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Policy Blog: Five Questions: Choosing Wisely

J. Stuart Wolf, Jr., MDJ. Stuart Wolf, Jr., MD
July, 14, 2014

In 2013, the AUA officially joined the "Choosing Wisely" campaign and released its first "Choosing Wisely List of Things Providers and Patients Should Question." Spearheaded by the ABIM Foundation, this initiative is designed to bring together the physician community to reduce unnecessary care and expense by promoting patient-physician conversations on health care. Physician organizations around the country, including the AUA, are participating in the initiative by providing evidence-based recommendations on tests and procedures that should spark dialogue between patients and their doctors.

We recently sat down with AUA Science & Quality Council Chair Dr. J. Stuart Wolf, Jr. to discuss why the AUA first got involved in Choosing Wisely and what the Association's continued involvement will be.

Q: Why did the AUA get involved with Choosing Wisely?

As noted in the introduction, the Choosing Wisely campaign is focused on the reduction of unnecessary medical care. This is an important issue in the current health care debate in the United States. In their 2012 report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America the Institute of Medicine estimated that almost 10 percent of health care spending in the United States is for unnecessary services (and another 20 percent is due to inefficient delivery, excess administrate costs and other wasteful overspending). Recognizing this, the AUA was eager to participate in the Choosing Wisely campaign. This fits well with the AUA's interest in improving quality of care, facilitating shared decision making and being a good steward of our resources.

Q: How are physicians using the Choosing Wisely lists and materials?

The Choosing Wisely statements generally start with "Don't" or "Avoid." It seems that the organizers anticipated patients questioning their physician if one of the tests on the Choosing Wisely list is ordered. I suspect that is not being done very often. I think that there are 2 greater utilities of the lists. First, there is often media coverage when a list is released, and the resulting publicity raises awareness about the overuse of a test or treatment. Second, each association that publishes a list promotes it to its own members, which provides an opportunity for provider education. The AUA already has excellent practice guidelines, but the pared down and very direct Choosing Wisely statements are an additional forum. The five Choosing Wisely statements on the AUA's current list (submitted in 2012) are:

  1. A routine bone scan is unnecessary in men with low-risk prostate cancer.
  2. Don't prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.
  3. Don't order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia.
  4. Don't treat an elevated PSA with antibiotics for patients not experiencing other symptoms.
  5. Don't perform ultrasound on boys with cryptorchidism.

If every AUA member avoided these unnecessary tests and treatments, the improvement (in terms of cost, administrative burden and patient time) would be considerable!

Q: Are the items identified by the Choosing Wisely campaign new guidelines that practices should follow?

In general, the AUA's Choosing Wisely statements are based on practice guidelines and best practice statements. For our 2012 submission, an AUA committee reviewed these materials and through a consensus process created the five-item list. These recommendations were reviewed and approved by the AUA Board of Directors. Other organizations have used varying approaches, some more rigorous and some less rigorous.

Q: How does the campaign fit in with the overall quality landscape?

The Choosing Wisely campaign is a delightfully straightforward way to improve quality. Most quality initiatives are more complex, requiring the engagement of many stakeholders and difficult changes in delivery systems. Choosing Wisely? Pretty simple – don't order that test, avoid that treatment, etc. Nothing is ever that simple, though. Just as we sometimes see conflicting practice guidelines from different groups, some Choosing Wisely lists contradict each other. The ABIM foundation makes no effort to align the lists from the more than 50 organizations that have provided them. Guidelines (and Choosing Wisely statements) are the result of the synthesis of objective evidence with the values and priorities of the groups developing them. Since the values and priorities of urologists might differ from say, family medicine practitioners, it is not surprising that our statements might differ. One of the challenges in improving quality is trying to resolve these differences.

Q: Should urologists get involved with Choosing Wisely? How can they participate?

The AUA is currently in the process of creating another list of five statements for the Choosing Wisely website. This time, after carefully considering scores of statements based on clinical practice guidelines and best practice statements, the best candidate statements will be put forth to the AUA membership for comment. This member input/voting is very important. Please consider participating when the announcement is made. The AUA's Choosing Wisely list needs to be relevant and useful to our members.

Learn more about the AUA's participation in Choosing Wisely.

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