ASN Partners with Campaign to Cut Wasteful Health Care Spending and Improve Care

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The American Society of Nephrology recently joined forces with other leading medical organizations in a campaign to identify and reduce wasteful health care spending while improving patient outcomes at the same time.

Called Choosing Wisely, the campaign is part of a multiyear effort spearheaded by the American Board of Internal Medicine (ABIM) Foundation “to help physicians be better stewards of finite health care resources,” according to the foundation’s website, www.abimfoundation.org. Together with eight leading medical specialist organizations and Consumer Reports, ASN is part of the first wave of the ABIM Foundation’s campaign and was set to participate in a press conference unveiling the effort in Washington, DC, on April 4.

“ASN’s dedication to this important effort reflects the society’s commitment to curing kidney disease and the leading role ASN and its members play in improving the kidney health of nearly 30 million Americans,” said ASN President Ronald J. Falk, MD, FASN.

Spiraling costs of care

The cost of health care in the United States has grown exponentially, burdening patients and providers alike. A recent report from the nonpartisan Congressional Budget Office estimated that up to 30 percent of health care charges are spent on procedures that are redundant, not necessary, or potentially harmful—jeopardizing patient safety and squandering resources. Failure to reduce this needless spending could lead to a dramatic increase in medical costs. The Centers for Medicare & Medicaid Services predicts that if no action is taken to reduce expenditures, health care spending will balloon to 19.3 percent of the U.S. gross domestic product, or $4.3 trillion, by 2019.

Choosing Wisely aims to start a conversation among patients, health care providers, and other stakeholders about using the most appropriate tests and treatments and avoiding care whose harm may outweigh the benefits. In addition to ASN, other medical societies announced as partners in the program’s first wave include the American Academy of Allergy, Asthma & Immunology, American Academy of Family Physicians, American College of Cardiology, American College of Physicians, American College of Radiology, American Gastroenterological Association, American Society of Clinical Oncology, and the American Society of Nuclear Cardiology.

Organizations joining Choosing Wisely as part of a second wave include the American Academy of Otolaryngology–Head and Neck Surgery, American Association of Hospice and Palliative Medicine, American College of Rheumatology, American Geriatrics Society, American Society for Clinical Pathology, American Society of Echocardiography, Society of Hospital Medicine, and the Society of Nuclear Medicine.

Consumer Reports, the nation’s leading independent, nonprofit consumer organization, will help the effort by partnering with other consumer groups to distribute patient-friendly resources to spark discussion about the need—or lack thereof—for many tests and procedures frequently ordered in the United States.

The Choosing Wisely goals align closely with ASN’s mission. ASN regularly advocates for improved care for patients, better health for populations, and lower health care costs.

“The campaign reflects my personal commitment that ASN and its members work in partnership with patients and others to see that those managing their kidney health achieve the best possible quality of life now,” Falk said. “ASN’s focus on innovative approaches such as Choosing Wisely will lead the way to future cures.”

ASN’s “Five Things”

As part of the campaign, participating medical societies each came up with a list of five medical tests or procedures commonly used in their field that merit questioning and discussion (see sidebar, page 5).

In tackling issues such as avoiding nonsteroidal anti-inflammatory drugs (NSAIDS) in those with hypertension, heart failure, or chronic kidney disease (CKD), or not placing peripherally inserted central catheters (PICCs) in stage III–V CKD patients, ASN’s choices for tests or procedures worth questioning will provoke dialogue both inside and outside the world of kidney disease.

Amy Williams, MD, chair of the ASN Quality and Patient Safety (QPS) Task Force, predicted that “it’s going to shake up the medical community a bit and will make nephrologists as well as other physicians aware of specific kidney safety concerns.”

Compiled by leaders in the field of kidney disease who have a thorough understanding of the evidence-based medicine behind the list, ASN’s Five Things may help modify how other providers as well as nephrologists and team members treat patients with kidney disease. Incorporating changes into the work flow will require some adjustments, but “overall we are decreasing the number of unnecessary tests, decreasing harm to patients, and, if you look at it financially, we will be saving a lot of money. It’s a win-win,” Williams said.

ASN’s Five Things aligns the highest level of patient care with evidence-based medicine, and may not reflect prevailing practices and structures. Williams described the current system as disjointed, adding that “we’re reimbursed for the intensity of services that we provide the patient instead of being reimbursed for the outcome or the value of the care provided.”

To those outside the kidney community, some recommendations may at first appear controversial. The recommendation to not perform routine cancer screening for dialysis patients with limited life expectancies with no signs or symptoms of cancer may raise eyebrows. Yet existing guidelines for cancer screening were not designed for those with chronic illnesses like kidney disease. They were designed for the general population and need to be tailored to fit the needs of patients with kidney disease. Treatment of pain and anemia also must be calibrated to meet the unique needs of the kidney patient, while following accepted guidelines.

Early involvement of the nephrologist is crucial for improving outcomes in patients with kidney disease, especially those undergoing dialysis. Whether preserving vasculature for future dialysis or deciding when to initiate the treatment, the nephrologist has to be part of these important conversations. The fourth recommendation—to avoid placing PICC lines in patients with stage III–V CKD without consulting nephrology—highlights the need for nephrologists to be involved with the kidney patient’s care early on. Using PICC lines can lead to complications of the peripheral vasculature, which serve as the patient’s “lifeline” (arteriovenous fistula) once they’ve started dialysis. ASN’s Five Things list also emphasizes the critical partnership of patients, families, and the nephrology team in shared decision-making, such as whether to initiate dialysis and when to do so.

ASN’s methodology

ASN’s QPS Task Force—comprised of one member of each of the 10 ASN advisory groups, as well as ASN President Falk, ASN Public Policy Board President Thomas H. Hostetter, MD, and ASN Manager of Policy and Government Affairs Rachel Shaffer—addressed the ABIM Foundation’s request for a Five Things list (see box, page 5). Together with Shaffer, members consulted with their respective advisory groups about the Choosing Wisely initiative and its goals, and were asked to submit tests and procedures that should be reconsidered or ceased altogether within their specific area of expertise in nephrology.

More than 100 ideas were submitted for review, which were narrowed to 20 potential items that the QPS Task Force believed were most influential. In an online survey the task force voted for what they considered the seven most important points and then narrowed the field to six top contenders, all of which received at least 50 percent of the votes.

The ASN Public Policy Board (which oversees the QPS Task Force) examined the six final potential items, and after weighing their potential impact on patient care unanimously voted to eliminate one item and approve the remaining five. With the list finalized, two members of the task force drafted evidentiary statements and a list of the primary organizations whose resources or research evidence supported each item.

ASN encourages members to continue the discussion about tests and procedures whose merits should be questioned and to share their opinions about the Five Things and ASN’s methodology by contacting communications@asn-online.org.

Raising awareness

Partnering with the Choosing Wisely initiative is just one part of the ASN QPS Task Force’s campaign to raise awareness about quality and patient safety issues in the kidney population and to develop and promote resources to help address them. They are consulting with ASN’s 10 advisory groups to identify specific patient safety issues relevant to all areas of nephrology practice. The Task Force is also examining approaches to promote research in the field, including designing tools to help kidney care professionals address potential patient safety problems, and authoring position papers on key points. Another important step is educating patients and their families about their roles in promoting safety and quality, and including them as members of the nephrology team. Among other things, the Task Force is investigating the possibility of recommending that ASN participate in the Department of Health and Human Services Partnership for Patients to continue raising the profile of kidney patient safety.

The Choosing Wisely initiative and ASN’s Five Things aim to start the conversation between patients and physicians on making informed choices to deliver the most appropriate care. To learn more about the ABIM Foundation and its Choosing Wisely campaign visit www.ChoosingWisely.org.