ABSTRACT & COMMENTARY
The Choosing Wisely ® Top 5 List in Critical Care Medicine
By Eric C. Walter, MD, MSc
Pulmonary and Critical Care Medicine, Northwest Permanente and Kaiser Sunnyside Medical Center, Portland
Dr. Walter reports no financial relationships relevant to this field of study.
This article originally appeared in the December 2014 issue of Critical Care Alert. It was edited by David J. Pierson and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
SYNOPSIS: The Choosing Wisely Campaign was introduced in 2011 by the American Board of Internal Medicine to identify practices and procedures physicians and patients should question. The critical care top 5 list was developed through a collaborative effort of several critical care societies.
SOURCE: Halpern SD, et al. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: The Choosing Wisely top 5 list in critical care medicine. Am J Respir Crit Care Med 2014;190:818-826.
The Choosing Wisely Campaign began in 2011 in an effort to identify five specialty-specific tests and/or interventions that should be avoided, as they are costly and provide minimal benefit to patients. To date, more than 50 specialties have developed their own "Top 5" lists. In 2012, a collaborative task force with members from the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine convened to develop the critical care top 5 list. The article by Halpern and colleagues describes the nearly year-long process that went into developing the list and presents the final list with rationale and explanation for each item.
The task force’s first job was to identify criteria to evaluate proposed items. This allowed for transparency and consistency. The chosen criteria included: 1) strength of evidence, 2) prevalence, 3) aggregate cost, 4) relevance to critical care, and 5) innovation. Using these criteria as guidelines, each author then individually proposed topics to be considered for the top 5. Initially, 58 unique items were proposed by the authors. An iterative process was then carried out to narrow the list down to the final 5:
- Do not order tests at regular intervals (i.e., daily) but rather in response to clinical questions.
- Do not transfuse red blood cells (RBC) in hemodynamically stable, nonbleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.
- Do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of an ICU stay.
- Do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
- Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
Rationales are provided for each recommendation and include unnecessary expenses, lack of benefit, or potential harm to the patient or family. Often, evidence-based medicine was used to support individual recommendations.
In this article, Halpern and colleagues present the critical care top 5. They also describe the process through which the list was created and provide a succinct explanation and rationale for each recommendation. All of this helps to add credibility to the list.
Critical care accounts for approximately 3-4% of all health care costs ($100 billion per year). The Choosing Wisely campaign was born out of the philosophy that physicians have a responsibility to practice cost-effective care. As described in the article, the 2002 Physician Charter for Medical Professionalism states that "physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."1 This requirement was championed by medical ethicist Howard Brody, who recommended each specialty identify a "top 5" list of tests or interventions that are commonly used but do not provide meaningful benefit to patients,2 which became the Choosing Wisely campaign.
Many will argue that the critical care task force got it wrong. They should have considered antibiotic stewardship, CT scanning, futile care, etc. The fact that there are many tests and interventions that could have been considered should not minimize the value of the final list. To the contrary, it should open all of our eyes to our professional requirement to consider the cost and value for all of our many daily decisions in the ICU.
For too long, patients have requested health care and physicians have practiced health care as if resources were not limited. This cannot continue. For all the downsides and red tape associated with payers, whether they be insurance companies or the government, at a minimum they act as a needed brake on an, at times, runaway system. If, as physicians, we do not want this pressure placed upon us then we need to "seize the moral high ground," as Dr. Brody wrote,2 and take it upon ourselves to practice in a cost-effective manner.
1.Sox HC, et al. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002;136:
- 2.Brody H. Medicine’s ethical responsibility for health care reform — the top five list. N Engl J Med 2010;362:283-285.