Choosing Wisely and the perceived drivers of endoscopy use.

摘要: Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with specialty medical societies including Gastroenterological Association (AGA)1. seeks to reduce several categories overutilization health care services (e.g., overtreatment, and failures coordination execution processes)2. based on principles Parsimonious Medicine: an appeal professionalism physicians’ “good, sound judgment” identify apply clinical evidence 3. medicine suggests that appropriate utilization occurs when physician judgment best are applied within context individual patient’s needs3. addresses both physicians patients through publication lists “Five Things Physicians Patients Should Question” for each specialty. The items identified AGA highlight potential 1) pharmacologic treatments gastroesophageal reflux disease, 2) screening colonoscopy average risk individuals, 3) surveillance individuals low-risk polyps, 4) esophagogastroduodenoscopy (EGD) Barrett’s Esophagus (BE), 5) computed tomography (CT) functional abdominal pain.1 The success will depend how weight importance against other factors shape decisions at encounter. As part patient-centered, comparative effectiveness study (EGD), we conducted qualitative interviews explore patient perceptions one items.4 Analysis these perceived influence under over EGD practice guidelines. We in-depth 20 BE who use Veterans Administration (VA) system 14 gastroenterologists from three settings: tax-supported public, private academic, VA settings. We concluded sampling subgroup point thematic saturation5. Interview content was informed models decision-making6. Interviews elicited information about their experiences, perceptions, attitudes regarding EGD. guidelines decision making BE. All were recorded, transcribed, analyzed content.5 Of our sample BE, mean age participants 62.9±7.3 years; all male; 10 had without dysplasia 9 low-grade dysplasia. interviewed experienced endoscopists, 36% female, 50% practiced settings full or time; median (range 1–36) years post-fellowship experience. Table 1 describes quotes frame drivers as guideline-based cancer surveillance. Figure depicts themes EGD. Figure 1 Table 1 Drivers Utilization Among Gastroenterologists Our endorsed many (Figure drive EGD, than quality evidence, may not be influenced appeals evidence. These include, access payments healthcare (for patients), financial incentives medical-legal considerations physicians). results specifically co-sponsored AGA: follow-up examination should performed less per published dysplasia1. However, current indicative adherence this item; example, recent three-site (including facility) found common among insurance-related primary driver utilization6. The emphasis places unlikely mitigate overtreatment given some structural issues related heathcare delivery largely fee-for-service system. High critical because it anchors definitions (as illustrated 1). five directly address endoscopy (colonoscopy EGD) where guiding optimal time interval between repeat studies modest best, yet there multiple driving overutilization. Moreover, systematic changes affecting incentive structures medico-legal concerns needed encourage enable types shared consistent Without counteract favoring overutilization, struggle meaningfully impact making.