Choosing Wisely Recommendations Research Articles

Abstract PO5-16-06: Prophylactic Neurokinin-1 Receptor Antagonist Use Pre- and Post- Choosing Wisely Initiative among Women with Breast Cancer

Abstract Objective: In April 2012, the American Society of Clinical Oncology (ASCO) issued recommendations as a part of the Choosing Wisely (CW) campaign with the aim to identify the areas of low-value utilization. One of the CW recommendations is not to use expensive antiemetics, specifically Neurokinin-1 Receptor Antagonist (NK1-RA) for patients initiating low or moderate emetic risk chemotherapy. The purpose of this study was to determine the impact of CW on prophylactic NK1-RA use among women with breast cancer. Methods: Using Optum’s de-identified Clinformatics® Data Mart Database for 2010 to 2018, a retrospective cohort study was conducted for women aged ≥18 years with breast cancer with at least one newly initiated claim for low/minimal/moderate emetic risk chemotherapy (n = 25,549). All approved antiemetics - aprepitant, fosaprepitant, rolapitant, and netupitant/palonosetron) were included. An interrupted time series using a segmented regression model was used to assess the effect of CW on the prophylactic NK1-RA use. Results: The prophylactic use of NK1-RAs among patients with breast cancer receiving low/minimal/moderate emetic risk chemotherapy decreased from 11.1% pre-CW to 7.7% post-CW. Segmented regression analysis showed that there was a significant increase of 0.11 per 100 patients per quarter in the use of prophylactic NK1-RAs prior to CW recommendation. However, immediately after the CW (occurred in Q42013), there was a significant decline in prophylactic NK1-RA use by 1.03 per 100 patients in Q22014. For the time after intervention, there was a significant decline in NK1-RA use by 0.37 per 100 patients per quarter in the post-CW period compared to the pre-CW period (p< 0.05). Conclusion: This study highlights a significant but modest decline in the inappropriate use of prophylactic NK1-RAs after the implementation of CW antiemetic recommendation. Continued statewide or local educational efforts for dissemination of CW recommendations are needed to facilitate appropriate prophylactic use of NK1-RAs. Table. Adjusted* Interrupted Time Series Segmented Regression Analysis of Prophylactic NK1-RA use among women with breast cancer before and after the Choosing Wisely initiative *Adjusted for insurance, health plan type, age, comorbidity, and emetic risk Citation Format: Shweta Kamat, Britny Brown, Steven Cohen, Ami Vyas. Prophylactic Neurokinin-1 Receptor Antagonist Use Pre- and Post- Choosing Wisely Initiative among Women with Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-16-06.

Choosing Wisely in pediatric healthcare: A narrative review.

It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment. In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare. To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe. We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.

A Multidisciplinary Quality Improvement Project to Improve Appropriate Inherited Thrombophilia Testing at VA Connecticut

Background Many guidelines and expert opinions do not recommend inherited thrombophilia testing in unselected patients with venous thromboembolism (VTE), and per American Society of Hematology Choosing Wisely Recommendations, inherited thrombophilia testing is not recommended in patients with venous thromboembolism occurring in the setting of major transient risk factors. Furthermore, non-hematologists may lack knowledge on the effect of direct oral anticoagulants on these assays. From 2019 to 2021, 75% of inherited thrombophilia testing (protein C, S and antithrombin deficiencies and Factor V Leiden and prothrombin mutations) at VA Connecticut were ordered by non-hematologists. Of these orders, 55% of tests were ordered by primary care clinicians, 29% by inpatient teams, and the remainder by non-hematology specialists. Approximately 10% of testing by non-hematologists had abnormal results, generating further hematology consults and workup. Given that testing has limited clinical utility and can result in unnecessary downstream healthcare use, there is a need to improve guideline concordant and appropriate thrombophilia testing by non-hematologists. Methods The aim of this multidisciplinary quality improvement project was to decrease the number of inherited thrombophilia tests ordered by non-hematologists at VA Connecticut by 25% six months after our intervention implementation. Quality Improvement (QI) principles were used to identify root causes, which included complexity of and confusion over appropriate patient selection for testing, a lack of awareness of potential false positives with active anticoagulant use, limitations of our electronic medical record system (EMR) to provide clinical decision support tools to triage testing or provide education, and more. After multidisciplinary stakeholder engagement and feedback from hematology, internal medicine, laboratory medicine, and clinical informatics, we established a best practice alert (BPA) for inpatient and outpatient inherited thrombophilia testing at the time of order entry. Our BPA notified the ordering clinician that inherited thrombophilia testing rarely impacts the choice or duration of anticoagulation and is not recommended for most patients. The BPA recommended that as an alternative, clinicians can consider a hematology electronic consult (e-consult) for guidance and education regarding appropriate patient selection for testing. Data was collected from our EMR seven months after intervention initiation and analyzed via Excel 365. A control chart was used to assess the outcome measure, which was the number of orders for inherited thrombophilia testing by non-hematology clinicians per month. Our balancing measure was the number of hematology e-consults for inherited thrombophilia per month. Institutional pricing was used to determine costs associated with testing and potential cost savings. Results After our BPA implementation in January 2022, the mean number of monthly inherited thrombophilia tests from January to July 2022 decreased to 7.6 tests from 13.3 tests in 2021. All 7 monthly test order numbers post-implementation were below the mean, consistent with a potential trend towards a special cause variation shift. Inpatient testing decreased from 40 total tests in 2021 to 7 tests since implementation. The average cost of testing per month decreased from $653 to $366 with an estimated $2004 saved after intervention implementation. The mean number of hematology e-consults for inherited thrombophilia related questions increased to 3.4 consults per month during the first five months of the intervention period from 2.5 consults per month in 2021. Conclusion A best practice alert in the EMR reminding clinicians about the limited role of inherited thrombophilia testing in unselected patients and the option for hematology e-consult for further specialist guidance was associated with a trend towards reduced inherited thrombophilia testing. Furthermore, there were decreased costs associated with testing without any substantial increase in workload for the hematology service. The BPA remains in place, and data collection and analysis are ongoing. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

International comparison of the impact of COVID on adherence with supportive care focused Choosing Wisely recommendations (CWR).

28 Background: The reorganization of cancer care delivery during the COVID pandemic had the potential to catalyze improvement in CWR adherence by reducing provision of low value care to minimize in-person visits and mitigate potential issues with staff and resource shortages. We evaluated the impact of COVID on adherence with CWR for supportive care, relevant to colorectal and anal cancer patients with stage IV disease at Princess Margaret Cancer Centre (PM) in Canada and AC Camargo Cancer Center (AC) in Brazil. Methods: Eligible patients had a new patient consult 02/2020- 12/2020 (COVID) or the same period in 2019 (control). Performance on individual CWR in the 6 months following initial consultation was calculated as the proportion of eligible patients meeting the recommendation. Results: The PM and AC cohorts each consisted of 100 patients; demographic and disease characteristics of COVID and control cohorts were similar within each centre. Marginally fewer patients received surgery during COVID (PM: 38.3 vs 49.1%, p = 0.28; AC: 54.8 vs 55.2%, p = 0.97). At PM, more patients received radiation therapy during COVID (36.2 vs 24.5%, p = 0.21), whereas the opposite occurred at AC (7.1 vs 17.2%, p = 0.14). A higher proportion of both PM and AC patients treated during COVID died within 6 months of initial consult than in 2019 (PM: 10.6 vs 7.5%, p = 0.015; AC: 21.4 vs 8.6%, p = 0.029). Adherence to selected CWR is summarized below; whereby a higher proportion means higher concordance with CWR. Conclusions: There was low overall adherence to CWR across both centers with no significant changes to patterns of care for patients with stage IV disease during the COVID-19 pandemic.[Table: see text]

Choosing wisely recommendations regarding the top five list of procedures to avoid in the treatment of viral hepatitis: A position statement from the Brazilian Society of Hepatology endorsed by the Latin American Association for the Study of the liver

Introduction and ObjectivesThe Choosing Wisely (CW) initiative aims to improve daily practice supported by evidence concerning unnecessary medical tests, procedures, and treatments. This philosophy is essential in managing viral hepatitis (VH), which primary care physicians increasingly carry out. It is also essential to achieving disease elimination. Thus, the aim of our study was to propose evidence-based CW recommendations in VH. Materials and MethodsThe Brazilian Society of Hepatology (SBH) formed a panel of experts in VH who selected evidence-based CW recommendations, which were subsequently scrutinized and ranked by all members of SBH using a web-based approach. ResultsFive recommendations were chosen in order of importance: 1) do not order anti-HCV testing after achieving sustained virological response; 2) do not request serial HCV viral load to evaluate HCV progression, 3) do not add ribavirin to direct-acting antivirals in non-cirrhotic, naïve HCV patients; 4) do not screen for hepatocellular carcinoma in HCV patients with none to moderate fibrosis (≤ F2); 5) do not request anti-HBs after HBV vaccination, except for children born to HBV-infected mothers, hemodialysis patients, healthcare professionals, people who have had sexual contact with chronic HBV carriers, HIV-positive persons and immunocompromised individuals (hematopoietic stem-cell transplant recipients or persons receiving chemotherapy). ConclusionsCW recommendations may help general practitioners adopt a more rational and cost-effective approach in managing patients with VH in Brazil and Latin America, leading to lesser waste or harm to patients.

Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial.

To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. NCT02709772.

Implementation and Impact of Choosing Wisely Recommendations in Oncology.

The Choosing Wisely (CW) campaign, launched in 2012, includes oncology-specific recommendations to promote evidence-based care and deimplementation of low-value practices. However, it is unclear to what extent the campaign has prompted practice change. We systematically reviewed the literature to evaluate the uptake of cancer-specific CW recommendations focusing on the period before the declaration of the COVID-19 pandemic. We used Grimshaw's deimplementation framework to thematically group the findings and extracted information on implementation strategies, barriers, and facilitators from articles reporting on active implementation. In the 98 articles addressing 32 unique recommendations, most reported on passive changes in adherence pre-post publication of CW recommendations. Use of active surveillance for low-risk prostate cancer and reduction in staging imaging for early breast cancer were the most commonly evaluated recommendations. Most articles assessing passive changes in adherence pre-post CW publication reported improvement. All articles evaluating active implementation (10 of 98) reported improved compliance (range: 3%-73% improvement). Most common implementation strategies included provider education and/or stakeholder engagement. Preconceived views and reluctance to adopt new practices were common barriers; common facilitators included the use of technology and provider education to increase provider buy-in. Given the limited uptake of oncology-specific CW recommendations thus far, more attention toward supporting active implementation is needed. Effective adoption of CW likely requires a multipronged approach that includes building stakeholder buy-in through engagement and education, using technology-enabled forced functions to facilitate change along with policy and reimbursement models that disincentivize low-value care. Professional societies have a role to play in supporting this next phase of CW.

Evaluation of choosing wisely recommendations on preprocedural cardiovascular testing

Study objectiveThe Choosing Wisely (CW) initiative currently has multiple recommendations focused on avoiding preprocedural testing in asymptomatic patients prior to low-risk surgery. The purpose of this study was to measure the potential impact of the CW recommendations as they relate to preprocedural testing prior to cataract surgery. DesignRetrospective cohort study. SettingSingle academic medical center. ParticipantsPatients undergoing cataract surgery from 01/02/2018 to 12/31/2018. InterventionsN/A. Main outcome measuresPrevalence of preprocedural testing in elevated versus low cardiac risk patients as defined by the Revised Cardiac Risk Index (RCRI). ResultsOf a total 909 patients, 90 (9.9%) had some form of preprocedural testing ordered; testing was more common among elevated risk (n = 50/315, 15.9%) compared to low-risk patients (n = 40/594, 6.7%; p < 0.0001). Of the tests ordered, 9 were abnormal (4 in the low-risk cohort, 5 in the elevated risk cohort). ECGs were the vast majority of tests ordered (n = 88/90). No stress test orders or periprocedural adverse cardiovascular (CV) events were observed. Anesthesiology clinicians ordered 95.6% of preprocedural testing. “Routine” was the justification given for the substantial majority of tests ordered in both cohorts (90% low-risk, 86% elevated risk). ConclusionOur investigation confirms that cataract surgery has exceptionally low rates of postprocedural CV events. In contemporary practice, preprocedural CV testing for cataract surgery is not highly prevalent, rarely abnormal, and also not well justified by ordering clinicians. Our results may be considered as justification for revisions of some CW recommendations to potentially target higher prevalence areas of low-value care.

Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations

The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed. To analyze the characteristics and expected impact of Choosing Wisely recommendations. This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021. Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential). Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services). The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.

Implementation and impact of Choosing Wisely recommendations in oncology: A scoping review.

21 Background: The Choosing Wisely (CW) campaign launched in 2012 includes oncology-related recommendations (CWR) aimed at promoting evidence-based care and de-implementing low value practices; however, it remains unclear to what extent practice has changed as a result of the campaign. We undertook a scoping review to evaluate the extent of CWR uptake in oncology, and barriers and facilitators to implementation. Methods: A systematic search of MEDLINE, EMBASE, Cochrane, Emcare Nursing and Scopus was conducted for articles published between 2012 and March 6, 2020 pertaining to cancer-specific CWR. Articles were excluded if they did not report on cancer-specific recommendations, were commentaries/opinions, reported on screening or prevention, focused on pediatric populations, or were not in English. Retained articles were thematically grouped based on study objective. Implementation strategies, barriers and facilitators were summarized for articles implementing a recommendation into practice. Results: The search yielded 8565 articles; 98 articles were retained, addressing 32 unique recommendations. Use of active surveillance for low-risk prostate cancer (14/98) and reduction of imaging in early breast cancer (13/98) were the most commonly evaluated CWR. Of the 29 articles reporting on pre-post CW campaign adherence, 20 reported improved compliance without further intervention. In articles evaluating factors associated with CWR-concordance (62/98), age (23/62), stage or risk (22/62), and geographic location (21/62) most commonly influenced care decisions. Few articles described the development of interventions to improve concordance (1/98) or a protocol to evaluate implementation (2/98) with no further testing of their design. Of the 10/98 articles that evaluated implementation of a CWR, all reported improved compliance (range: 3-73% improvement). Implementation strategies were used in combination and most often included provider education (8/10), stakeholder engagement (6/10), and forced function (4/10). Preconceived views and reluctance to adopt new practices were the most commonly reported barriers to implementation; the use of technology to update practice and the use of education and evidence to build provider buy-in were the most common facilitators. Conclusions: In the eight years since the initial publication of oncology-specific CW recommendations, uptake has been limited. Publication of the recommendations has resulted in some passive improvements in care. Further adoption of CWR likely requires an implementation strategy that includes building stakeholder buy-in, and utilization of updated order sets and forced functions in technology to facilitate change. Future studies should assess the impact of the COVID-19 pandemic on the adoption of CWR and the de-implementation of low-value care.

P-79 CHOOSING WISELY IN VIRAL HEPATITIS: RECOMMENDATIONS FROM THE BRAZILIAN SOCIETY OF HEPATOLOGY

Choosing wisely (CW) initiative aims to improve daily practice supported by evidence avoiding unnecessary medical tests, procedures, and treatments. This philosophy is of utmost importance in managing viral hepatitis (VH), increasingly carried out by primary care physicians. Objective: To propose evidence-based CW recommendations in VH. The Brazilian Society of Hepatology (SBH) selected a panel of experts in VH who selected evidence-based CW recommendations, which were subsequently scrutinized and ranked by all members of SBH using a web-based approach. Results: Eight recommendations were chosen in order of importance, including 1) Do not order anti-HCV testing after achieving sustained virological response; 2) Do not request serial HCV viral load to evaluate HCV progression, 3) Do not add ribavirin to direct-acting antivirals in non-cirrhotic, naïve HCV patients; 4) Do not screen for hepatocellular carcinoma in HCV patients with none to moderate fibrosis; 5) Do not request anti-HBs after HBV vaccination, except for children born to HBV-infected mothers, hemodialysis patients, healthcare professionals, sexual contacts of chronic HBV carriers, HIV-positive persons and immunocompromised individuals (hematopoietic stem-cell transplant recipients or persons receiving chemotherapy); 6) Do not order complete HBV serology for screening HBV infection; 7) Do not order complete HBV serology for evaluation of acute hepatitis B; 8) Do not treat chronic hepatitis B based on a single ALT and viral load results, except in cirrhotic patients. These recommendations defined by SBH may help general practitioners adopt a more rational and cost-effective approach to handling VH cases in Brazil.

ASO Visual Abstract: Impact of Choosing Wisely Recommendations on Sentinel Lymph Node Biopsy and Postoperative Radiation Rates in Women Over Age 70 with Hormone Positive Breast Cancer

ASO Visual Abstract: Impact of Choosing Wisely Recommendations on Sentinel Lymph Node Biopsy and Postoperative Radiation Rates in Women Over Age 70 with Hormone Positive Breast Cancer

Impact of Choosing Wisely Recommendations on Sentinel Lymph Node Biopsy and Postoperative Radiation Rates in Women Over Age 70 Years with Hormone-Positive Breast Cancer.

In 2016, the Society of Surgical Oncology released a Choosing Wisely guideline recommending sentinel lymph node biopsy (SLNB) omission in females ≥70years of age with early-stage, hormone-positive, clinically node-negative invasive breast cancer. This study investigated the impact of this guideline on SLNB and radiotherapy rates, in addition to assessing temporal trends of nodal biopsy and factors associated with recurrence. The study involved a retrospective review of women who met the guideline criteria and underwent partial mastectomy at a single institution between 2009 and 2018. Using the same inclusion criteria, the National Cancer Database was queried to obtain a separate dataset. Statistical analyses included univariate comparisons, and multivariate logistic regression modeling to predict radiotherapy delivery. In our institutional series, 487 patients were included, 274 (56.3%) of whom received radiotherapy. There were 414 patients (85.0%) who underwent SLNB, with a nodal positivity rate of 11%. SLNB correlated with higher rates of radiotherapy (63.5% vs. 15.1%, p<0.001). Age <80years was an independent predictor of radiotherapy receipt (odds ratio 3.0, 95% confidence interval 0.22-0.52). SLNB performance decreased after 2016 (88.4% vs. 78.4%, p=0.003). Median follow-up was 4.8 years, with 19 (3.9%) documented recurrences. SLNB performance was not associated with recurrence (2.9% vs. 5.5%, p=0.279), whereas radiotherapy resulted in reduced recurrence (1.1% vs. 6.1%, p=0.002). One (0.2%) disease-related mortality was observed. Recurrence rates and disease-related mortality remain low in this demographic regardless of treatment rendered. Omission of SLNB and radiotherapy should remain a consideration, and efforts in both patient and physician education should continue.

Changes in Frequency of Surveillance Imaging of Survivors of Diffuse Large B-Cell Lymphoma After the American Society of Hematology Choosing Wisely Recommendations.

In 2013, the American Society of Hematology (ASH) published recommendations with Choosing Wisely to limit surveillance imaging in aggressive lymphoma. We studied surveillance imaging practice patterns for diffuse large B-cell lymphoma (DLBCL) before and after the ASH Choosing Wisely campaign. We used OptumLabs Data Warehouse, a national insurance claims database, to retrospectively study imaging frequency in survivors of DLBCL from 2008 to 2016. Three time periods were defined: Period 1 (2008 to 2010), Period 2 (2011 to 2013), and Period 3 (2014 to 2016). One thousand four hundred seventy-two patients were included. Median follow up was approximately 2 years. During the first and second years of surveillance, imaging remained stable between Period 1 (years 1 and 2: 199 [91%] and 137 [83%], respectively) and Period 2 (years 1 and 2: 257 [88%] and 172 [77%], respectively; P = .38), but decreased in Period 3 (years 1 and 2: 315 [78%] and 83 [61%], respectively; P < .01). In a multivariable logistic regression, year after 2012 was a significant predictor of decreased overuse (more than two scans per year in the first year of surveillance; [odds ratio, 0.49 for 2013 v 2008; P = .02]). Our study demonstrated the rate of surveillance scans-both computed tomography and positron emission tomography imaging-in DLBCL decreased after the ASH Choosing Wisely campaign. Multiple factors, such as changes in recommendations, reimbursement, and provider knowledge base, may have all contributed and should be studied further.

Klug entscheiden – Perspektiven: Was sind die entscheidenden Ansätze (Key Questions) für die Zukunft?

Gastroenterology offers a wide field for future "choosing wisely" recommendations (CWR). They should refer not only to an under- or overuse of diagnostic tools like laboratory or imaging tests but also to an evidence-based application of drug therapies und endoscopic interventions. Drugs like antibiotics or proton pump inhibitors are both often prescribed in the absence of clearly defined underlying diseases and not given when an indication is clear. Similar is true for the ordering of abdominal imaging methods. Computerized tomography of the abdomen too often is preferred over a qualified ultrasound study. Laboratory tests like amylase or lipase should not be ordered for asymptomatic patients since false positive values often end up with further useless and occasionally invasive examinations. Ordering both enzymes in acute pancreatitis will not provide any additional information. Similarly, CEA, ammonia or procalcitonin have either limited or no value in gastroenterology. Upper gastrointestinal endoscopy should not be performed in asymptomatic people without any risk factors. On the other hand, colonoscopy is still underused as a valuable screening tool for detection and secondary prevention of colorectal carcinomas in people over 50 years old.The dramatic rise in people suffering from obesity is paralleled by an enormous increase in severe cases of non-alcoholic fatty liver disease associated with high morbidity and mortality. This calls for CWRs addressing this causal relationship and offering not only patient centered therapeutic solutions but also calling for effective measures to regulate the marketing of highly processed food or sugar enriched soft drinks. Published guidelines in Gastroenterology will continue to be a rich source for delineating new CWRs. Nevertheless, CWRs are also needed in daily practice offering solutions for clinical problems not covered by guidelines. These, however, have to be based both on a broad interdisciplinary consent of experts in the field and on scientific evidence.

De-implementing wisely: developing the evidence base to reduce low-value care

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for...

Measuring implementation feasibility of clinical decision support alerts for clinical practice recommendations.

The study sought to describe key features of clinical concepts and data required to implement clinical practice recommendations as clinical decision support (CDS) tools in electronic health record systems and to identify recommendation features that predict feasibility of implementation. Using semistructured interviews, CDS implementers and clinician subject matter experts from 7 academic medical centers rated the feasibility of implementing 10 American College of Emergency Physicians Choosing Wisely Recommendations as electronic health record-embedded CDS and estimated the need for additional data collection. Ratings were combined with objective features of the guidelines to develop a predictive model for technical implementation feasibility. A linear mixed model showed that the need for new data collection was predictive of lower implementation feasibility. The number of clinical concepts in each recommendation, need for historical data, and ambiguity of clinical concepts were not predictive of implementation feasibility. The availability of data and need for additional data collection are essential to assess the feasibility of CDS implementation. Authors of practice recommendations and guidelines can enable organizations to more rapidly assess data availability and feasibility of implementation by including operational definitions for required data.

Bridging the Gap With Choosing Wisely Recommendations: What Laboratory Topics Matter Most to Other Medical Specialty Societies?

Abstract Introduction This study sought to evaluate the nature and frequency of laboratory recommendations made by medical societies other than ASCP. Methods Review of all 2012 to 2018 ABIM Choosing Wisely (CW) non-ASCP laboratory recommendations and categorization of recommendations per topic area. Results There are 107 total recommendations made by other medical specialties that involve laboratory medicine. The most common recommendations are (1) Transfusion Medicine: to minimize transfusion of PRCs (19 recommendations, 18%); (2) Women’s Health: Pap smear testing, other women’s health testing (18 recommendations, 17%); and (3) General Laboratory: reducing repetitive routine laboratory tests (10 recommendations, 9%). Most (64, 60%) recommendations addressed screening while 29 (27%) focused on treatment and 14 (13%) were related to monitoring disease. Conclusion Almost one-half (44%) of all recommendations fell into three common areas and there were more recommendations related to screening for disease than for treatment or monitoring. For Choosing Wisely to achieve increasing success, increasing efforts are needed to disseminate this information, promote multidisciplinary effective test utilization, and encourage continued laboratory medicine recommendations from all medical stakeholders.

LO87: Impact of an evidence-based clinical pathway for suspected renal colic in low-risk patients with previous nephrolithiasis on CT utilization and emergency department throughput

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures &amp;amp; Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.

Are We Choosing Wisely in Radiation Oncology Practice–Findings From an Australian Population-Based Study

To evaluate the adoption of the Royal Australian and New Zealand College of Radiologists Choosing Wisely (CW) radiation oncology recommendations before and after the release of the recommendations. The Victorian Radiotherapy Minimum Data Set captures details of radiation therapy delivered in the state of Victoria, Australia. This study included the following 3 groups of patients relevant to 3 of the 5 CW recommendations: women who received a diagnosis of early-stage breast cancer at age ≥50years who had breast radiation therapy (excluding nodal irradiation), patients with cancer who had palliative bone radiation therapy (excluding those with primary bone malignancies), and patients with cancer who had stereotactic radiation therapy to the brain (excluding those with primary malignancies of the central nervous system). The outcomes of interest were use of hypofractionated breast radiation therapy (<25 fractions), use of long-course palliative bone radiation therapy (>10 fractions), and use of adjuvant whole brain radiation therapy within 1month of stereotactic radiation therapy. The Cochrane-Armitage test was used to evaluate changes in practice over time. Among the 8204 patients who had breast radiation therapy, there was an increase in hypofractionation use from 42% in 2013 to 82% in 2017 (P<.001). The progressive increase in hypofractionation use was observed across institutions. Of the 15,634 courses of palliative bone radiation therapy delivered, only 1279 (8%) were >10 fractions, and this decreased from 10% in 2013 to 5% in 2017 (P<.001). Of the 1049 patients who received stereotactic radiation therapy for brain metastases, only 2% had adjuvant whole brain radiation therapy, and this decreased from 4% in 2013 to 0.7% in 2017 (P=.02). There was a significant change in radiation oncology practice in Australia between 2013 and 2017, in line with the CW recommendations. However, some of the recommendations need to be revised to reflect the rapidly evolving evidence in radiation oncology.