It has been just over a year since many in the chiropractic profession first learned that the American Chiropractic Association (ACA) joined more than 80 medical specialty society partners to participate in an initiative that is sponsored by the American Board of Internal Medicine Foundation. This initiative’s mission is to “promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” It is called the Choosing Wisely campaign1 and it has generated more spirited discussion among doctors of chiropractic than I can recall since release of the Mercy Conference Proceedings in 1993.
For those of you who are too new to the profession to remember chiropractic’s first foray into clinical guideline development, I recommend that you take a few minutes to learn more about this important history. Like Choosing Wisely, the Mercy Conference was well aligned with a rapidly changing healthcare environment, truly successful in increasing the cultural authority of the chiropractic profession in the eyes of many important stakeholders, and spurned by many in chiropractic who feared that the Proceedings would be used unfairly by insurers and others to restrict the ability of doctors of chiropractic to provide the care they thought best for patients. Then, as now, it was important to separate the facts from the fears. In the case of Choosing Wisely, we must ensure that all stakeholders involved, including chiropractors, patients, payors and policy-makers, understand what this initiative is, and even more importantly, what it is not.
What Choosing Wisely Is…
Choosing Wisely invites healthcare organizations to become more patient-centered by creating evidence-based lists of five procedures and/or tests that are in common practice and potentially offer both risks (e.g. iatrogenic disorders, costs) and benefits (e.g. detection of underlying pathology, impact on treatment plan) to the patient. The stated intent of this program is to promote informed discussions between doctors and patients that enable patients to fully participate in shared decision-making regarding their care, decision-making that takes into account an individual patient’s history, examination findings and treatment preferences. The chiropractic Choosing Wisely List2 is as follows (for full text and to download a PDF, click here):
- In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain.
- Do not perform repeat spinal imaging to monitor patients’ progress.
- Avoid prolonged or ongoing use of passive or palliative physical therapy treatments for low-back pain unless they support the goal(s) of an active treatment plan.
- Do not provide long-term pain management without psychosocial screening or assessment for possible related psychological disorders, most notably depression and anxiety.
- Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.
What Choosing Wisely Is Not…
Choosing Wisely lists are not guidelines, clinical care mandates, “never lists” or payor policies. As clearly stated on the Choosing Wisely website under the mission statement3, “Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.”
“Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.”
Although words such as “do not” and “avoid” are used consistently across all lists, this language should not be taken as a mandate. Yes, the terminology used is purposefully provocative. You must admit that it got your attention! However, the stated intent and purpose of the Choosing Wisely initiative makes it very clear that these are not the Five Commandments. It would be as inappropriate to blanketly restrict access to the tests and procedures included in Choosing Wisely for all patients as it would be to do the opposite.
Further, although words such as “do not” and “avoid” are used consistently across all lists, this language should not be taken as a mandate. … It would be as inappropriate to blanketly restrict access to the tests and procedures included in Choosing Wisely for all patients as it would be to do the opposite.
Over the next several weeks, myself and other authors will be writing a series of ACA blog posts that outline the intent, rationale, supporting evidence and concerns raised regarding each of the five tests and procedures included in the chiropractic Choosing Wisely list. I hope you will be part of this important conversation.
Dr. Goertz is the chair of ACA’s Committee on Quality Assurance. She is also ACA’s senior scientific advisor and CEO of the Spine Institute for Quality (Spine IQ).
References
- Choosing Wisely, http://www.choosingwisely.org/
- ACA and Choosing Wisely: Five Things Physicians and Patients Should Question, http://www.choosingwisely.org/wp-content/uploads/2017/08/ACA-Choosing-Wisely-List.pdf
- Our Mission, Choosing Wisely, http://www.choosingwisely.org/our-mission/
