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Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question.

ABSTRACT: OBJECTIVE:We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients. METHODS:We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement and perceived high prevalence advanced to a survey of ACR members, who comprise >90% of the US rheumatology workforce. To increase the response rate, a nested random sample of 390 rheumatologists received more intensive survey followup. The samples were combined and weighting procedures were applied to ensure generalizability. Items with high ratings underwent literature review. Final items were then selected and formulated by the task force. RESULTS:One hundred five unique items were proposed and narrowed down to 22 items during the Delphi rounds. A total of 1,052 rheumatologists (17% of those contacted) participated in the member-wide survey, whereas 33% of those in the nested random sample participated; respondent characteristics were similar in both samples. Based on survey results and available scientific evidence, 5 items (relating to antinuclear antibodies, Lyme disease, magnetic resonance imaging, bone absorptiometry, and biologic therapy for rheumatoid arthritis) were selected for inclusion. CONCLUSION:The ACR Top 5 list is intended to promote discussions between physicians and patients about health care practices in rheumatology whose use should be questioned and to assist rheumatologists in providing high-value care.

SUBMITTER: Yazdany J

PROVIDER: S-EPMC4106486 | biostudies-literature | 2013 Mar

REPOSITORIES: biostudies-literature

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Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question.

Yazdany Jinoos J Schmajuk Gabriela G Robbins Mark M Daikh David D Beall Ashley A Yelin Edward E Barton Jennifer J Carlson Adam A Margaretten Mary M Zell Joann J Gensler Lianne S LS Kelly Victoria V Saag Kenneth K King Charles C

Arthritis care & research 20130301 3

<h4>Objective</h4>We sought to develop a list of 5 tests, treatments, or services commonly used in rheumatology practice whose necessity or value should be questioned and discussed by physicians and patients.<h4>Methods</h4>We used a multistage process combining consensus methodology and literature reviews to arrive at the American College of Rheumatology's (ACR) Top 5 list. Rheumatologists from diverse practice settings generated items using the Delphi method. Items with high content agreement ...[more]

PMID: 23436818

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Project description:BackgroundNational guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening.ObjectiveTo determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening.DesignNational Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey.ParticipantsCommunity-dwelling adults 55-97 years old (n = 3816).Main measuresSelf-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates.Key resultsAmong women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001).ConclusionOver 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

Project description:ImportanceThe extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood.ObjectiveTo examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults.DesignRetrospective analysis of overall means and clinician-level variation in performance on three new measures.SubjectsAdults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017.MeasuresTwo electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication.ResultsSixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively.ConclusionsWithin the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

Project description:ObjectivesThis study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP).DesignThis is a qualitative exploratory study using semistructured interviews.SettingThis study was conducted in a large metropolitan public healthcare organisation in urban Australia.ParticipantsFollowing purposive sampling, 20 patients and 2 carers participated. Patient participants aged 18 years or older were eligible if they were attending the healthcare organisation for a CT scan and referred by their GP. Carers/family were eligible to participate when they were in the role of an unpaid carer and were aged 18 years or older. Participants were required to speak English sufficiently to provide informed consent. Participants with cognitive impairment were excluded.FindingsEighteen interviews were conducted with the patient only. Two interviews were conducted with the patient and the patient's carer. Fourteen participants were female. Five themes resulted from the thematic analysis: (1) needing to know, (2) questioning doctors is not necessary, (3) discussing scans is not required, (4) uncertainty about questioning and (5) valuing the Choosing Wisely questions. Participants reported that they presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of their problem. They reported ambivalence about engaging in shared decision-making with their doctor, although many participants reported valuing the Choosing Wisely questions.ConclusionsShared decision-making is an important principle underpinning Choosing Wisely. Practice implementation requires understanding patients' motivations to engage in shared decision-making with a focus on attitudes, beliefs, knowledge and emotions. Systems-level support and education for healthcare practitioners in effective communication is important. However, this needs to emphasise communication with patients who have varying degrees of motivation to engage in shared decision-making and Choosing Wisely.

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Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question.

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Choosing wisely: the American College of Rheumatology's Top 5 list of things physicians and patients should question.

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