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ACEP and the Choosing Wisely Campaign « The Central Line

ACEP and the Choosing Wisely Campaign


ACEP President Dr. David SeabergA campaign called Choosing Wisely has gotten some attention of late because of its stated goal of reducing health care costs by eliminating tests and procedures that are not “necessary.” Since Choosing Wisely launched, nine medical specialty organizations have offered up their top five items for the chopping block.  These range from CT scans for fainting from the American College of Physicians to antibiotics for chronic sinusitis from the American Academy of Allergy, Asthma and Immunology.

ACEP was asked to join the campaign in 2011, and after extensive review and discussion at the Committee level, ACEP declined.  There are several reasons for our initial response:

  • Emergency physicians have no right of refusal with our patients and often pick up the slack for other members of our esteemed profession. A recent member poll showed that 97% of us report seeing patients on a daily basis who are sent to the emergency department by their primary care physician. Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered either because their office practice is swamped, the office is closed, or they lack the facilities to perform these tests. 
     
  • ABIM, the organization sponsoring the campaign, refused to allow any discussion of liability reform as a component of the Choosing Wisely campaign. To quote from the letter ACEP Past President Dr. Sandy Schneider sent to Daniel Wolfson, ABIM’s Executive VP and COO: “This is a significant issue in emergency medicine and a critical factor as to why emergency physicians order the number of tests and procedures they do.  Unlike primary care physicians, emergency physicians are not chosen by their patients, who have a greater tendency to sue for any perceived untoward event. In addition, we often lack prior care information. It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.”
     
  • Emergency physicians approach our patients with the goal of eliminating anything life threatening. We cannot afford to miss anything, even something that seems like a long-shot. The consequences may be life or death for our patients. A test that is unnecessary for 99 patients may save the life of patient number 100.
     
  • Emergency medical care constitutes just 2 percent of all health care spending in the United States, no doubt in part because so much of the care we deliver is uncompensated. We are masters of efficiency and improvisation but there is only so far a dollar can be stretched. Emergency departments have been closing at an alarming rate across the country because so much care isn’t paid for. This is not the place to cut costs any further.
     
  • Lastly, should ACEP participate in this campaign, it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.

ACEP is dedicated to advancing emergency care and promoting evidence-based quality improvement measures for its patients. To that end, we are reevaluating our response to the Choosing Wisely campaign by developing a workgroup, comprised of members from the Reimbursement, Medical-Legal, EM Practice, Clinical Policies, Quality and Performance, and Public Relations Committees to examine the issue and prepare a proposal for ACEP Board consideration.

DAVID SEABERG, MD, FACEP
President, American College of Emergency Physicians

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  1. #1 by Thomas Benzoni - May 11th, 2012 at 11:44

    Dr. Seaberg:

    As they say in England, Hear, Hear!

    Liability reform must be a part of any such discussions, and, until we stop being our own worst enemies, saying to payors: “Here is where we are not adding value to your purchase” this problem is best not addressed. We can only hurt ourselves, and I put 2 folks upstairs last night on court commital for that.

  2. #2 by Hamad Husainy - May 14th, 2012 at 09:58

    Dr. Seaberg,

    I completely agree with your comments regarding this issue. I think that there may be several tests however that we as emergency physicians have all but eradicated(i.e. amylase for undiff. abd. pain and myoglobin for chest pain) that might be places to start if we do decide to take part. This also may be a venue to address continued issues regarding chronic pain management. Looking forward to seeing this unfold.

  3. #3 by Ashley Shreves - May 15th, 2012 at 12:09

    I appreciate your comments about the challenging position of emergency physicians in the current system. That said, we mostly have fantastic jobs and are well-compensated, so it feels a little unfair when we repeatedly portray ourselves as victims. It’s also absurd to assume that the challenges of our job preclude our ability to identify a single test that could be considered unnecessary. Actually, the limited resources and time constraints of our environment should be greater motivators for us to eliminate wasteful testing and treatments. Antibiotics for URIs? XRays for ankle injury in which the Ottawa rule is negative? Admission “screening” EKGs and chest XRays for healthy, noncardiac, nonrespiratory-related hospital admissions? Blood cultures for healthy, non-septic patients with cellulitis? Chest CT to rule out PE in patients who are PERC negative?

    As a specialty, we can decide that we are special, disregard actual risk assessments, and continue ordering unlimited tests in our pursuit of ruling out every possible life-threatening condition a patient could have, regardless of how remote. We could disregard the larger community we live in and the resources that this practice pattern drains from other necessary and critical settings like education, and we can ignore how harmful this approach can be to individual patients by exposing them to the real harms of over-testing. Of course, in the long run, we will be punished for this self-centered approach by regulation from the outside—and I find that more frightening than the prospect of risking reimbursement for an ankle XRay that never should have been ordered in the first place.

  4. #4 by Corita Grudzen - May 15th, 2012 at 14:50

    Dr. Seaberg,
    I applaud your efforts to reconsider joining the Choosing Wisely campaign. I am certain we can find tests (such as routine coags for patients not on coumadin) that we would all agree have no benefit to patients, and have the potential to cause harm from false positives. I believe we as emergency physicians all recognize there is enourmous waste in the system, and that we need to take responsibility for eliminating it where we can. If we don’t, someone else will surely do it for us.

  5. #5 by Seth Trueger - May 15th, 2012 at 15:27

    Dr. Seaberg,

    Of course we must be cautious, but parsimony is coming whether we like it or not. If we do not take steps to decrease costs by curtailing unnecessary testing on our own to terms, our reimbursements will decline on someone else’s terms (likely someone who does not have the best interests of the patient in mind).

    Certainly we need to be critical and recommendations for unnecessary testing should be evidence based and patient centered, but fear of litigation for eliminating bad medical practice is not going to help our patients, our specialty, or ourselves.

  6. #6 by DH Newman - May 15th, 2012 at 17:13

    Respectfully, I disagree.

    -Specialists are often referred patients with expectations for certain tests. They do not capitulate, they choose with their training, based on the merits. We are not unique.

    -We cannot speak from one side of mouth about ordering tests out of medicolegal fear, and then with the other side of our mouths reject guidelines that would protect and support not ordering those same tests

    -We will not ‘miss’ anything important by not ordering, for instance, an amylase. Or a PTT. Thus, this is not about the danger: these tests are meaningless.

    -Finally, we should stand up and agree that no one should be reimbursed for an amylase.

    Change is coming, and we will have to rein in excess testing. The real question here is this: will we lead, or will we follow? I believe it will harm us in the long run not to join this important campaign.

  7. #7 by Ian Greenwald - May 17th, 2012 at 07:44

    Dr. Seaberg,
    I also respectfully disagree with ACEP not participating in the Choosing Wisely campaign. You cited one reason ACEP was not participating had to do with our approach to “eliminating anything life threatening…even something that seems like a long-shot.” I think we need to stop hiding behind this false shield. We of course can never eliminate everything life threatening. We risk stratify based on a careful history and physical exam. When appropriate, we obtain diagnostic studies to assist in this process. But drawing a line in the sand on unnecessary, unhelpful and potentially risky practices seams like a really good idea and would help our brethren. Change is afoot. Our professional societies should be thought leaders in the evolution of our health care paradigm and not hide behind bogeymen.

  8. #8 by Eduardo LaCalle - May 17th, 2012 at 12:44

    Dr. Seaberg,
    I also would like to see ACEP participate in the Choosing Wisely campaign. We may or may not achieve the kind of tort reform we want by the legislative process, but if we define our own standard of care, we create some level of protection for our discipline.

    These hypothetical 5 unnecessary tests would likely be those we associate with defensive medicine, that practice that further burdens overburdened EDs and potentially harms patients. Furthermore, I fear if we don’t take the reins on defining unnecessary care, then we live with others’ decisions (see CMS and head CTs).

    We should sign on cautiously and thoughtfully, but this is a real opportunity that should not be missed.

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