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Are the Top 5 Recommendations Enough to Improve Clinical Practice?: Comment on “Application of ‘Less Is More’ to Low Back Pain”

Are the Top 5 Recommendations Enough to Improve Clinical Practice?: Comment on “Application of... I am not a physician, but I have relevant patient experience. For the past 20 years, I have had no significant back pain. Before that, I had a bad back for 20 years, with almost daily sciatica pain and frequent episodes of a misaligned spine, with crippling muscle spasms. Seeking relief, I visited neurologists, orthopedists, chiropractors, acupuncturists, physical therapists, and finally a physiatrist. The cure came from the mind-body connections offered by my physiatrist. My experience is that curing back pain is complex and that testing often reinforces a bioskeletal problem when there is frequently a large psychological component involved. Is this a case of testing preventing a cure?1 The authors of “Application of ‘Less Is More’ to Low Back Pain”2 in this issue of the Archives refer to this phenomenon as patient “labeling.” In their article, Srinivas et al2 address the many dimensions of a lower back pain diagnosis. The primary aim of the study is to offer evidence for a recommendation by the National Physicians Alliance as part of its “Promoting Good Stewardship in Clinical Practice” project, which published the following admonition in the Archives in 2011: “Don't do imaging for low back pain within the first 6 weeks unless red flags are present.”3(p1388) The article by Srinivas et al2 is unique in that it goes beyond a review of the overwhelming evidence against the overuse of imaging. It estimates the cost of unnecessary imaging at almost $300 million, discusses reasons for the failure to convert evidence into practice, and identifies the issue of labeling a person with an illness. The study also reviews the comparative outcomes of patients with low back pain who undergo magnetic resonance imaging vs standard lumbar radiography and finds no difference in outcomes. However, the authors mention an important barrier in putting this recommendation into practice: in randomized trials, “patients with low back pain expressed more satisfaction when they received routine lumbar imaging or advanced imaging, although clinical outcomes were not better than those for patients who did not undergo imaging.”2 Nonadherence to the evidence likely has both supply and demand components. Groups of more than 50 physicians that own imaging equipment have higher imaging rates.2,4 Additional issues are downstream costs of surgery, false-positive results, and other follow-up tests and office visits, which surely drive the total cost of unnecessary imaging well beyond the $300 million mark.5,6 Srinivas et al2 recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions. Avorn and Fischer7 outline several strategies for translating comparative effectiveness research into practice. Solutions include early planning for disseminating findings to clinical groups and to relevant patient populations. They recommend improving physician education by reducing pharmaceutical industry influence and academic detailing, providing more evidence-based information through educational visits to physician offices, and incorporating evidence in computerized physician order entry systems. The article by Srinivas et al2 also addresses financial incentives and how they can foster or inhibit appropriate use of health resources. Skeptical of pay for performance, Avorn and Fischer state, “Particular care must be taken to ensure that any incentive-based system places a premium on making the most appropriate clinical decisions, instead of the least expensive ones. Physicians' resistance that is cognitively, rather than economically, based raises a completely different set of issues.”7(p1897) The ABIM Foundation, along with 9 specialty societies and Consumer Reports, is taking a different approach in disseminating evidence-based tests and procedures. Based on the experience of the National Physicians Alliance with the Good Stewardship project, the ABIM Foundation developed the “Choosing Wisely” campaign. On April 4, 2012, the 9 specialty societies each announced 5 tests or procedures in their fields that are commonly used but are often unnecessary. These lists of “Five Things Physicians and Patients Should Question” provide specific evidence-based recommendations that physicians should discuss with patients to produce wise care decisions tailored to individuals' situations.8 Another 8 specialty societies will join the campaign at a later date. Consumer Reports will work with specialty societies to translate the recommendations into patient-friendly explanations, which will be disseminated through a consumer-based and employer-based coalition. On the physician side, the ABIM Foundation will fund the development of videos that will advise physicians on having conversations about tests or procedures that patients request but may be unnecessary or potentially harmful. The aims are to increase awareness of resource use among patients and physicians and to inspire rational conversations without hysteria and references to “death panels.” Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice. What makes this campaign potentially effective is multistakeholder participation and its heavy reliance on multiple communication pathways and how others, particularly health care delivery systems, can have a natural role. What attributes are critical to the success of Choosing Wisely? They include the following: Specialty society leadership includes communicating on an ongoing basis with their members by featuring the identified tests and procedures at their meetings and in their journals and newsletters. Physicians trust their specialty societies and prefer evidence-based data. Leaders from patient and consumer organizations, employers, and physician groups have come together to talk about appropriate clinical decisions in a new way. The campaign uses tools for patients and physicians to foster informed decision making. Opportunities exist to use these recommendations within health care systems that are transforming how they deliver and pay for care. Training programs could also use the lists to discuss evidence-based care and guideline development. The campaign's duration is 3 to 5 years, during which time more specialty societies will join and the campaign will address other issues about appropriate care. The campaign has the ability to begin conversations that will change attitudes about resource use and, together with design and reimbursement changes, will cause behavioral changes among physicians and patients. In summary, the Choosing Wisely campaign can have an essential role in disseminating the best evidence about appropriate care to a broad audience of physicians and patients. The initiative will implement the lessons of the “Less Is More” series. Back to top Article Information Correspondence: Mr Wolfson, ABIM Foundation, 510 Walnut St, Ste 1700, Philadelphia, PA 19106 (DWolfson@ABIM.ORG). Published Online: June 4, 2012. doi:10.1001/archinternmed.2012.1943 Financial Disclosure: None reported. References 1. Sarno JE. Healing Back Pain: The Mind-Body Connection. New York, NY: Warner Books; 1991 2. Srinivas SV, Deyo RA, Berger ZD. Application of “Less Is More” to low back pain [published online June 4, 2012]. Arch Intern Med. 2012;172(13):isa1200071016-1020Google Scholar 3. Good Stewardship Working Group. The “Top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref 4. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-98119468091PubMedGoogle ScholarCrossref 5. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001;322(7283):400-40511179160PubMedGoogle ScholarCrossref 6. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289(21):2810-281812783911PubMedGoogle ScholarCrossref 7. Avorn J, Fischer M. “Bench to behavior”: translating comparative effectiveness research into improved clinical practice. Health Aff (Millwood). 2010;29(10):1891-190020921491PubMedGoogle ScholarCrossref 8. ABIM Foundation. Choosing Wisely. 2012. http://choosingwisely.org/. Accessed March 27, 2012 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Are the Top 5 Recommendations Enough to Improve Clinical Practice?: Comment on “Application of ‘Less Is More’ to Low Back Pain”

Archives of Internal Medicine , Volume 172 (13) – Jul 9, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1943
Publisher site
See Article on Publisher Site

Abstract

I am not a physician, but I have relevant patient experience. For the past 20 years, I have had no significant back pain. Before that, I had a bad back for 20 years, with almost daily sciatica pain and frequent episodes of a misaligned spine, with crippling muscle spasms. Seeking relief, I visited neurologists, orthopedists, chiropractors, acupuncturists, physical therapists, and finally a physiatrist. The cure came from the mind-body connections offered by my physiatrist. My experience is that curing back pain is complex and that testing often reinforces a bioskeletal problem when there is frequently a large psychological component involved. Is this a case of testing preventing a cure?1 The authors of “Application of ‘Less Is More’ to Low Back Pain”2 in this issue of the Archives refer to this phenomenon as patient “labeling.” In their article, Srinivas et al2 address the many dimensions of a lower back pain diagnosis. The primary aim of the study is to offer evidence for a recommendation by the National Physicians Alliance as part of its “Promoting Good Stewardship in Clinical Practice” project, which published the following admonition in the Archives in 2011: “Don't do imaging for low back pain within the first 6 weeks unless red flags are present.”3(p1388) The article by Srinivas et al2 is unique in that it goes beyond a review of the overwhelming evidence against the overuse of imaging. It estimates the cost of unnecessary imaging at almost $300 million, discusses reasons for the failure to convert evidence into practice, and identifies the issue of labeling a person with an illness. The study also reviews the comparative outcomes of patients with low back pain who undergo magnetic resonance imaging vs standard lumbar radiography and finds no difference in outcomes. However, the authors mention an important barrier in putting this recommendation into practice: in randomized trials, “patients with low back pain expressed more satisfaction when they received routine lumbar imaging or advanced imaging, although clinical outcomes were not better than those for patients who did not undergo imaging.”2 Nonadherence to the evidence likely has both supply and demand components. Groups of more than 50 physicians that own imaging equipment have higher imaging rates.2,4 Additional issues are downstream costs of surgery, false-positive results, and other follow-up tests and office visits, which surely drive the total cost of unnecessary imaging well beyond the $300 million mark.5,6 Srinivas et al2 recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions. Avorn and Fischer7 outline several strategies for translating comparative effectiveness research into practice. Solutions include early planning for disseminating findings to clinical groups and to relevant patient populations. They recommend improving physician education by reducing pharmaceutical industry influence and academic detailing, providing more evidence-based information through educational visits to physician offices, and incorporating evidence in computerized physician order entry systems. The article by Srinivas et al2 also addresses financial incentives and how they can foster or inhibit appropriate use of health resources. Skeptical of pay for performance, Avorn and Fischer state, “Particular care must be taken to ensure that any incentive-based system places a premium on making the most appropriate clinical decisions, instead of the least expensive ones. Physicians' resistance that is cognitively, rather than economically, based raises a completely different set of issues.”7(p1897) The ABIM Foundation, along with 9 specialty societies and Consumer Reports, is taking a different approach in disseminating evidence-based tests and procedures. Based on the experience of the National Physicians Alliance with the Good Stewardship project, the ABIM Foundation developed the “Choosing Wisely” campaign. On April 4, 2012, the 9 specialty societies each announced 5 tests or procedures in their fields that are commonly used but are often unnecessary. These lists of “Five Things Physicians and Patients Should Question” provide specific evidence-based recommendations that physicians should discuss with patients to produce wise care decisions tailored to individuals' situations.8 Another 8 specialty societies will join the campaign at a later date. Consumer Reports will work with specialty societies to translate the recommendations into patient-friendly explanations, which will be disseminated through a consumer-based and employer-based coalition. On the physician side, the ABIM Foundation will fund the development of videos that will advise physicians on having conversations about tests or procedures that patients request but may be unnecessary or potentially harmful. The aims are to increase awareness of resource use among patients and physicians and to inspire rational conversations without hysteria and references to “death panels.” Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice. What makes this campaign potentially effective is multistakeholder participation and its heavy reliance on multiple communication pathways and how others, particularly health care delivery systems, can have a natural role. What attributes are critical to the success of Choosing Wisely? They include the following: Specialty society leadership includes communicating on an ongoing basis with their members by featuring the identified tests and procedures at their meetings and in their journals and newsletters. Physicians trust their specialty societies and prefer evidence-based data. Leaders from patient and consumer organizations, employers, and physician groups have come together to talk about appropriate clinical decisions in a new way. The campaign uses tools for patients and physicians to foster informed decision making. Opportunities exist to use these recommendations within health care systems that are transforming how they deliver and pay for care. Training programs could also use the lists to discuss evidence-based care and guideline development. The campaign's duration is 3 to 5 years, during which time more specialty societies will join and the campaign will address other issues about appropriate care. The campaign has the ability to begin conversations that will change attitudes about resource use and, together with design and reimbursement changes, will cause behavioral changes among physicians and patients. In summary, the Choosing Wisely campaign can have an essential role in disseminating the best evidence about appropriate care to a broad audience of physicians and patients. The initiative will implement the lessons of the “Less Is More” series. Back to top Article Information Correspondence: Mr Wolfson, ABIM Foundation, 510 Walnut St, Ste 1700, Philadelphia, PA 19106 (DWolfson@ABIM.ORG). Published Online: June 4, 2012. doi:10.1001/archinternmed.2012.1943 Financial Disclosure: None reported. References 1. Sarno JE. Healing Back Pain: The Mind-Body Connection. New York, NY: Warner Books; 1991 2. Srinivas SV, Deyo RA, Berger ZD. Application of “Less Is More” to low back pain [published online June 4, 2012]. Arch Intern Med. 2012;172(13):isa1200071016-1020Google Scholar 3. Good Stewardship Working Group. The “Top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref 4. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-98119468091PubMedGoogle ScholarCrossref 5. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. BMJ. 2001;322(7283):400-40511179160PubMedGoogle ScholarCrossref 6. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289(21):2810-281812783911PubMedGoogle ScholarCrossref 7. Avorn J, Fischer M. “Bench to behavior”: translating comparative effectiveness research into improved clinical practice. Health Aff (Millwood). 2010;29(10):1891-190020921491PubMedGoogle ScholarCrossref 8. ABIM Foundation. Choosing Wisely. 2012. http://choosingwisely.org/. Accessed March 27, 2012

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 9, 2012

Keywords: low back pain

References