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Wednesday, May 30, 2018

Doctors aren't top opioid prescribers in NH | New Hampshire



The highest-volume prescribers of opioids in New Hampshire are not doctors, but nurse practitioners and physician assistants who work at specialty pain clinics, according to Medicare and Medicaid data reviewed by the New Hampshire Union Leader.

The data show that the top 25 prescribers of oxycodone HCL and Oxycontin wrote more than 22,500 prescriptions for the two drugs for Medicare and Medicaid patients in 2013. 

None of the top five had a doctor’s license. Four of the five worked at specialty pain clinics. And one — physician assistant Christopher Clough — was permanently banned from prescribing narcotics and working in the pain care field by the state Board of Medicine earlier this year.

The data come from two sources. Data from Part D Medicare billings were obtained through ProPublica, a non-profit journalism website that has compiled publicly available data from the Center for Medicare and Medicaid Services. The New Hampshire Union Leader obtained digital Medicaid billing records from the New Hampshire Department of Health and Human Services.


The most recent ProPublica data are for 2013, which is more than a year before the heroin and opioid abuse crisis rose to prominence in the Granite State. Of the top 25 prescribers, nine are physicians, 12 are nurse practitioners, four are physician assistants.

New Hampshire law allows nurse practitioners to work independently and issue prescriptions without physician oversight; physician assistants must be overseen by a doctor.



Kelly Doherty, a nurse practitioner of 15 years, issued more Medicare prescriptions for oxycodone HCL than anyone else in New Hampshire. Doherty, who now heads the palliative care program at Cornerstone VNA, said she was working in 2013 at Interventional Spine Medicine, a specialty pain clinic in Barrington.

She said her job was to manage medications at the practice, a job that involves drug testing, calling patients randomly to count their pill supply, and other efforts to discourage abuse.

She was not surprised at the findings. And she disputed contentions that prescription opioids are responsible for the heroin epidemic.

“Even Tylenol can be addicting. Any pain medicine can cause addiction when used inappropriately,” she said.

“I believe the heroin epidemic is due to the government’s lack of initiative in mental health treatment. It does not start with me prescribing drugs to people who need it.”







Doctors aren't top opioid prescribers in NH | New Hampshire

Death Panels: What Physicians are doing to protect Patient rights


Many years ago when HMOs and the Affordable Care Act were embryonic some proposed end of life management by committee.  In most cases the issue resolved around the costs of end of life and near death expense to the health finance system. 
Expensive life-extending treatments would require a review by a committee.  In most cases, the treatment reviews would take place by administrators in health plans and/or government programs.
No one can dispute the inflation of health care expense. Many solutions have been proposed and initiated with varying success or even paradoxical increases in cost and bureaucracy


In California on Friday, the California Medical Association killed Assembly Bill 3087 (Kalra) – dangerous legislation that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all health care services in all clinics, hospitals and physician practices in California. Due in large part to staunch opposition led by CMA, the bill died in the Assembly Appropriations Committee.The California Assembly struggles to contain it's health care costs for Medi-caid. This proposed bill would have extended far beyond the reach of government programs.Through CMA’s Grassroots Action Center, thousands of physician members contacted their legislators because AB 3087 would have:
  • Decimated California’s health care delivery system.
  • Disrupted care and limited choice for millions of California patients.
  • Caused 175,000 health care workers to lose their jobs.
  • Forced hospitals to close and pushed health care providers into early retirement
  • Caused a “brain drain” of talented medical students and residents fleeing California for more ideal working conditions.













May 29, 2018 - 2018 - California Medical Association

Monday, May 21, 2018

The Ebola superhighway: Why the new outbreak terrifies public health authorities | TheHill



A new outbreak of the Ebola virus that has killed at least two dozen people has sent public health officials scrambling to contain the epidemic as it threatens to spread far beyond the remote jungles of the Congo River Basin — and raises new questions about the World Health Organization’s (WHO) preparations for the next killer virus.
EBOLA spread follows the rivers, which are transportation corridors in the jungles of the Congo

How Ebola got its name.

The U.S. government is preparing its most direct response yet to the outbreak that appears to have begun in April, readying staffers from the Centers for Disease Control and Prevention (CDC) to deploy to multiple communities in Congo.
Ministry of Health officials first identified cases of viral hemorrhagic fever when it reached the town of Bikoro earlier this month. On Thursday, officials said a new case had been identified in Mbandaka, a city of 1.2 million.
The new case in Mbandaka has raised the alarm among public health officials because it is the first time the virus has ever landed in a city that sits directly on the Congo River.
In all eight of the previous known Ebola outbreaks in Congo, the virus has been contained within remote jungle villages or relatively small towns, where isolated populations are less likely to spread the disease.
But the Congo River is effectively the region’s highway system. Barges and boats travel from Kisangani in the east through major cities including Bumba, Mbandaka — and eventually Kinshasa, the capital of Congo and home to more than 11 million people, as well as Brazzaville, the capital of the Republic of Congo.
“The Congo River connects three national capitals and multiple other large cities,” said Jeremy Konyndyk, who led the U.S. Agency for International Development’s Office of Foreign Disaster Assistance during the 2014-2015 outbreak. “The fact that there are now several cases in an urban center of more than a million people underscores the potential for this outbreak to get out of control.”
If the Ebola virus traveled upriver from Bikoro to Mbandaka, some officials wonder, has it also traveled downstream toward Kinshasa, which offers direct air traffic to cities including Brussels, Paris, Dubai and Lagos, Nigeria?
“We don't know what's happening along the river, because the river is used by a lot of barges,” said Pierre Rollin, one of the world’s leading experts on the Ebola virus at the CDC. “None of the outbreaks have been by the river or in the big towns. So we have a lot of caution before claiming we know what's going on.”
Previous outbreaks have been snuffed out in the Congo, Rollin said, because the area is so remote that humans did not have a chance to travel far enough to transmit the virus before succumbing.
That was not the case four years ago in West Africa, where the virus spread widely across international boundaries. Commercial and cultural travel throughout Guinea, Liberia and Sierra Leone — across borders drawn a century and a half ago by colonizers with little regard for traditional tribal boundaries — is far more common than it is in Congo.
The present outbreak has raised anew questions about WHO and its capacity to respond to deadly viral threats. Following the West Africa outbreak, when the ill-prepared WHO endured withering criticism for its lackluster response to the initial round of cases, the agency has undergone a remarkable round of self-flagellation, reorganizing to prioritize emergency preparedness and response while cutting bureaucracy.
“We’ve seen WHO activate much more quickly, at much larger scale, and in more effective partnership with players like” Doctors Without Borders, said Konyndyk, who sat on an independent panel that advised WHO on reforming its emergency functions after the West Africa outbreak.
The first WHO investigative team arrived in Bikoro on May 5, about a month after the first suspected cases are likely to have emerged in Ikoko Impenge. A logistics team arrived on May 9, and the United Nations began daily flights carrying supplies and personnel between Kinshasa and Mbandaka on May 13. 
Tedros Adhanom Ghebreyesus, the WHO’s director general, visited Bikoro on May 13, in part to show the urgency of the situation.
“A major lesson learnt from the West Africa Ebola outbreak was that WHO needed a flexible fund to rapidly respond to outbreaks and emergencies,” Tarik Jasarevic, a WHO spokesman, said in an email from Geneva. The agency’s new Contingency Fund for Emergencies, already activated in Congo, has made cash available to responders far more quickly than in the West Africa case.
Still, some wonder why it took the Congolese Ministry of Health and the WHO a month to spot the virus in the first place.
“We are doing better at response, but not much better at rapid detection, which is important,” said Tom Frieden, a former CDC director who now runs the public health organization Resolve to Save Lives. “This was spreading for a while before [it was] recognized.”
Aiding the response further is a new vaccine, finalized in the last days of the West Africa outbreak. About 4,000 doses of the vaccine are headed to the epicenter of the new outbreak, where they will be used in two ways: First, health-care workers, those most vulnerable to exposure, will be vaccinated. Then, those who have come into contact with anyone infected, and the contact’s contacts, will be vaccinated, a practice known as ring vaccination.
“That part should really add another arm to the response. It's not the response by itself, because you still have to do all the rest,” Rollin said.
Congo is also far more prepared to respond to an Ebola outbreak because the virus is known to be endemic to the region. The first modern outbreak of the Ebola virus occurred in the village of Yambuku, about 370 miles from the site of the present one, back in 1976.






The Ebola superhighway: Why the new outbreak terrifies public health authorities | TheHill

Wednesday, May 16, 2018

Diabetic Education and Prevention by telehealth (smartphone or computer) at home or work

Over 80 million Americans have pre-diabetes

The risk factors for pre-diabetes

1. Male
2. Family history of diabetes
3. High blood pressure
4. Inactive
5. Age.  Increased as you age
6. Weight

Now, according to your score (which you can determine in the video in this article) if your total score is over five it is likely you are pre-diabetic.


This educational program is available online. Discuss this with your physician. Their are courses on weight management, nutrition, exercise and others, all in the comfort of your home or workplace. If you own a smartphone, the possibilities are unlimited. 


Ref: www.fruitstreet.com. 

Monday, May 14, 2018

Ebola outbreak: WHO preparing for 'worst-case scenario' - CNN



It's back,  and probably has never been gone. In the first real test of the new Ebola vaccine WHO is about to embark on a vaccination program in Africa, and the fate of our species may depend upon it's results.

Does that sound a bit histrionic?

You be the judge.

The World Health Organization is preparing for the "worst-case scenario" as it continues to respond to the Ebola outbreak in the Democratic Republic of Congo.
Peter Salama, deputy director-general of emergency preparedness and response at the WHO, said in Geneva, Switzerland, on Friday that it's "going to be tough and it's going to be costly to stamp out this outbreak."
There have been 34 cases of Ebola virus disease reported during the past five weeks, the WHO said Friday. Of those, two have been confirmed using laboratory tests, 14 are suspected, and 18 -- who are deceased -- are considered probable for the disease. Three of the patients are health care workers.
The number of suspected, probable and confirmed cases is significant, so we are very concerned, and we are planning for all scenarios, including the worst-case scenario," Salama said.

Ebola virus disease, which most commonly affects people and nonhuman primates such as monkeys, gorillas, and chimpanzees, is caused by one of five Ebola viruses. On average, about 50% of people who become ill with Ebola die.
The disease is endemic to the Democratic Republic of Congo, and this is the nation's ninth outbreak since the discovery of the virus in the country in 1976.
The latest outbreak is occurring in the Bikoro health zone, 400 kilometers (about 250 miles) from Mbandaka, the capital of Equateur province.

Bikoro health zone has a population of about 163,000, with three hospitals and 19 health centers, most with limited functionality, according to the WHO.
Given the remote location of the outbreak, Salama said, response efforts will be extremely challenging. "It is a dire scene in terms of infrastructure," he said.
"To give you a sense, we are talking about an area that is 280 kilometers even from the provincial capital of Equateur," he said.
The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission, either through direct contact with bodily fluids such as blood or secretions or contact with materials that are contaminated with these liquids.
Personal protective equipment, body bags, boxes for transportation and interagency emergency health kits will all be sent to the affected region Saturday, the WHO said. Two mobile laboratories will also be deployed.
Médecins Sans Frontières is setting up four five-bed mobile isolation units to increase the hospital bed capacity in Bikoro, which is currently 15 beds, according to the WHO.
Initial control efforts are focusing on tools such as surveillance and monitoring, safe burials and case management.
Vaccines along with doctors and epidemiologists are on standby in case they are needed, according to the UN.
 
If they are needed, "WHO is in discussions with the government and, if pertinent, will seek approval from the national regulatory authority and the Ethics Review committee to use vaccines against Ebola as part of the response," spokesman Tarik Jasarevik said.
The current vaccine against Ebola is experimental and not a licensed product. Salama pointed out that its use also comes with many challenges, as the vaccine needs to be stored long-term at temperatures between minus 60 and minus 80 degrees Celsius (minus 76 to minus 112 Fahrenheit).
"This is not a simple logistical effort; it's not like doing a polio campaign with oral polio vaccines, where we get it immediately out to the field. This is a highly complex sophisticated operation in one of the most difficult terrains on Earth," Salama said.

West Africa experienced the largest recorded outbreak of Ebola over a two-year period beginning in March 2014; a total of 28,616 confirmed, probable and suspected cases were reported in Guinea, Liberia and Sierra Leone, with 11,310 deaths, according to the WHO.



Ebola outbreak: WHO preparing for 'worst-case scenario' - CNN

Sunday, May 13, 2018

Comfort in my final hours

My name is Lucy.
I have stage IV liver cancer. I wanted everything done — even though the doctors told me this disease is terminal. My family, my church and my friends were praying for “the cure.”
Though I believed in God and the hereafter, I wasn’t ready to go. 74-years-old with beautiful children, grandchildren, and a great-granddaughter.
I woke up confused. In the background — wherever I was — I could hear music: “How great thou art.” One of my favorites.
I had a tube in my mouth, and I couldn’t talk. My wrists were restrained, and I couldn’t move. They had me tied down. Everything was blurry. My chest hurt like someone had pounded on it. People in white coats and scrubs surrounded me. I became aware that I was in a room with doctors and nurses and respiratory therapists.
A man introduced himself. He said he was a respiratory therapist, and he was going to pull the “tube” out of my mouth. The endotracheal tube. I gasped and took a deep breath, and I could barely talk.
The team explained to me that I was in the ICU. And because I wanted everything done to me, I had been emergently intubated, restrained, pain and sedation meds given through my veins continuously. My heart decided to stop, and “the team” did CPR on my fragile body. Because by now, I didn’t want to eat. I had lost over 25 pounds from the liver cancer.
I was told that some of my ribs cracked during CPR. I had pneumonia.
A palliative nurse came to talk to me within a few days. I wasn’t out of the jungle yet.
The palliative nurse talked to me about comfort, about acceptance, about peace and being pain-free and being with my family and friends surrounding me.
The palliative nurse talked to me about comfort, about acceptance, about peace and being pain-free and being with my family and friends surrounding me.
Comfort care. DNR, DNI.
New words for me.
I was so sick, so tired, so much in pain. I led a wonderful life.
Now, it was time for acceptance.
I remember those words from my doctors: terminal, no cure, palliative chemo … extending your life.
But at what cost?
Was it worth staying in an ICU in a comatose state? Was it worth having your chest beaten on with CPR and cracked ribs and pneumonia set in? Was it worth being tied down?
I knew the answers.
I was always stubborn. But maybe it was time for acceptance.
Maybe the prayers being sent my way were meant for a peaceful death. A peaceful entrance into the heavens.
I called my family in with my physician, my nurse, and the palliative care nurse.
New words for me.
I was so sick, so tired, so much in pain. I led a wonderful life.
Now, it was time for acceptance.
I remember those words from my doctors: terminal, no cure, palliative chemo … extending your life.
But at what cost?
Was it worth staying in an ICU in a comatose state? Was it worth having your chest beaten on with CPR and cracked ribs and pneumonia set in? Was it worth being tied down?
I knew the answers.
I was always stubborn. But maybe it was time for acceptance.
Maybe the prayers being sent my way were meant for a peaceful death. A peaceful entrance into the heavens.
I called my family in with my physician, my nurse, and the palliative care nurse.
I begged my family to please not put me on a ventilator again.
Please let me be comfortable.
Please make me comfort care.
DNR and do not intubate and do not treat.
I slept quietly going in and out of consciousness. My sons and daughters gathered around. They laughed and cried and told many fun stories of when they were young! My grandchildren and great-granddaughter held hands as they sang “Yes, Jesus Loves Me.”

Another favorite of mine.
And their tiny voices uplifted me and my soul.
I was surrounded by love.
This time — I was ready.
Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.




Comfort in my final hours

Wednesday, May 9, 2018

Where Does the Law Against Kickbacks Not Apply? Your Hospital - WSJ

Hospitals enjoy safe harbor regulations regarding purchasing supplies.  It works against the patient.


Doctors have long struggled to care for patients amid artificial shortages of, and soaring prices for, hundreds of drugs—notably generic sterile injectable products, including saline, epinephrine, chemotherapeutic agents, anesthetics, painkillers, antibiotics, even sterilized water.
So when Amazon Business signaled last year that it planned to infuse competition into the marketplace for hospital supplies, clinicians were optimistic that scarce items would soon reappear. Wrong. Mighty Amazon has now backed away from the market. CNBC, which reported the news in April, attributed the decision partly to the barrier posed by hospitals’ tight relationships with group purchasing organizations, or GPOs.
Amazon achieved its remarkable success by building a sophisticated e-commerce platform that promotes competition, transparency and low prices. In contrast, the GPO industry, which supplies doctors with hundreds of billions in medical products each year, rests on myriad conflicts of interest. The result is not only shortages but higher prices.
Four giant GPOs—Vizient, Premier Inc., HealthTrust, and Intalere—control purchasing for most of the supplies used by thousands of hospitals, outpatient clinics and nursing homes. These buying cartels literally sell a market share, taking money from drugmakers and other vendors in exchange for exclusionary supply contracts.
The paradox is that buying groups were promoted as a means to reduce cost for hospitals by ordering large amounts at reduced costs.  It totally eliminates smaller suppliers.
Hospitals sometimes even get a cut of the GPOs’ fees. The industry is very secretive, but when Premier was considering an initial public offering in 2013, Thomas Finn, an analyst at HCMatters.com, explained: “As a member-driven enterprise, it is common knowledge that Premier and other GPOs ‘share back’ with their members and owners. In fact, many hospital executives who are part of the Premier alliance have learned to rely on that share back as an integral part of their annual compensation.”
In turn, GPOs primarily use three big “authorized distributors”: McKesson, AmerisourceBergen and Cardinal Health. The supply chain is set up so that only authorized distributors, which pay fees to the GPOs, are entitled to manufacturers’ rebates for products covered by the contracts. Since smaller wholesalers can’t get the rebates, they’re effectively frozen out.
The results of this anticompetitive system are higher costs and inevitable supply breakdowns. For example, the GPOs would have the public believe that Hurricane Maria triggered shortages of sterile IV solutions by damaging Baxter International ’s Puerto Rican plants. In fact, shortages of saline and other solutions have existed for years, forcing the U.S. to import them from several countries. The deeper reason is that GPOs have relied almost exclusively on Baxter for these products, concentrating production and discouraging potential competitors. Although information on contract terms is confidential, a Baxter press release touting a 2007 deal with Novation (now Vizient) describes the terms as “an extended single source award for IV solutions.”
GPOs didn’t always operate this way. The first was founded in 1910 when several New York City hospitals banded together to buy supplies in bulk. Members paid dues to cover administrative expenses. This nonprofit “co-op” model worked for decades. What perverted the system was a rule that began to allow cash to flow from manufacturers to the GPOs. In the mid-1980s, Congress gave GPOs a “safe harbor” by exempting them from the laws against taking kickbacks from suppliers.
A 2010 report by the Senate Finance Committee found no independent empirical evidence that GPOs save hospitals money. In 2002, however, the Government Accountability Office studied purchases of safety needles and pacemakers in one metropolitan area and found hospitals that negotiated on their own often obtained lower prices. Our estimate, based on accumulated evidence including interviews with former GPO contracting officers, is that the current system may inflate costs by 30% or more. Still, most administrators are enculturated to the GPO system, and the web of rebates and fees helps keep it in place.
Making matters worse, in 2003 the Department of Health and Human Services advised drug makers that the safe harbor would protect rebates paid to pharmacy benefit managers. This has created an upward spiral in the cost of drugs sold through these middlemen, as drugmakers compete for placement on PBM formularies by offering ever-larger rebates.
Without Amazon, the best hope for ending this travesty remains congressional repeal of the safe harbor. 
If Washington is truly interested in lowering medical costs, here’s a straightforward idea: cancel the safe harbor and force the middlemen feeding at the health-care trough to compete on the merits.
Mr. Zweig, a former Journal reporter, is executive director of Physicians Against Drug Shortages (PADS). Dr. Blum is an associate professor at the West Virginia University School of Medicine, a past president of the American College of Emergency Physicians, and a co-chair of PADS.

Write your congressman.










Where Does the Law Against Kickbacks Not Apply? Your Hospital - WSJ

Monday, May 7, 2018

Do you use . "Patients like Me?" for your Chronic Illness? “Generalized Platform” for Members with Chronic Illness: Web-Based Survey Study of Benefits Arising | Wicks | Journal of Medical Internet Research

Many of my readers may have not heard of  "Patients like me " a web site for patients with chronic illnesses. 


ABSTRACT

Background: Launched in 2006 for patients with amyotrophic lateral sclerosis, PatientsLikeMe is an online community offering patient-reported outcomes, symptom tracking, and social features. Every member of the site can see all the data reported by every other member, view aggregated reports, identify “patients like them,” and learn about treatment options in order to live better with their condition. In previous studies, members reported benefits such as improved condition knowledge, increased medication adherence, and better management of side effects. However, the site evolved in 2011 from condition-specific “vertical” communities consisting only of people with the same disease to a “generalized platform,” in which every patient could connect with every other patient regardless of condition and with generic, rather than condition-specific, data tools. Some, but not all, communities received further custom tracking tools.
Objective: We aimed to understand (1) whether members of PatientsLikeMe using the generalized platform still reported similar benefits and (2) assess factors associated with benefits, such as community customization, site use, and patient activation.
Methods: A cross-sectional retrospective custom survey was fielded to 377,625 members between 2016 and 2017 including the Patient Activation Measure (PAM). A benefit index was developed for comparability across conditions.
Results: The invitation was viewed by 26,048 members of whom 11,915 did not respond, 5091 opted out, 1591 provided partial data, and 17 were screened out. Complete responses were received from 7434 participants. Users perceived greatest benefit in understanding how their condition may affect them (4530/6770, 66.91% participants, excluding “does not apply” answers), understanding what might help them live better with their condition (4247/6750, 62.92%), which treatments were available (4143/6898, 60.06%), understanding treatment side effects (4182/6902, 60.59%), and important factors in making treatment decisions (3919/6813, 57.52%). The benefit index was 29% higher for the “most activated” patients (PAM level 4 vs PAM level 1; relative risk [RR]=1.29, P<.001), 21% higher for conditions with some community customization versus none (RR=1.21, P<.001), and 11% higher in those using the site most often versus least (RR=1.11, P<.001).
Conclusions: Members of the generalized platform reported a range of benefits related to improved knowledge and understanding of their condition and treatment management. Condition-specific customization may improve their experience still further. Future studies will explore longitudinal changes to patient activation.

All of this has evolved into a general platform, 

J Med Internet Res 2018;20(5):e175

doi:10.2196/jmir.9909




JMIR-Scaling PatientsLikeMe via a “Generalized Platform” for Members with Chronic Illness: Web-Based Survey Study of Benefits Arising | Wicks | Journal of Medical Internet Research

Tuesday, May 1, 2018

Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network

Choosing Wisely, a campaign to stimulate conversations between physicians and patients about unnecessary tests, treatments, and procedures, began in the United States in 2012. It was designed as a national campaign about overuse. Yet since its launch, the campaign has spread to more than 20 countries worldwide. Choosing Wisely has been hailed by some as a success, evident in its spread internationally and measured through structure and process indicators, such as recommendations developed, societies engaged, and physicians apprised. The conversation has been stimulated, and now delivery systems and clinical practices are beginning to develop interventions that go beyond conversations and recommendations. The success of the campaign in the next 5 years will be measured by the ongoing engagement of physicians in these interventions and, more importantly, associated outcomes. The effectiveness of quality improvement efforts by these delivery systems will determine how influential campaigns are in actually reducing unnecessary tests and treatments—a true measure of benefit.1

Choosing Wisely will also contribute to controlling rising health expenditures by engaging patients, and making them aware of the conflict between expense and proper diagnosis and treatment.  The issue of cost control thus far has been an upward-down plan.  Choosing Wisely now will create a downward-up path, and enable patients to help control costs.

The age of data analytics which has been empowered by health information technology has created an enormous mountain of health care, diagnoses, and treatment, making it possible to create treatments based upon risk and good outcomes along with the quality of care.  

Alignment With Norms and Values

Innovations that are compatible with norms and values of adopters are more likely to be successful. Choosing Wisely focuses on conversations between physicians and patients, the basis of clinical interactions. A concern in advancing campaigns is maintaining the focus on professionalism and ensuring physician autonomy in making decisions with patients.

The concepts of diffusion of innovation are relevant to understanding the success to date of Choosing Wisely campaigns and to informing strategies that would ensure future viability. This Viewpoint uses diffusion of innovation science to explore factors that facilitated the spread of Choosing Wisely campaigns and how these enabling factors can address challenges in dissemination and implementation.
There are various examples of movements to shift medical culture that had early momentum and resulted in significant changes but were met with major challenges around influence and outcomes. Nearly 2 decades ago, the quality and safety movement galvanized the medical community worldwide by identifying the extent to which preventable errors and lapses in safety were occurring. 
Contextual Factors That Influence Diffusion
Although there are concerns about government motivations, to date Choosing Wisely campaigns have aligned diverse groups of stakeholders in medicine and health care systems (such as patient organizations, national clinician societies, and health administrators) on shared goals. Health care reform in the United States and elsewhere—emphasizing payment reform and shifting from volume to value—has made the campaign even more relevant. In other single-payer health care systems, budgetary pressures provide similar impetus. As organizations continue to react to such changes and shape strategy, Choosing Wisely offers an approach that could align physician, patient, and payer interests.
In many countries, health system leaders and managers are partnering with physicians on implementation strategies of campaign recommendations. Although the evidence base for Choosing Wisely is still modest, there is a growing literature demonstrating reductions in utilization through implementation. For example, in Canada and the United States, pilot projects that include well-thought-out interventions to implement recommendations have returned good preliminary results.7 Ultimately, the key to sustained uptake of Choosing Wisely will be more systematic collection and diffusion of this kind of evidence at the system level.

AMA. Published online April 19, 2018. doi:10.1001/jama.2018.2202



Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network