Are Choosing Wisely Recommendations Being Followed? New Study Identified Low Levels of Adherence

VBCC - November 2014, Vol 5, No 9 - ASCO Quality Care Symposium
Alice Goodman

Boston, MA—The American Board of Internal Medicine Foundation’s Choosing Wisely campaign has the potential to rein in healthcare costs and improve patient care. Each year since 2012, the American Society of Clinical Oncology (ASCO) has listed 5 tests or interventions that should not be used routinely in clinical practice, but so far no data have been published on whether oncologists are following these recommendations.

A team of researchers from the Hutchinson Institute for Cancer Outcomes Research (HICOR) at Fred Hutchinson Cancer Research Center in Seattle, WA, has been tackling that question for the first time. They presented their findings at the 2014 ASCO Quality Care Symposium.

HICOR partnered with Premera Blue Cross to take a first step in determining patterns of care related to ASCO’s Choosing Wisely recommendations. The goal of the research was to characterize adherence to each of the 5 recommendations, and then zero in on opportunities to improve care.

Overall, for 3 of the 5 recommendations, approximately 30% to 50% of patients may have received tests or interventions that were not supported by evidence.

The investigators noted that measuring Choosing Wisely adherence provides a baseline, rather than a quality score, that can guide quality improvement and cancer care delivery and further research.

“It is a huge challenge to measure adherence to Choosing Wisely, and that is one of the reasons our work received a lot of attention at the Quality Care Symposium. Our goal in working with Premera and the cancer registry is to identify patterns of care in Western Washington, confer with local oncology providers to address areas where care can be improved, and develop interventions,” said Karma L. Kreizenbeck, Project Director at HICOR, who presented the data at the meeting.

Ms Kreizenbeck and colleagues linked data from the Cancer Surveillance System (CSS), a part of the Surveillance, Epidemiology, and End Results program, which covers 4.5 million people and records approximately 27,000 cases annually, with enrollment and claims data from Premera Blue Cross, a not-for-profit commercial insurer that covers approximately 1.2 million lives in western Washington State.

The investigators developed algorithms for each of the 5 Choosing Wisely recommendations. The linkage of CSS and health insurance enrollment files identified 24,263 patients with cancer, with some exclusions for lack of data on diagnosis.

Relatively Good Adherence
Adherence was relatively good to recommendations 2 and 3. Recommendation 2 says not to use positron emission tomography (PET), computed tomography (CT), or radionuclide bone scans in the staging of patients with early prostate cancer that is at low risk of spreading. Recommendation 3 says to not use PET, CT, and radionuclide bone scans in the staging of patients with early breast cancer that is at low risk of spreading.

Poor Adherence
However, the data showed that adherence to recommendations 1, 4, and 5 was suboptimal. Recommendation 1 says to avoid unnecessary anticancer therapy and focus on symptom relief and palliative care for patients with advanced cancers that are unlikely to benefit for chemotherapy or radiation at that late stage. Ms Kreizenbeck and colleagues found, however, that 41% of patients with cancer were receiving chemotherapy or radiation in the last 60 days before death.

Recommendation 4 says that routine tests for biomarkers and advanced imaging should not be used routinely for patients who have completed curative breast cancer treatment. The data presented by Ms Kreizenbeck and colleagues showed that 41% of these women were still undergoing testing for biomarkers and advanced imaging.

Recommendation 5 says to avoid the use of colony-stimulating factors (CSFs) in patients undergoing chemotherapy who have a <20% risk for developing febrile neutropenia. Again, the data presented by the team of researchers showed that 40% of patients with breast cancer and 36% of those with non–small-cell lung cancer were receiving CSFs with chemotherapy that had a <20% risk for febrile neutropenia.

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