North Carolina Choosing Wisely Campaign

“The Choosing Wisely North Carolina Collaboration is a unique and important effort that aligns the interests of consumers, practitioners, employers, and payers to improve health, provide better transparency in health care, and reduce unnecessary care for all North Carolinians. NCHQA is proud and pleased to help bring these key stakeholders together to improve the quality of medical choices made by patients and practitioners.”

– Dr. Don Bradley, NCHQA Chair

The North Carolina Choosing Wisely campaign is a collaborative, statewide effort led by the North Carolina Healthcare Quality Alliance (NCHQA). The campaign aims to reduce the use of unnecessary tests and treatments in North Carolina by (1) implementing select Choosing Wisely recommendations within participating health care systems, and (2) raising awareness of the problem of overuse among providers and patients in the broader community. Key North Carolina Choosing Wisely partners include Duke Medicine, Cornerstone Health Care, the North Carolina Medical Society, Blue Cross Blue Shield of North Carolina and the State Health Plan for Teachers and State Employees.

NCHQA aims to dramatically improve the delivery of health care in North Carolina and the health of all North Carolinians by bringing together the full range of stakeholders in the health care delivery system. NCHQA provides overall coordination for the North Carolina Choosing Wisely effort, while mobilizing its constituent organizations to conduct Choosing Wisely outreach and education.

Duke Medicine is an integrated academic health system located in Raleigh-Durham, North Carolina. It includes three hospitals, a large faculty practice of 1,800 physicians, a Home Care and Hospice service, as well as an extensive primary care network, with 24 practices in seven counties. In collaboration with the North Carolina Choosing Wisely effort, Duke Medicine aims to reduce (1) use of antibiotics for viral-based illnesses, (2) unnecessary use of DEXA screening for osteoporosis and (3) avoidable carotid artery stenosis screening.

Cornerstone Health Care is a group of more than 320 physicians and advanced practice providers based in High Point, North Carolina. Cornerstone is a physician-owned and -led multi-disciplinary practice with more than 90 locations in communities throughout central North Carolina. Cornerstone’s Choosing Wisely efforts will focus on (1) use of antibiotics for viral-based illnesses (2) unnecessary DEXA screening and (3) avoidable Pap tests.

The North Carolina Medical Society (NCMS) is a professional association of approximately 12,000 medical students, residents, practicing and retired physicians and physician assistants. Through its Foundation, the Toward Accountable Care Consortium (TAC), and its specialty society partners, NCMS disseminates Choosing Wisely messaging to state and regional medical societies and health care organizations. In addition, NCMS will conduct provider outreach to foster physician leadership, patient/consumer partnership and intrinsic professional motivation around the topic of overuse.

Blue Cross and Blue Shield of North Carolina (BCBSNC) is the state’s largest health insurer, with more than 3.8 million customers. In collaboration with NCHQA, BCBSNC is developing a North Carolina Choosing Wisely communications plan. This effort will include outreach activities to educate and engage consumers, physicians, practice administrators, local media, and BCBSNC employees.

The State Health Plan for Teachers and State Employees (Plan) provides health care coverage to more than 685,000 teachers, state employees, retirees, current and former lawmakers, state university and community college personnel, and their dependents. The Plan will use multi-modal media, such as postcards, brochures and electronic newsletters, to deliver the Choosing Wisely messages to members in all 100 North Carolina counties and beyond.

Join the North Carolina Choosing Wisely campaign today by notifying NCHQA of your interest. Your organization will be added to the statewide partners list, and you will receive relevant articles and new materials as available.

Late Summer Feature

Implementing a Choosing Wisely Program in Your Practice, Organization, or Community

After two years of grant work, our clinical partners are seeing results. Fewer unnecessary antibiotics are being prescribed and fewer Pap tests and DEXA scans performed. Other organizations and health professionals want to know how to get started with Choosing Wisely. Here are some recommendations from the ABIM Foundation, Consumer Reports, and the Centers for Disease Control and Prevention

Clinical Practice

The ABIM Foundation has developed an implementation plan which includes the following five steps:

1. Engage your provider
2. Engage your staff
3. Engage your patients
4. Establish an implementation plan for the practice
5. Use data to understand and improve performance

More information can be found at https://www.stepsforward.org/modules/choosing-wisely

Employers

Choosing Wisely Implementation Guide

Community

2017 Antibiotic Use in the United States: Progress and Opportunities

Flu Season and Antibiotics Feature

Prevention

• Get a flu shot
• Wash hands often using soap and water for at least 20 seconds
• Cover mouth and nose with tissue when coughing or sneezing OR cough/sneeze into your upper sleeve
• Stay home if you are sick
• Keep sick children home from school
• Avoid close contact with people who are sick

Dr. Heather Spry, Cornerstone Health Care, in an exam room with poster of the Five Questions to Ask Your Doctor Before You Take Antibiotics.

Flu and Antibiotics

Misuse of antibiotics leads to the rise in superbugs — those bacteria resistant to antibiotic treatment. Not completing the antibiotics that are prescribed, or taking antibiotics when they are not necessary, contributes to the problem. It is important for physicians and patients to discuss when and when not to use antibiotics. Antibiotics fight bacteria, not viruses. With flu season upon us, remember that the flu is a virus and therefore not responsive to antibiotic treatment.

The following articles, brochures, and posters can be used by providers in their waiting/exam rooms and by patients and families for their own benefit. These materials can be downloaded and printed. Most of the materials are also available in Spanish.

Antibiotics for Respiratory Illnesses in Adults

Antibiotics: When You Need Them and When You Don’t

Antibiotics: Will They Help You or Hurt You?

Five Questions to Ask Your Doctor About Antibiotics (poster)

Virus or Bacteria, What’s Got You Sick

What You Can Do About It

Pharmacists: How to educate about use of antibiotics

Public Health: Article regarding a public health antibiotic stewardship campaign

Choosing Wisely: Antibiotics.

Steps to Reduce Use of Antibiotics

Adult Vaccines

Take Control of Your Health

Antibiotics for Respiratory Illness in Adults

Antibiotics for Respiratory Illness in Children

CDC Get Smart Week:  November 13-19

Symptom Relief: How to feel better when you have a sore throat, ear pain, runny nose, sinus pain or cough.

Archive: Summer Feature

Carotid Artery Stenosis Screening

Recommendation: Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.

There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction.

This recommendation is provided solely for informational purposes and is not intended as a substitute for consultation with a medical professional. Patients with any specific questions about this recommendation or their individual situation should consult their physician.

— American Academy of Family Physicians

DEXA for Osteoporosis

Recommendation: Don’t use dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women under age 65 or men under 70 with no risk factors.

DEXA is not cost-effective in younger, low-risk patients, but is cost effective in older patients.

— American Academy of Family Physicians

The following materials can be used by providers in their waiting/exam rooms and patients and their families for their own benefit. They can be downloaded and printed. They are available in English and Spanish.

Carotid Artery Stenosis Screening

(Carotid Ultrasound) Screening Tests: When You Need Them, When You Don’t

Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients – American Academy of Family Physicians (AAFP)

DEXA Scans

Bone Density Tests: When You Need Them and When You Don’t

Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors – AAFP

Additional materials include the following:

DEXA Screening

Carotid Artery Stenosis Screening

Archive: Spring Feature

Cervical Cancer Screening

“Cervical Cancer was once one of the most common causes of cancer deaths for American women. But over the last 30 years, the cervical cancer death rate has decreased by more than 50%. The main reason for this was the increased use of cervical cancer screenings.” (American Cancer Society)

Screening is still very important, but screening recommendations have changed as more is known about cervical cancer.

Current recommendations include the following:

• Don’t perform routine annual cervical cytology screening (Pap test) in women 30-65 years of age. (American College of Obstetricians and Gynecologists)
• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer. (American Academy of Family Practice)

The following posters, brochures, rack cards and wallet cards can be used by providers in their waiting/exam rooms and by patients and their families for their own benefit. They can be downloaded and printed. Some may be available in Spanish.

Brochure — Pap Test: Recommendations for When or When Not to Get a Pap Test

Poster, Rack, and Wallet Cards — Five Questions to Ask Your Doctor Before You Get Any Test, Treatment or Procedure

Opioids

The overuse or misuse of opioids (potentially addictive pain killers) has become a national problem. North Carolina has experienced its share of the alarming rise of deaths. Elected officials, health care professionals and other concerned groups are working to address this dangerous issue. The Choosing Wisely campaign developed materials to speak to the use of opioids. The following materials are available in English and Spanish.

• Avoid Opioids for Most Long-term Pain
• Medicines to Relieve Chronic Pain: When You Need Opioids (narcotics) and When You Don’t

Back Pain

Many adults suffer from back pain. There are interventions and medications that can be helpful in relieving the pain without resorting to opioids. The Choosing Wisely campaign developed materials that identify activities and medications that can be used to reduce back pain. The following items are available in English and Spanish.

• Back Pain Tests and Treatments: What You Should Consider Beforehand
• Treating Lower Back Pain: How Much Bed Rest Is Too Much
• Imaging Tests for Lower-back Pain: You Probably Don’t Need an X-ray, CT Scan, or MRI
• Do You Have Lower-back Pain?
• Neck and Back Pain – When You Need Tests for Your Nerves and Muscles and When You Don’t

Wellness

Achieving your highest level of health is the primary goal of wellness. Choosing the most appropriate point of health care and then seeking preventive care throughout life are two important practices for individuals and families. For further information, please go to this link.

You may also like Getting the Right Care to Stay Healthy as You Age.

Health Care Providers

Based on a recent survey, physicians recognize the need to address unnecessary utilization of tests and procedures with their patients. To help physicians identify tests or procedures whose necessity should be questioned or discussed, Choosing Wisely asked over 70 medical specialty societies to recommend standards of practice for reducing unnecessary drug prescribing, testing and imaging. The recommendations can be viewed in their entirety or grouped by society.

Four topics

The North Carolina Choosing Wisely initiative focuses on evidence-based recommendations for the following four specific topics; however, we encourage physicians to review any of the specialty society lists of things that physicians and patients should discuss.

Antibiotics for Respiratory Illness

• Avoid prescribing antibiotics for upper respiratory infections – Infectious Disease Society of America

Carotid Artery Stenosis Screening

• Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients – American Academy of Family Physicians (AAFP)

DEXA Scans

• Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors – AAFP

Pap Tests

• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer –AAFP
• Don’t perform routine annual cervical cytology screening (Pap tests) in women 30-65 years of age – American College of Obstetricians and Gynecologists

Talking with patients

The following information and materials from the ABIM Foundation, Choosing Wisely, Consumer Reports and the Centers for Disease Control and Prevention (CDC) have been developed to assist physicians in talking with patients about when and when not to test or treat.

Videos

Brochures , Posters, & Other Print Materials

Pap Test: Recommendations for When or When Not to Get a Pap Test

(Carotid Ultrasound) Screening Tests: When You Need Them, When You Don’t

Bone Density Tests: When You Need Them and When You Don’t

Antibiotics for Respiratory Illnesses in Adults

Antibiotics: When You Need Them and When You Don’t

Antibiotics: Will They Help You or Hurt You?

Five Questions to Ask Your Doctor About Antibiotics (poster)

Virus or Bacteria, What’s Got You Sick

What You Can Do About It

Pharmacists: How to educate about use of antibiotics

Public Health: article regarding a public health antibiotic stewardship campaign

Five Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure

Five Questions rack cards

Five Questions wallet cards

Physician Communication Modules. These interactive instructional modules were developed by the Drexel University College of Medicine to help physicians engage patients in conversations about overuse.

Choosing Wisely Action Manual. This implementation guide developed by the Washington State Choosing Wisely Task Force provides practical, step-by-step recommendations for integrating Choosing Wisely into clinical practice.

What Doctors Wish Their Patients Knew. This informative article provides both physicians and patients with insights into what questions to ask and how to answer them.

Patients and Families

Taking the best care of yourself and your family includes talking with your doctor about necessary tests and treatments. Based on your situation, some tests or treatments may not be needed. There are five questions to ask your doctor that might help you.

• Do I really need this test or procedure?
• What are the risks?
• Are there simpler, safer options?
• What happens if I don’t do anything?
• How much does it cost?

The following tips on talking with your doctor are from the National Institutes of Health (NIH)

• Write down list of questions and concerns before appointment
• Consider bringing a close friend or family member with you
• Take notes about what the doctor says or ask the friend/family member to do this for you
• Learn how to access your medical records so you can keep track of test results, diagnoses, treatment plans, medicines and prepare you for the next visit
• Ask for the doctor’s contact information and their preferred method of communication
• Remember that nurses and pharmacists are good sources of information

Videos

PSA

Pap Test

Talking with Your Doctor

Brochures/Posters

Pap Test: Recommendations for When or When Not to Get a Pap Test

(Carotid Ultrasound) Screening Tests: When You Need Them, When You Don’t

Bone Density Tests: When You Need Them and When You Don’t

Antibiotics for Respiratory Illnesses in Adults

Antibiotics: When You Need Them and When You Don’t

Antibiotics: Will They Help You or Hurt You?

Five Questions to Ask Your Doctor About Antibiotics (poster)

Virus or Bacteria, What’s Got You Sick

What You Can Do About It

GetSmart

Upper Respiratory Illness Symptom Relief Without Antibiotics

Common Illnesses

Multiple Health Topics

www.choosingwisely.org/patient-resources

Employers and Payers

Employers are searching for ways to to encourage employees to seek high value care as a means to improve their health and that of their families. Payers are also looking for ways to help clients and providers maintain quality care while while avoiding unnecessary tests or procedures. Choosing Wisely provides the evidence-based recommendations and educational materials needed to launch a company-wide campaign.

Employer Toolkit

The Choosing Wisely Employer Toolkit was developed to help employers educate their employees about overuse of health care services. Payers will find the materials readily adaptable to their use as well. The Employer Toolkit includes the following:

• Information about Choosing Wisely
• Quick start guide
• Consumer Reports resources (videos, posters, and brochures)
• Sample timeline and editorial calendar
• Tips for how to integrate with wellness, enrollment, and other campaigns
• Sample campaigns
• Articles such as
  • When to say “Whoa!” to Doctors
  • Five Things Physicians and Patients Should Question
  • Partnering with Your Doctor
  • Five Things Your Doctor Might Not Tell You
  • Ten Ways to Reduce Your Drug Costs

Making Healthy Choices

For more information on starting an employer campaign refer to the Getting Started guide.

For more information on promoting messages to employees refer to Making Healthy Choices.

Articles, Blogs, and More

As the campaign grows in North Carolina, NCHQA and its partners are creating multi-modal communications about Choosing Wisely.

State Health Plan newsletter — Be Wise and well this New Year: Five Questions to Ask Your Provider

Blue Cross Blue Shield Blog

North Carolina Public Health Association newsletter (scroll to page 2)

State Health Plan Webpage and Mailer

Duke Cuts Antibiotic Prescriptions by 24%: Provider and patient education result in a significant decrease in antibiotic prescribing for Duke Health.

Fighting Antibiotic Resistance, One Prescription at a Time: North Carolina significantly reduces the use of antibiotics.

Antibiotic Prescription Fill Rates Declining in the U.S.: The Blue Cross Blue Shield Association released a nationwide report on the decline of antibiotic prescriptions being filled in each state. North Carolina had a 27% decline compared to the surrounding states: Virginia 8%, South Carolina 18%, and Tennessee 15%.