Download Choosing Wisely - The Annals of Thoracic Surgery

SPECIAL REPORT
Choosing Wisely: Cardiothoracic Surgeons
Partnering With Patients to Make Good Health
Care Decisions
Douglas E. Wood, MD, John D. Mitchell, MD, DeLaine S. Schmitz, RN, MSHL,
Sean C. Grondin, MD, MPH, John S. Ikonomidis, MD, PhD, Faisal G. Bakaeen, MD,
Robert E. Merritt, MD, Dan M. Meyer, MD, Susan D. Moffatt-Bruce, MD, PhD,
T. Brett Reece, MD, and Michael A. Smith, MD
University of Washington, Seattle, Washington (DEW); University of Colorado Denver School of Medicine, Aurora, Colorado
(JDM, TBR); The Society of Thoracic Surgeons, Chicago, Illinois (DSS); Foothills Medical Centre, Calgary, Alberta, Canada (SCG);
Medical University of South Carolina, Charleston, South Carolina (JSI); Baylor College of Medicine, Houston, Texas (FGB); Falk
Cardiovascular Research Center, Stanford, California (REM); University of Texas Southwestern, Dallas, Texas (DMM); Ohio State
Medical Center, Columbus, Ohio (SDM); St. Joseph’s Hospital and Medical Center, Phoenix, Arizona (MAS)
C
REPORT
hoosing Wisely is an initiative focused on helping
physicians to be better stewards of finite health care
resources and encouraging physicians and patients to
discuss appropriate medical decision making. The principles focus on the imperative of helping physicians and
other stakeholders make wise, evidence-based decisions
that simultaneously promote high-quality care, and also
assure sustainability of the health care system. Patients
are engaged in partnership with Consumer Reports, who
have promoted Choosing Wisely as “educating consumers about appropriate care.” Variability in health care
and a quest for safety and value have highlighted the
perils associated with overuse or misuse of procedures
and tests, and an appreciation of the unintended consequences of patient harm and increased costs.
The initiative originated from a physician charter on
medical professionalism published in 2002 and subsequently endorsed by more than 130 medical professional
societies that articulates commitment to improving access to high-quality health care, and advocates for a just
and cost-effective management of finite health care resources [1]. The Promoting Good Stewardship in Medicine project piloted by the National Physicians Alliance
was funded in 2009 by the American Board of Internal
Medicine (ABIM) Foundation’s “Putting the Charter into
Practice” grant. The initial project resulted in three lists
of five specific steps that physicians in internal medicine,
family medicine, and pediatrics could utilize in their
practice to encourage effective use of health care resources [2]. This original campaign evolved into the
multiple-year Choosing Wisely initiative in which the
ABIM Foundation reached out to specialty societies to
identify a list of five tests or procedures that may be
overused or misused.
Criteria for developing a Choosing Wisely list were as
follows: (1) limited to items that fall within the purview of
the specialty; (2) supported by evidence; (3) thoroughly
Address correspondence to Dr Wood, Division of Cardiothoracic Surgery,
University of Washington, Box 356310, 1959 NE Pacific, AA-115, Seattle,
WA 98195-6310; e-mail: [email protected].
© 2013 by The Society of Thoracic Surgeons
Published by Elsevier Inc
documented and publicly available upon request; (4)
frequently ordered/costly; (5) easy for a lay person to
understand; and (6) measurable/actionable.
The first release of the Choosing Wisely initiative took
place in April 2012 when nine specialty society lists were
released. Recommendations were disseminated to physicians and consumers through a collaborative effort
between the ABIM Foundation and Consumer Reports.
There was a uniformly favorable public response, with
the physician groups praised for their professionalism
and proactive efforts to improve utilization of health care
resources while empowering a dialogue between patients and physicians regarding appropriateness of many
commonly performed tests and procedures. Sixteen additional specialty societies, including The Society of Thoracic Surgeons (STS), are participating in the February
2013 phase II release, and several other specialty groups
are slated for a release later in 2013. Participation in
Choosing Wisely is a proactive and responsible initiative
to improve the physician-patient dialogue, enhance patient safety, and to be accountable for the use of health
care resources.
Creation of STS Choosing Wisely List
In May 2012, STS Executive Committee agreed to participate in phase II of the Choosing Wisely initiative and
appointed Douglas E. Wood, MD, as first vice president,
to lead the project. The list selection process involved
input from several workforces, including the Workforce
on Adult Cardiac and Vascular Surgery, Workforce on
General Thoracic Surgery, and Workforce on EvidenceBased Surgery.
Selection of Draft Recommendation
Initial conference calls with the chairs of the Workforce
on Adult Cardiac and Vascular Surgery, Workforce on
General Thoracic Surgery, and Workforce on EvidenceBased Surgery provided each chair with an overview of
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http://dx.doi.org/10.1016/j.athoracsur.2013.01.008
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WOOD ET AL
CHOOSING WISELY FOR GOOD HEALTH CARE DECISIONS
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Table 1. Possible Misused/Overused Cardiothoracic Tests/Procedures: Seventeen Initial Candidates for Consideration Provided
by STS Workforces
Workforce on Adult Cardiac and Vascular Surgery
2. No need for pulmonary function tests if no
respiratory symptoms, able to climb 3 flights of stairs
3. No need for unstable angina unless symptoms
4. No need for daily laboratory draws in hospital unless
purpose driven
5. No need for chest roentgenogram unless purpose
driven
6. No need for discharge echocardiography on valve
patients
7. No need for discharge computed tomography scan on
aortic surgery patients
1. Patients with suspected or biopsy proven stage I non-small cell
lung cancer who are asymptomatic do not require brain imaging
before definitive care
2. Patients who have no cardiac history do not require preoperative
stress testing before noncardiac thoracic surgery
3. Chest computed tomography scans for screening and follow-up
of solitary pulmonary nodules should be performed at intervals
as determined by the Fleisher guidelines
4. Comprehensive metabolic panels are not indicated for routine
preoperative screening in otherwise healthy patients preparing
for noncardiac thoracic surgery
5. Patients with localized esophageal cancer who are asymptomatic
do not require bone scan imaging before definitive care
6. A statement about the frequency of postoperative lung cancer
follow-up, namely, every 3 to 4 months or every 6 months?
7. Echocardiography to estimate pulmonary hypertension in lung
volume reduction surgery and other high-risk lung surgeries is
inaccurate and of little practical use
8. Pulmonary function testing in low-risk patients going for wedge
(ie, solitary lung metastasis) is unnecessary
9. Routine frozen section of bronchial margins for peripheral lung
cancers is unnecessary
10. For routine pulmonary resections for cancer, antibiotic
prophylaxis does not need to continue until all chest tubes are
removed
the Choosing Wisely initiative, the criteria for list selection provided by the ABIM Foundation, and the project
time line. The Workforce on Adult Cardiac and Vascular
Surgery and Workforce on General Thoracic Surgery
were assigned to work with their respective workforce to
identify five to 10 overused or misused procedures or
tests in the areas of adult cardiac and general thoracic
surgery.
Seventeen candidates for consideration were provided
by the two workforces (Table 1).
Based on the criteria outlined by the ABIM Foundation,
the workforce chairs and Dr Wood narrowed the list from
17 recommendations to eight, which were subsequently
approved by STS leadership to undergo further vetting
by a membership survey, as well as evaluation of the
evidence by the Workforce on Evidence-Based Surgery
(Table 2).
Vetting the Draft Recommendations
Member Survey
The US STS membership was informed of the Choosing
Wisely initiative on July 10, 2012, by STS Weekly, an
e-communication designed to alert members to important deadlines, announcements, and other timely information. The announcement included a link to an online
survey inviting participants to review the Choosing
Wisely criteria provided by the ABIM Foundation and
indicate their level of agreement with the eight draft
recommendations. The Zoomerang survey utilized a fivepoint scale ranging from strongly agree to strongly dis-
agree. Members who did not agree with a draft recommendation were encouraged to provide a rationale and a
peer-reviewed reference to support their position. Seventy-five percent to 90% of respondents either agreed or
strongly agreed to six of the eight draft recommendaTable 2. Eight Recommendations of Cardiothoracic Tests/
Procedures Approved to Undergo Further Vetting by STS
Membership Survey and Evaluation by STS Workforce on
Evidence-Based Surgery
1. Patients who have no cardiac history do not require
preoperative stress testing before noncardiac thoracic
surgery
2. Before cardiac surgery, there is no need for pulmonary
function testing in the absence of respiratory symptoms
3. Before cardiac surgery, there is no need for a routine
carotid workup in the absence of symptoms
4. Patients with suspected or biopsy proven stage I NSCLC do
not require brain imaging before definitive care in the
absence of neurologic symptoms
5. Prophylactic antibiotics should not be continued beyond 24
hours postoperatively after thoracic surgery, or beyond 48
hours after cardiac surgery
6. Chest computed tomography scans for follow-up of solitary
pulmonary nodules should not be performed more
frequently than intervals recommended by Fleisher
guidelines.
7. A predischarge echocardiogram is not needed after cardiac
valve replacement surgery
8. It is not necessary to obtain daily chest roentgenograms and
blood laboratory tests after cardiothoracic surgery in the
absence of clinical indications
REPORT
1. No need for carotid ultrasonography unless left main
disease, symptoms or carotid bruits
Workforce on General Thoracic Surgery
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WOOD ET AL
CHOOSING WISELY FOR GOOD HEALTH CARE DECISIONS
tions. The other two draft recommendations received less
member support, with 50% and 54% of respondents
either agreeing or strongly agreeing.
Evidence Review
Each of the eight recommendations was assigned to a
member of the Workforce on Evidence-Based Surgery
with instructions to conduct a systematic search of the
literature using Ovid MEDLINE, CINAHL, and the Cochrane Library with the help of a university librarian.
Based on the literature search findings, the Workforce
members were asked to draft evidentiary statements
utilizing the template provided by the ABIM. Six of the
eight draft recommendations were considered to be supported by the scientific evidence, whereas two recommendations were not.
Selection of the Final Five Recommendations
On August 15, 2012, Dr Wood presented the evidentiary
statements for each of the eight recommendations to STS
Executive Committee by conference call. The Executive
Committee discussed the list in detail and rejected the
two recommendations that lacked supporting evidence.
An additional recommendation was rejected because it
was already a PQRS performance measure; therefore, it
was less likely to have an impact than one of the other
recommendations. The Executive Committee approved
the remaining five recommendations, thereby finalizing
the Society’s Choosing Wisely list.
(1) Patients Who Have No Cardiac History and
Good Functional Status Do Not Require
Preoperative Stress Testing Before Noncardiac
Thoracic Surgery
●
REPORT
●
Functional status has been shown to be reliable
for prediction of perioperative and long-term cardiac events. In highly functional asymptomatic
patients, management is rarely changed by preoperative stress testing. It is, therefore, appropriate to proceed with the planned surgery without
it.
Preoperative stress testing should be reserved
for patients with low functional capacity or
clinical risk factors for cardiac complications
such as history of ischemic heart disease, heart
failure, cerebrovascular disease, diabetes mellitus, and chronic renal insufficiency, and patients
needing pneumonectomy.
Unnecessary stress testing in patients with low risk for
cardiac complications can be harmful because it increases the cost of care and delays treatment without
altering surgical or perioperative management in a
meaningful way. Furthermore, low-risk patients who
undergo preoperative stress testing are more likely to
receive beta-blockers, which can have unnecessary and
deleterious effects in low-risk patients.
Cardiac complications are indeed significant contributors to morbidity and mortality after noncardiac thoracic
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surgery, and it is important to identify patients preoperatively who are at risk for these complications. The most
valuable tools in this endeavor include a thorough history, physical examination, and resting electrocardiogram. Cardiac stress testing can be an important adjunct
in this evaluation, but it should be used only when
clinically indicated.
Sources
1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/
AHA 2007 guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines (writing committee to revise
the 2002 guidelines on perioperative cardiovascular
evaluation for non-cardiac surgery). Circulation
2007;116:e418-99.
2. Poldermans D, Bax JJ, Boersma E, et al. Guidelines
for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk
Assessment and Perioperative Cardiac Management in Non-Cardiac Surgery of the European
Society of Cardiology. Eur Heart J 2009;30:2769-812.
3. Brunelli A, Varela G, MD, Salati M, et al. Recalibration of the revised cardiac risk index in lung resection candidates. Ann Thorac Surg 2010;90:199-203.
4. Wijeysundera DN, Beattie WS, Elliot RF, et al.
Non-invasive cardiac stress testing before elective
major non-cardiac surgery: population based cohort study. BMJ 2010;340:b5526.
(2) Do Not Initiate Routine Evaluation of Carotid
Artery Disease Before Cardiac Surgery in the
Absence of Symptoms or Other High-Risk
Criteria
●
●
●
●
●
Studies show that the presence of asymptomatic
carotid disease in patients undergoing cardiac
surgery does not import the clinical significance to
justify preoperative screening in more than the
subgroup of “high-risk” patients.
High-risk patients include those with history of
cerebrovascular accident or transient ischemic attack, left main coronary disease, peripheral vascular disease, hypertension, smoking, diabetes
mellitus, or age more than 65 years.
Data suggest the incidence of perioperative stroke
to be related more to the atherosclerotic burden
the patient may have rather than to the degree of
carotid artery stenosis.
The presence of increased severity of carotid
artery stenosis or the presence of a carotid bruit
does not equate to an increased risk of stroke after
cardiac surgery.
Intraoperative techniques of optimizing hemodynamics and minimizing aortic manipulation in
at-risk patients may have more effect on decreas-
ing the risk of stroke after cardiac surgery than the
use of preoperative carotid artery screening for
the majority of patients.
The ACC/AHA 2011 guidelines for coronary artery
bypass graft surgery recommended carotid artery screening to reduce neurologic complications in a subset of
higher risk patients. In addition, a recent consensus
report from the United Kingdom questioned whether
neurologic sequellae developing in cardiac surgery patients with asymptomatic carotid disease are due to the
carotid artery disease or rather act as a surrogate for an
increased stroke risk from atherosclerotic issues with the
aorta. Although the consensus panel acknowledged the
clinical importance of bilateral carotid disease (ⱖ70%
stenosis) in the setting of cardiac surgery, they found the
concept of routine screening to lack supporting data
regarding cost effectiveness. Instead, they recommended
targeting “high-risk” patients for preoperative carotid
artery evaluation.
In a series of more than 45,000 patients undergoing
coronary artery bypass graft surgery at the Cleveland
Clinic published in 2011, a 1.6% incidence of stroke was
observed, with the majority of strokes (58%) occurring
postoperatively. Risk factors for stroke identified included older age and variables suggesting a significant
atherosclerotic burden. The larger proportion of postoperative strokes point to issues other than carotid artery
stenosis as a causative factor for stroke.
A recent meta-analysis examining the issue of stroke
after cardiac surgery in the patients with asymptomatic
carotid disease found that patients with unilateral disease did not have increasing risk of stroke with increasing severity of the stenosis. Finally, even the presence of
a carotid bruit correlates poorly with the degree of
carotid stenosis. The Northern Manhattan Stroke Study
concluded that carotid duplex studies should be considered in high-risk asymptomatic patients, irrespective of
findings on auscultation [6].
Sources
1. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/
AHA guideline for coronary artery bypass graft
surgery. Circulation 2011;124:e652-735.
2. Stansby G, Macdonald S, Allison R, et al. Asymptomatic carotid disease and cardiac surgery consensus. Angiology 2011;62:457-60.
3. Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery
bypass grafting. JAMA 2011;305:381-90.
4. Naylor AR, Bown MJ. Stroke after cardiac surgery
and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41:607-24.
5. Cournot M, Boccalon H, Cambou JP, et al. Accuracy
of the screening physical examination to identify
subclinical atherosclerosis and peripheral arterial
disease in asymptomatic subjects. J Vasc Surg 2007;
46:1215-21.
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WOOD ET AL
CHOOSING WISELY FOR GOOD HEALTH CARE DECISIONS
1133
6. Ratchford EV, Jin Z, Di Tullio MR. Carotid bruit for
detection of hemodynamically significant carotid
stenosis: the Northern Manhattan Study. Neurol
Res 2009;31:748-52.
(3) Do Not Perform a Routine Predischarge
Echocardiogram After Cardiac Valve Replacement
Surgery
●
●
Predischarge cardiac echocardiography is useful
after cardiac valve repair. It provides information
regarding the integrity of the repair and allows
the opportunity for early identification of problems that may need to be addressed surgically
during the index hospitalization. Unlike valve
repair, there is lack of evidence that supports the
routine use of cardiac echocardiography predischarge after cardiac valve replacement.
Scenarios that would justify the use of predischarge cardiac echocardiography include inability
to perform intraoperative transesophageal echocardiography, clinical signs and symptoms worrisome for valvular malfunction or infection, or a
large pericardial effusion.
Although there are no studies specifically addressing
the timing of the initial postoperative evaluation of a
cardiac prosthetic valve for establishment of baseline
readings, existing guidelines recommend a postoperative
transthoracic echocardiographic study at the first visit, 2
to 4 weeks after hospital discharge. At that time, surgical
incisions are better healed, ventricular function has had
the opportunity to recover or improve, and anemia with
its attendant hemodynamic state has abated.
Sources
1. Zoghbi WA, Chambers JB, Dumesnil JG, et al.
Recommendations for evaluation of prosthetic
valves with echocardiography and doppler ultrasound: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves.
J Am Soc Echocardiogr 2009;22:975-1014.
2. Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA
2006 guidelines for the management of patients
with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing
committee to revise the 1998 guidelines for the
management of patients with valvular heart disease). Circulation 2006;114:e84-231.
3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008
Focused update incorporated into the ACC/AHA
2006 guidelines for the management of patients
with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing
committee to revise the 1998 guidelines for the
management of patients with valvular heart disease). Circulation 2008;118:e523-661.
REPORT
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4. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/
ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/
SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,
American Society of Echocardiography, American
Heart Association, American Society of Nuclear
Cardiology, Heart Failure Society of America,
Heart Rhythm Society, Society for Cardiovascular
Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular
Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2011;24:229-67.
(4) Patients With Suspected or Biopsy Proven
Stage I NSCLC Do Not Require Brain Imaging
Before Definitive Care in the Absence of
Neurologic Symptoms
REPORT
The brain is a frequent site of extrathoracic metastasis
associated with non-small cell lung cancer (NSCLC).
Some clinicians perform routine screening by brain
magnetic resonance imaging (MRI) or computed tomography (CT) scans to rule out occult brain metastasis in asymptomatic patients before surgical resection
of early stage lung cancer. The purported benefits of
early detection of intracranial brain metastases include
avoidance of a noncurative pulmonary resection and
early treatment of solitary brain metastasis. This practice of routine screening for occult brain metastases
has not been evaluated by a randomized clinical trial
and may not be cost effective.
In most studies, the diagnostic yield of CT scanning or
MRI of the brain in NSCLC patients (of varying stages)
with a negative neurologic examination is 0% to 10%.
Pooled data from retrospective studies that included a
comprehensive clinical evaluation demonstrated that
only 3% of patients who have a negative neurologic
evaluation present with intracranial metastasis. At least
one study, limited to stage I patients, reported a prevalence of 1.3%. The current published literature on routine
brain imaging with either MRI or CT scan is conflicting;
however, most reports do not support routine screening
for occult brain metastases. The joint statement of the
American Thoracic Society and the European Respiratory Society published in 1997 did not advocate preoperative imaging of the brain in patients with NSCLC who
present without neurologic symptoms. Toloza and colleagues determined that the estimated negative predictive value of clinical neurologic examination for the
evaluation of brain metastases was 94%; therefore, the
investigators concluded that routine imaging in asymptomatic NSCLC patients is not warranted. In addition,
the current National Comprehensive Cancer Network
(NCCN) NSCLC guidelines do not recommend preoperative brain imaging for asymptomatic patients with Stage
IA NSCLC.
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Sources
1. Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer.
ACCP evidence-based clinical practice guidelines
(2nd edition). Chest 2007;132(Suppl):178-201.
2. Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for
non-small-cell lung cancer with clinical stage T1-2
N0. Ann Thorac Surg 1999;68:1039-42.
3. American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small cell lung cancer. Am J Respir
Crit Care Med 1997;156:320-32.
4. Toloza EM, Harpole L, McCory DC. Noninvasive
staging of non-small cell lung cancer: a review of
the current evidence. Chest 2003;123(Suppl):137-46.
5. National Comprehensive Cancer Network. NCCN
clinical practice guidelines in oncology: non-small
cell lung cancer. Version 3.2011.Available at: www.
nccn.org/professionals/physician_gls/pdf/nscl.pdf.
6. Colice GL, Birkmeyer JD, Black WC, Littenberg B,
Silvestri G. Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of
metastases. Chest 1995;108:1264-71.
(5) Before Cardiac Surgery There Is No Need for
Pulmonary Function Testing in the Absence of
Respiratory Symptoms
Pulmonary function tests can be helpful in determining
risk in cardiac surgery, but patients who have no pulmonary disease are unlikely to benefit, and testing may not
be justified.
Symptoms attributed to cardiac disease that are respiratory should be better characterized with pulmonary
function tests, especially in patients prone to pulmonary
disease such as smokers and patients with strong family
or occupational history.
Risk models for cardiac surgery developed from
review of STS National Adult Cardiac Database incorporate a variable for chronic lung disease. The degree
of lung impairment (denoted as none, mild, moderate,
or severe) is a composite based on the patient’s forced
expiratory volume in 1 second (FEV1) impairment, use
of pharmacologic aids to control respiratory symptoms,
and pulmonary history. Only recently have actual FEV1
and diffusion capacity of lung for carbon monoxide
data been collected in the database. “None” is the
baseline for risk with chronic lung disease. In the
absence of respiratory symptoms or suggestive medical history, pulmonary function testing is quite unlikely to change patient management or assist in risk
assessment. Although some data are beginning to
emerge about preoperative pulmonary rehabilitation
before cardiac surgery for patients with even mild to
moderate obstructive disease, that does not directly
extrapolate to asymptomatic patients.
Sources
1. Shahian DM, O’Brien SM, Filardo G, et al. The
Society of Thoracic Surgeons 2008 cardiac surgery
risk models. Part 1— coronary artery bypass grafting surgery. Ann Thorac Surg 2009;88(Suppl):2-22.
2. O’Brien SM, Shahian DM, Filardo G, et al. The
Society of Thoracic Surgeons 2008 cardiac surgery
risk models. Part 2—isolated valve surgery. Ann
Thorac Surg 2009;88(Suppl):23-42.
3. Ried M, Unger P, Puehler T, Haneya A, Schmid C,
Diez C. Mild-to-moderate COPD as a risk factor for
increased 30-day mortality in cardiac surgery. Thorac Cardiovasc Surg 2010;58:387-91.
4. Adabag AS, Wassif HS, Rice K, et al. Preoperative
pulmonary function and mortality after cardiac
surgery. Am Heart J 2010;159:691-7.
Conclusions
STS has long been a leader in data-driven and patientcentered health care. That has been highlighted by clinical risk-adjusted databases, quality initiatives such as
ProvenCare Lung Cancer, and a long history of development of rigorous evidence-based guidelines to inform
clinical practice. Choosing Wisely allows STS to continue
that leadership alongside like-minded specialty societies
SPECIAL REPORT
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CHOOSING WISELY FOR GOOD HEALTH CARE DECISIONS
1135
to empower the physician-patient dialogue and to avoid
unnecessary procedures that may harm patients while
driving up health care costs. Responsible use of health
care resources is one of the key principles of professionalism that cardiothoracic surgeons and other physicians
advocate and adhere to. Patients need to know when to
say “whoa!” to doctors, and physicians need to be empowered to avoid tests or procedures that are not supported by evidence. If we have selected those procedures
correctly, a common response should be “but that is what
I do!”
That is the point. The goal is to challenge common
practice; practice that may be imbedded in tradition,
routine, or defensive medicine, yet does not have good
justification. The Choosing Wisely list is not meant to
be rigid or constraining, but is meant to educate both
surgeons and patients, and to empower the two together to make better decisions about their health care
choices.
References
1. Medical professionalism in the new millennium: a physician
charter. Ann Intern Med 2002;136:243– 6.
2. The Good Stewardship Working Group. The “top 5” lists in
primary care: meeting the responsibility of professionalism.
Arch Intern Med 2011;171:1385–90.
REPORT
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