Identifies five tests and treatments dermatologists and their patients should question
By Ruth Carol, contributing writer, December 02, 2013
You’ve heard the old adage “too much of a good thing,” but probably not in the context of health care…until now.
The American Academy of Dermatology (AAD) recently identified five commonly performed medical tests and treatments that are not only potentially unnecessary, but could be harmful, as part of the Choosing Wisely® campaign. (See sidebar for list.)
Launched by the American Board of Internal Medicine Foundation in 2012, the campaign’s goal is to encourage conversations between physicians and patients about what care is really necessary for specific conditions. To date, more than 50 medical specialty societies and nearly 20 consumer groups are involved in the campaign. The societies identify the “Five Things Physicians and Patients Should Question” while Consumer Reports develops accompanying patient-friendly materials and works with consumer groups to disseminate them widely. The AAD is joining in the third wave of lists released between now and March 2014. The additional 30-plus lists build on a library of more than 130 tests and procedures already identified.
“The Choosing Wisely campaign is a unique opportunity for our specialty, from within, to identify areas where we think certain tests, treatments, or procedures might sometimes be used at the wrong times or in the wrong circumstances,” noted Jack Resneck Jr., MD, the AAD’s Choosing Wisely Workgroup’s advisor and associate professor and vice chair of dermatology at the University of California San Francisco School of Medicine. “As dermatologists, we have special expertise to make these assessments and help patients and their referring physicians to better weigh the risks and benefits of specific interventions.” [pagebreak]
Why this, why now?
It is estimated that as much as 30 percent of the nation’s health care spending is wasted on duplicative or unnecessary services, according to the Institute of Medicine and others. Moreover, these inefficiencies could lead to harm. By one estimate, cited when the IOM released the report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” earlier this year, approximately 75,000 deaths could have been averted in one year if care had been delivered at an optimal level.
“The Choosing Wisely campaign comes at a time when it is becoming increasingly recognized that we need to change the way we practice medicine,” said Kathryn Schwarzenberger, MD, a workgroup member and the Amonette-Rosenberg Professor and Chair of the University of Tennessee’s dermatology department. There is an increasing focus on making sure that physicians are providing the right treatment to the right patient.
Alice J. Watson, MD, MPH, a workgroup member and resident of the Harvard Combined Dermatology Program in Boston, pointed out that dermatology as a specialty is facing a lot of external pressure and uncertainty around payment. Consequently, it’s important that dermatologists demonstrate that they are committed to being good stewards of the health care resources they manage, said Mary-Margaret Chren, MD, a workgroup member and professor at University of California San Francisco School of Medicine. “Taking responsibility for making these recommendations from within our specialty is far more desirable than having insurers and government payers fill the void and make them for us,” Dr. Resneck added.
A list is created
The six-member workgroup was convened this past January. Members included dermatologists who also serve on the Academy’s Board of Directors; Council on Science and Research; Council on Government Affairs, Health Policy, and Practice; Research Agenda Committee; Clinical Guidelines Committee; Access to Dermatology Care Committee; Patient Safety and Quality Committee; Resource-Based Relative Value Scale Committee; and Workgroup on Innovative Payment and Delivery. [pagebreak]
To start, the workgroup members reviewed the AAD’s clinical practice guidelines, quality measures, and appropriate use criteria for Mohs micrographic surgery, all of which are backed by strong evidence, noted Roseanne Fischoff, MPP, the AAD’s director of science, quality, and practice. According to the Choosing Wisely criteria, patients and physicians should choose treatments that are supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.
To establish the list, members conducted several telephone calls during which they discussed individual lists they had developed. Common themes emerged and the group then reworked them to fit the paradigm set by Choosing Wisely, Dr. Schwarzenberger recalled.
The workgroup members agreed that it was important that the list reflect the breadth of practice, said Dr. Watson, who noted that developing the list involved a rigorous, objective process. “It was impossible to cover everything we do, but we wanted to touch on key areas,” she said. “Regardless of your practice, there is something you can take from the list.”
The workgroup members also focused on areas that had the greatest potential for overuse/misuse as well as the greatest potential for improvement in patient outcomes. They wanted the list to result in high-impact, easy-to-implement recommendations. Providers who follow these recommendations are expected to have a positive impact on the quality of health care and hopefully decrease the amount of money spent on it, Dr. Schwarzenberger said.
Given that non-dermatologists provide a great deal of dermatology care, the workgroup members wanted to make sure that the guidelines were not esoteric things that only dermatologists would understand, Dr. Watson noted. “They had to be things that were meaningful and understandable to family care doctors as well as patients,” she added. [pagebreak]
This list has the added benefit of helping educate patients about dermatologic care. Sometimes patients request tests and treatments that might not be necessary and it can be difficult to dissuade them. Physicians may feel as if they don’t have enough time to have lengthy conversations with their patients about the pros and cons of each test/treatment. Dermatologists can use this list as a way to educate patients about appropriate care, noted Brett Coldiron, MD, the Academy’s president-elect and a clinical assistant professor at the University of Cincinnati, who chaired the workgroup.
An unexpected benefit of the process was the opportunity to step back and think about the care that you provide on a daily basis and how you provide it, Dr. Chren said. Dr. Watson agreed. “It’s helpful as a specialty to take the time to debate and examine how we practice and ask how we can do better.”
This past March, the recommended list was reviewed and approved by the AAD’s Council on Science and Research as well as its Board of Directors. While workgroup members were pleased with the list, many hope it will not be the last. “As more evidence comes out, we should continue to question in order to deliver the best possible care for our patients,” Dr. Watson said. All of those involved with this effort had a very positive experience and are excited about the AAD’s participation in Choosing Wisely, Fischoff added. “The Academy would certainly consider developing another list.”
The current list is available online in two formats: for doctors, at www.aad.org/choosing-wisely, and for patients at www.aad.org/choosingwisely.