This Drive to Five Won’t Survive?

By  |  June 5, 2011 | 

Approximately one year ago, the Public Policy Committee briefly discussed the benefit of assembling a top five list of “avoidable” interventions, physician ordered, that were of marginal value.  The goal was to enlighten SHM members as to how we as a society could contribute to improving hospital efficiency, and perhaps patient outcomes. It is the “doing our part” thing.

At the time, an ER doc had published a list that identifies the same, mainly interventions ER physicians should defer due to their, shall we say, wayward nature.  The fact I cannot recall the tests, or the citation may be indicative of that effort; well intentioned, but lacking heft.  It is the purpose behind this post.

With great fanfare, two recent publications received similarly distinguished attention, one from the Archives of Internal Medicine, and the other from NEJM.  They both expounded upon the need for doctors to identify tests or treatments and scale back—for obvious reasons.  Whether any effort in this vein is effective, and I am doubtful, is a meritable discussion.  However, the two, which the medical press reported correspondingly (and equally) in their behavior changing promise, are vastly different.  So much so, that to categorize them both as an actionable “call to arms” is doing one piece a disservice.

Here are clipped recommendations from each:

Archive of Internal Medicine

New England Journal of Medicine

  • Are they different?
  • Which one would you distribute to trainees for implementation?
  • Which is likely to leave clinicians with a sense of ambiguity?
  • Is one likelier to lead to organizational antibody production or promotional incontinence?

You probably guessed that the specificity of the IM over the oncologic recommendations are more accessible and likelier to produce change.  I am not dismissive of the NEJM citation however; it is just the “broadness” of the appeal, and its “where do I go with this” character, that convinces me that this list will wilt in the sometimes vainglorious pile of past distinguished explorations (at 2000+ currently).

If you were to envision a hospitalist to do list, compare A & B, and C & D:

A. When non-indicated, avoid gut prophylaxis on the general medical wards

B. Do not order PPI or H2 blockers unless a non-ventilated patient has GERD, PUD, end organ failure, or a coagulopathy.  Hard stop.

C. Avoid unnecessary indwelling urinary catheter use.

D. Unless urinary retention, skin breakdown, palliative comfort, or need for urinary output measurement for <24 hours present, indwelling catheter use is potentially harmful and not recommended. Hard stop.

This is an illustrative example, not perfect, but meant to exemplify what may or may not facilitate alteration in behaviors.  It will take work to construct directives like those published in the Archives to initiate a coherent effort—but not impossible.

Overall, however, I am not optimistic that pains like these will result in transformation.  On one hand, physicians have had years to mull over guidelines, but to no avail.

CER and IPAB like bodies (? with teeth) hold promise, and unless professional societies make hay, and pronto, docs will continue to brandish a less than stellar reputation in the change agent department.

Our Call!


Our Call?


BONUS #1:  There are chocolate people.  There are vanilla people.  There are dog people, and there are cat people.

It is 4PM on Friday.  You watch your hospitalist colleague who is on call that weekend greet an innocent clerk leaving on the elevator.  The clerk says, “have a great weekend!”  The hospitalist responds preeminently, “oh, I am on call this weekend, I will be here!”  Or, conversely, the hospitalist says, “thanks.”

Which one are you?

BONUS #2: Anyone who knows me, knows that this, for me, is treif. Reboot.  Let me tell you, I had an epiphany this weekend, and heroin has nothing on this stuff.  Number one in NYC.  Go there.  You will hate me for it.



  1. Bill Rifkin June 8, 2011 at 9:40 pm - Reply

    I think we are comparing apples and oranges. The top 5 concept comes from Brody, H, NEJM, N Engl J Med 2010; 362:283-285 which suggests each specialty identify “five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” Note it is not reducing practices that have zero benefit, but also low yield to cost. The NEJM cancer article takes this task on for oncology. It deals with some very expensive items, and mostly evidence based. The Archives article (using the IM group as the example) is simply a poll of some docs as to which of the obvious/easy EBM based items are most important. Do we really need a group discussion to say we should use generic statins? This is not “cutting edge” or asking for a shift in priorities/thinking, just asking to not be ignorant. Ditto the others. They are not controversial or frankly, very expensive. Who needs to be told not to order annual ECGs as “screening”? Whomever is doing this has a lot more to learn than a top five. Frankly, the list makes IM look shabby. These are the hot button issues? How about an IM list of: 1. don’t refer stable angina patients for PCI, treat them medically 2. don’t perform PSA testing (or document a very intensive informed consent process), 3., Stop referring for mammograms and pap smears when life expectancy is below median 4. Get your HTN patients to goal, 5. Reduce the percentage of COPD, CHF, CAD, DM patients you refer to specialists.
    As to how to get docs to comply? Follow the money. I agree publishing guidelines and order sets etc has not worked. When they have more skin in the game, perhaps some change will happen. For example, in a large group or ACO, the hand wringing over the cardiologist who stents too much or etc will mean their money not Medicare’s. Instead of calls from the Medical Director of a hospital re: your LOS 2.5 SD above the mean, you will get the call from your practice Medical Director saying change or leave. Maybe.

  2. Brad Flansbaum
    Brad Flansbaum June 8, 2011 at 10:07 pm - Reply

    Your suggested five are good, but similarly, resemble those in the citation, insofar as they are prescriptive, directed interventions.

    We can disagree on the “shabbiness” of the choices from the Archives text. They are nonetheless implementable, first step strategies–that provide value if adopted.

    Pondering your response, I wonder how we would have received Pronovost’s checklist (his successful central line bundle) several years ago, before its notoriety and proven success. Overly simple, clunky and difficult, or a step in the right direction–but the results speak for themselves, and resolutely.

    If a sensible “list” saves costs, is easily implemented, and reduces needless morbidity (or mortality), I see little downside. The fact it was developed through surveying physicians for me, is immaterial.

    We can disagree of course, and would not be the first time. 🙂

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About the Author: Brad Flansbaum

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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