Figure 1. “Top 5” activities in family medicine. AACE indicates American Association of Clinical Endocrinology4; ACOG, American College of Obstetrics and Gynecology5; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; Ann IM, Annals of Internal Medicine8; Cochrane, Cochrane Database of Systematic Reviews9; DEXA, dual energy x-ray absorptiometry; ECG, electrocardiogram; NOF, National Osteoporosis Foundation10; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.11
Figure 2. “Top 5” activities in internal medicine. AACE indicates American Association of Clinical Endocrinology4; ACOG, American College of Obstetrics and Gynecology5; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; Ann IM, Annals of Internal Medicine8; Cochrane, Cochrane Database of Systematic Reviews9; DEXA, dual energy x-ray absorptiometry; ECG, electrocardiogram; LDL, low-density lipoprotein; NOF, National Osteoporosis Foundation10; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.11 Lipitor is manufactured by Pfizer, New York, New York; Crestor, by AstraZeneca, Wilmington, Delaware.
Figure 3. “Top 5” activities in pediatrics. AAP/AAFP indicates the American Academy of Pediatrics/American Academy of Family Practice14; ACPM, American College of Preventive Medicine6; AHCPR, Agency for Healthcare Policy and Research7; CT, computed tomography; ED, emergency department; EE, Essential Evidence15; FDA, US Food and Drug Administration16; NAEPP, National Asthma Education and Prevention Program17; NICE, National Institute for Health and Clinical Excellence18; and OME, otitis media with effusion.
The “Top 5” Lists in Primary CareMeeting the Responsibility of Professionalism. Arch Intern Med. 2011;171(15):1385-1390. doi:10.1001/archinternmed.2011.231
Author Affiliations: All members of The Good Stewardship Working Group were authors.
Background Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled “Promoting Good Stewardship in Clinical Practice” that aimed to develop a list of the top 5 activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved.
Methods Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities. A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians.
Results The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities that could improve clinical care.
Conclusions Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities that could lead to higher quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the activities, the potential positive impact on medical care quality and cost, and the ease with which the activities could be performed. We recommend that these “Top 5” lists of activities be implemented in primary care practice across the United States.
In 2009, the American Board of Internal Medicine Foundation launched “Putting the Charter into Practice,” a program providing small grants to advance principles of professional commitment in medicine, in keeping with the Physician Charter,1 a document jointly issued in 2002 by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine. These principles include improving patients' access to high-quality care, practicing evidence-based care, advocating for just and cost-effective distribution of finite resources, and maintaining trust by minimizing conflicts of interest.
The National Physicians Alliance (NPA) was founded in 2005 and today represents 22 000 members across specialties and across the United States. The NPA's primary mission is to ensure affordable, high-quality health care for all; the organization is committed to building a sustained network of physician leaders dedicated to achieving this goal.
The NPA was awarded a grant by the American Board of Internal Medicine Foundation to develop and disseminate 5-activity lists of evidence-based, quality-improving, resource-sparing activities that could be incorporated into the practices of primary care providers in family medicine, internal medicine, and pediatrics. Each activity was to be well supported by evidence, have beneficial effects on patient health by improving treatment and/or reducing risks, and, where possible, reduce costs of care.
Simultaneously, an editorial on the medical ethics of health care reform by Howard Brody2 called on each medical specialty to generate top-5 lists of diagnostic tests or treatments that are commonly ordered but that offer limited benefits or carry risks that outweigh their benefits. Brody asserted that by focusing on the top 5 examples of the most egregious causes of waste in each specialty, the medical profession could demonstrate to a skeptical and concerned public that high-quality care and efficient use of resources are complementary.
To compile an evidence-based top-5 list that would improve quality of care in the context of limited resources, the NPA initiated a project entitled “Promoting Good Stewardship in Clinical Practice.”
The project began by assembling working groups in each of the 3 primary care specialties. An e-mail solicitation was sent to all NPA members, inviting participation by interested primary care physicians. The project director (S.R.S.) selected a chairperson and 4 other physicians for each working group from among the respondents to the e-mail solicitation. Selection took into account geographical, gender, and racial and/or ethnic diversity and yielded 15 members: 10 women, 2 Asian Americans, 1 African American, 1 Hispanic American, and 2 physicians from rural areas.
Each working group met in a series of teleconference calls to delineate the candidate top-5 activities. The groups agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits, reduce risks and harms to patients and communities, and reduce costs.
A modification of nominal group process was used to generate an initial list of top-5 activities.3 A shared Google document was used to generate the list and conduct the voting online in real time.
A research assistant reviewed the literature to find evidence supporting or refuting the candidate top-5 activities and reported this to the working groups. Working groups modified their candidate activities in response to these findings, and each group generated a preliminary list of top-5 activities for field testing.
Working group members were asked to recruit 3 to 5 physicians from their specialties to serve as initial field testers. Project goals were explained to the 83 initial testers, and each tester consented to participate. Each completed an online survey in which they rated candidate activities for their specialty on 5 parameters: (1) frequency with which they engaged in this activity in their practice; (2) the potential impact of the activity on quality of care; (3) the potential impact of the activity on cost of care; (4) the strength of the evidence supporting the activity; and (5) the ease or difficulty of implementing the activity in their own practice.
Physicians in the 3 primary care specialties were recruited for the second round of field testing through a general e-mail invitation sent to all NPA members. The 172 second-round testers completed the same survey as the initial testers.
The activity was considered well supported if, on average, a majority of the survey respondents rated the activity in the 2 highest categories on the 5-point scale (ie, “significant” or “large” on the quality-of-care and economic-impact parameters, “somewhat strong” or “very strong” on the evidence parameter, and “not difficult” or “easy” on the ease-of-implementation parameter).
The first question on the survey asked the respondents “How often are you confronted with patients where you would have to decide whether or not to do the following tests or procedures?” The responses, however, seemed to indicate that a substantial number of the respondents misinterpreted the question and reported how often they followed the recommendation.
The question was rephrased in the beta test to “How often do you need to make a decision whether or not to order the following tests, procedures, or treatments?” The problem with misinterpretation persisted. Therefore, the data from the first question on the survey, titled “Frequency Encountered,” were deemed to be invalid and were not considered further in deciding whether to keep the item.
Members of the working groups were unanimous in their belief that most of the candidate activities were sufficiently common in primary care practice to be included. For clinical encounters that were not as common, such as children presenting with minor head trauma, the working group believed that this was important enough to include anyway.
In the first round of testing, the 83 field testers generally rated the items favorably (Table), but 1 activity in the family medicine list—not doing routine blood chemical analysis for asymptomatic, healthy adults—showed weak support. While 70.3% felt that the evidence supporting the recommendation was somewhat strong or very strong, only 37.0% felt that adhering to the recommendation was quite important or critically important to the quality of care, and only 48.1% felt that it would be easy or not difficult to implement. Therefore, the activity was dropped, and another candidate activity (not routinely prescribing antibiotics for mild to moderate sinusitis) replaced it for the second field test. All other activities underwent only minor wording changes, based on the feedback of the first field testers.
A second round of field testing was performed on the revised lists with a new group of 172 primary care physicians. The results of the second field test are also listed inTable. These testers endorsed the activities on the revised list.
The final top-5 lists are presented in the Figures 1, 2, and 3. Although working groups functioned independently of one another, some activities arose in more than 1 group. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities. This commonality across specialties reinforced the importance and relevance of addressing overuse of these activities. When substantively similar items arose in different groups, one working group was designated as the lead on that item, modified the wording in response to field testers from all relevant specialties, and returned the activity to the second working group for ratification.
Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities where changes in practice could lead to higher-quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the recommendations, the potential positive impact on quality and cost, and the ease with which the recommendations could be implemented.
The items generated by the 3 working groups reflect the opinions of the physicians serving on the working groups. A different group of physicians might have elaborated a different list. We believe that the specific items included on the list may be less important than the process for developing a consensus to change clinical behavior to improve care and reduce risk and cost.
The physicians recruited for field testing may not be representative of physicians in the 3 primary care specialties. A larger sample of physicians selected to reflect the demographic characteristics of the specialties might have responded differently to the survey questions. Resource limitations of this study precluded recruiting a representative sample. Finally, the field testing relied on the opinions of the physicians who participated in the survey rather than on empirical data or actual implementation in practice.
The top-5 lists will be distributed to all NPA physicians in the respective primary care specialties. A virtual practice community will be formed to support physicians' efforts to implement the recommended activities in their practices.
Many of the field testers believed that successful implementation would depend on enlisting patient agreement with the recommendations. Misunderstanding and miscommunication between physicians and patients explain a significant part of why unnecessary and even harmful tests and treatments are ordered. For example, many primary care physicians state that pressure from patients leads them to prescribe antibiotics when they are not indicated. Yet studies have shown that, in fact, patients don't expect antibiotics nearly as often as doctors believe they do.19- 21
Patient satisfaction and understanding are closely related, and physicians can improve patient satisfaction by focusing on understanding. This can be achieved by acknowledging and validating patient concerns while providing factual information in an easy-to-understand manner, explicitly clarifying the rationale for a selected course of action, and providing a contingency plan that empowers the patient.22
With this in mind, the NPA is planning to produce training videos to help physicians gain their patients' understanding and support by learning the communication skills necessary to enlist patient partnership in collaborative work. Videos will also be produced specifically for patients, explaining the rationale for the recommendations by clarifying that risks outweigh benefits, and the link between overutilization and increases in insurance premiums.
Patient-centered approaches that discuss expectations and share information with patients have been shown to successfully reduce antibiotic prescriptions in primary care.23 Effective implementation of the top-5 lists must respect patients' values and beliefs while also honoring clinical logic and protecting finite resources.24
The NPA also plans to request the endorsements of consumer groups and patient safety groups for the recommendations in the top-5 lists. Having such endorsements will help dispel the misconception that these clinical recommendations represent rationing and support the idea that often less is truly more.
Correspondence: Stephen R. Smith, MD, 899 Montauk Ave, New London, CT 06320 (Stephen_R_Smith@brown.edu). Reprints: National Physicians Alliance, 888 16th St NW, Ste 800, Washington, DC 20006.
Accepted for Publication: March 24, 2011.
Published Online: May 23, 2011. doi:10.1001/archinternmed.2011.231
Author Contributions: All members of The Good Stewardship Working Group are authors and had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
The Good Stewardship Working Group Members:Irene Aguilar, MD, Department of Medicine, University of Colorado Health Sciences Center, Denver; Zackary D. Berger, MD, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Danielle Casher, MD, Roxborough Pediatrics, Philadelphia, Pennsylvania; Ricky Y. Choi, MD, Department of Pediatrics, University of California, San Francisco; Jonas B. Green, MD, Department of Medicine, University of California, Los Angles; Elizabeth G. Harding, MD, North County Community Healthcare, Flagstaff, Arizona; Jeffrey R. Jaeger, MD, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia; Arthur Lavin, MD, Department of Pediatrics and Advanced Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio; Rebecca Martin, National Physicians Alliance, Washington, DC; Lynda G. Montgomery, MD, Department Family Medicine, Case Western Reserve University School of Medicine; Nancy Morioka-Douglas, MD, Geriatric Education Center, Stanford University School of Medicine, Stanford, California; Judith A. Murphy, MD, retired; Lauren Oshman, MD, Concord, New Hampshire, Family Medicine; Bethany Picker, MD, Family Medicine Residency Program, Central Maine Medical Center, Lewiston; Stephen R. Smith, MD, Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Shubha Venkatesh, MPH, University of Connecticut School of Medicine, Farmington; Mozella Williams, MD, Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore; Gwendolyn M. Wright, MD, Department of Pediatrics, Linda Vista Family Health Center, San Diego, California.
Financial Disclosure: None reported.
Funding/Support: Funding for this project was provided by the American Board of Internal Medicine Foundation.