necessary. Currently more than 300 recommendations about tests and procedures can be found on the Choosing Wisely Web site. 4 In October 2014, the American Academy of Nursing joined the Choosing Wisely campaign with the first 5 recommendations targeted to and written by nursing professionals. The first recommendation is one midwives will appreciate: “Don't automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first.”5 Written jointly by representatives of the American Academy of Nursing, the American College of Nurse-Midwives (ACNM), and the Association of Women's Health, Obstetric, and Neonatal Nurses, it follows the standard Choosing Wisely format: a “don't” statement followed by the rationale, background, and referenced supporting evidence. This Choosing Wisely recommendation is consistent with a longstanding ACNM Clinical Bulletin6 and echoes a consumer-oriented list entitled “What to reject when you're expecting.” 7 As midwives well know, each laboring woman's situation is unique. Having these Choosing Wisely recommendations can facilitate conversations around what treatments are appropriate and necessary and can help us in our efforts to determine an appropriate treatment plan together with women. It would behoove many of us in clinical practice and education to peruse these recommendations in order to start these conversations with our patients and students, as well as with fellow professionals. This endorsement by the American Academy of Nursing may be helpful in creating evidence-based practice change on hospital labor units where continuous electronic fetal monitoring (EFM) remains routine. A number of other Choosing Wisely recommendations from the American College of Obstetricians and Gynecologists and the American Academy of Family Physicians also provide evidence-based guidance for midwifery practice. Examples include not scheduling elective, nonmedically indicated inductions of labor or cesarean births before 39 0/7 weeks’ gestation and not scheduling elective, nonmedically indicated inductions of labor between 39 0/7 and 41 0/7 weeks’ gestation unless the cervix is deemed favorable. Moving beyond the labor room to ambulatory settings, midwives can find recommendations for not performing routine annual cervical cytology screening (Papanicolaou tests) in women aged 30 to 65 years, not treating women who have mild cervical dysplasia of less than 2 years in duration, and not screening for ovarian cancer in asymptomatic women at average risk.8 Primary care practice is informed by evidence-based guidance about not routinely prescribing antibiotics for acute mild-to-moderate sinusitis unless symptoms last for 7 or more days or worsen after initial clinical improvement, and not requiring a pelvic or other physical examination to prescribe oral contraceptive medications.9 Being familiar with Choosing Wisely recommendations can help us provide high-quality health guidance to the women in our care. The expansion of Choosing Wisely to include recommendations from nurses, midwives, and other clinicians is a welcome, timely, and appropriate addition to the growing campaign to encourage needed care versus wasteful or harmful care practices. These examples reflect the midwifery approach to care and remind us to consistently work with women to choose wisely among the tests and procedures available. The American Academy of Nursing partnership with the ABIM Foundation has produced the first of what we hope will be many recommendations with a midwifery stamp of approval. We look forward to additional recommendations in this campaign and applaud the input and impact of midwifery.