April 26, 2023
Two clinical teams have been named 2023 Choosing Wisely® Champions by AMDA. The award honors individual clinicians and teams of clinicians who have gone above and beyond to make significant contributions to advance the ideals of the ABIM Foundation’s Choosing Wisely campaign by working to reduce unnecessary tests, treatments, and procedures in health care.
In 2016, the ABIM Foundation introduced the Choosing Wisely Champion program “to recognize clinicians who are leading efforts to reduce overuse and waste in medicine. The program was created to acknowledge the work of those dedicated to providing appropriate care and encourage others to follow their lead.” AMDA is among the participating organizations that have selected champions from among its members.
The first team of 2023 Choosing Wisely champions, led by Katherine Coffey-Vega, MD, a geriatrician and director of transitions of care management at the Carilion Clinic in Roanoke, VA, applied Choosing Wisely practices in the emergency department at Carilion Roanoke Memorial Hospital. Specifically, she and Dr. Jeff Goode collaborated to create a program that addressed the AMDA Choosing Wisely recommendation: “Don’t recommend aggressive or hospital-level care for frail individuals without a clear understanding of the individual’s goals of care and the possible benefits and burdens.” They also applied other Choosing Wisely recommendations addressing inappropriate medication use in their initiative. Early results suggest that this program has promoted delirium prevention strategies, medication reconciliation, and the establishment of care goals at the start of hospital care.
“Receiving this award means a great deal. I am a common-sense practitioner, and I have always loved the Choosing Wisely concept. These recommendations help us be good stewards with the resources we have and continually provide quality care,” said Dr. Coffey-Vega.
She added that the Choosing Wisely recommendation she chose to address “is a key focus of the work I am doing on the frontline. I am passionate about this cause.” Reducing the hospital length of stay, she suggested, is possible with good oversight, quality care, and partnerships between practitioners and care settings, initiated at the earliest possible opportunity and always with patient preferences as a guide. The results of her project, she said, exceeded her expectations.
Choosing Wisely is a valuable tool, Dr. Coffey-Vega suggested. “Through the years, when I am teaching about a particular topic, I have often pointed to Choosing Wisely as an authority, and I think most people agree. The recommendations are based on the literature, clinical evidence, avoiding waste and harm, and optimizing outcomes while incorporating expert guidance. Every principle is a bottom line after considering various sources of authority,” she said. Choosing Wisely, she explained, “is a way to reground us in good practices and gives us a foundation to stand on when we offer or don’t offer interventions.”
The second team, led by Zachary Palace, MD, medical director of Hebrew Home at Riverdale in New York, began an initiative to eliminate the long-term use of sedative hypnotic medications for sleep induction in the nursing home population. The initiative was based on the AMDA Choosing Wisely recommendation: "Don’t routinely prescribe or continue sedative hypnotics for long-term treatment of sleep disorders in geriatric populations." Key to the program was ongoing communications and education with clinical team members, including the consultant pharmacist, and residents’ families. During the first year, there was a 53% reduction in sedative hypnotic usage. To date, it is down 64%.
“As a geriatrician and medical director, my focus has always been on practicing high-quality medicine with a focus on maintaining the best possible quality of life and using proven measures to reduce adverse outcomes and avoid issues of polypharmacy,” said Dr. Palace. “The Choosing Wisely initiative helped give our project more credence, particularly when educating families and residents. This is not just a home-grown project but a national effort to improve geriatric care.”
Dr. Palace noted, “The first thing we looked at was patients who were getting diuretics in the afternoon and evening and moved them to the morning. That was one factor. We also tried to increase the number of activities during the day and strongly discouraged patients from taking afternoon naps. Instead, we encouraged them to stay up and participate in activities.” Dr. Palace and his team also worked to reduce sedative/hypnotic doses and switch to PRN when possible.
The program has been so successful that it is now on the radar for new admissions. Dr. Palace said, “It’s not uncommon for residents to come in on these medications so we try and address this early.” He noted that weekly meetings with medical staff, including physicians and nurse practitioners, helped increase the program’s success. “We didn’t get much resistance from prescribers,” he said. He also noted that some residents were more likely to oppose the change because they had been taking these medications for years. Ongoing education efforts, plus the recommendation which came from experts at AMDA, helped overcome their concerns.