Implementation of the Choosing Wisely Campaign at a Medical Clinic Internship

Mendonça, Dilton Rodrigues; Aguiar, Carolina Villa Nova; Lins-Kusterer, Liliane; Correia, Luis Cláudio Lemos; Vieira, Adriane Veloso Andrade; Menezes, Marta Silva

doi:10.1590/1981-5271v44.3-20190277.ING

Abstract:

Objective:

to evaluate the implementation of the Choosing Wisely (CW) campaign strategies at a medical clinic internship.

Methods:

This interventional study involved internship teachers and students, using online questionnaires on the SurveyMonkey platform, and face-to-face activities. Using the Delphi technique, teachers identified three unnecessary situations that commonly occur in practice. The recommendations were grouped by frequency and subject, adapted to the CW format. A Likert scale was used to classify the specialists’ opinion aiming to obtain the final list of recommendations. Before the introduction of the CW campaign, we conducted an Objective Structured Clinical Examination (OSCE). Two groups of students were compared: one group that underwent the same OSCE evaluation before the implementation of the CW campaign (110), and another group that participated of all educational actions (n = 98). The CW campaign was implemented by developing educational actions using the recommendations during workshops, banners, and theoretical evaluation, in addition to an Objective Structured Clinical Examination (OSCE).

Results:

after grouping the recommendations, 24 items remained. The specialists selected eight recommendations by frequency, addressing unnecessary behaviors such as requesting multiple exams, overuse of non-hormonal anti-inflammatory drugs, the indication of digestive endoscopy in younger patients with dyspepsia, excessive chest X-rays in intensive care unit, prescribing antibiotic prophylaxis for longer than recommended, routine indication of allergic tests, inadequate initial screening for thyroid assessment, and spirometry in asymptomatic patients. The educational actions resulted in a process of awareness and discussion among the participants, evidenced by theoretical evaluation (> 95%), as well as in the OSCE, where the level of successes was higher in the exposed group when compared to the nonexposed group (p = 0.001).

Conclusion:

the implementation of the CW campaign improved the clinical skills of medical clinic internship students and allowed positive discussions about cost-consciousness in health.

Keywords:
Medical Education; Internship and Residency; General Practice; Health Care Costs

[1] ADDRESS FOR CORRESPONDENCE
Dilton Rodrigues Mendonça. Av. Dom João VI, nº 275, Brotas, Salvador/BA, Brasil. CEP: 40290-000. Fone: 557132768200. E-mail: diltonmendonca@bahiana.edu.br

N.	Items*	Total Score (Likert-type)	Strongly agree % (n)	Moderately agree % (n)	Moderately disagree % (n)	Strongly disagree % (n)
1	Avoid prescribing multiple tests to inpatients whose results will not influence therapeutic management.	52	100 (13)	0 (0)	0 (0)	0 (0)
2	Avoid prescribing non-steroidal anti-inflammatory drugs in most clinical situations with self-limiting evolution.	52	100 (13)	0 (0)	0 (0)	0 (0)
3	Do not request upper gastrointestinal endoscopy for patients below the age of 50 with recent onset dyspepsia and no warning signs.	52	100 (13)	0 (0)	0 (0)	0 (0)
4	Do not request daily chest x-rays in an intensive care unit for patients who are not on mechanical ventilation and have a stable clinical course.	52	100 (13)	0 (0)	0 (0)	0 (0)
5	Do not prescribe antibiotic prophylaxis for longer than recommended.	52	100 (13)	0 (0)	0 (0)	0 (0)
6	Do not request allergy skin tests routinely and without well-established clinical criteria.	52	100 (13)	0 (0)	0 (0)	0 (0)
7	Avoid requesting tests at the initial screening for patients at risk of thyroid disease, prioritizing TSH levels first.	52	100 (13)	0 (0)	0 (0)	0 (0)
8	Do not request spirometry for asymptomatic patients with no risk factors for lung disease.	52	100 (13)	0 (0)	0 (0)	0 (0)
9	Do not order a colonoscopy or do not repeat it at short intervals, especially in less than five years, without considering well-established clinical criteria and risk factors.	51	92 (12)	8 (1)	0 (0)	0 (0)
10	Avoid imaging studies for the diagnosis of acute low back pain in the emergency unit.	51	92 (12)	8 (1)	0 (0)	0 (0)
11	Do not prescribe antibiotics for acute respiratory infections suggestive of viral etiology.	51	92(12)	8 (1)	0 (0)	0 (0)
12	Do not perform chest-computed tomography for patients with uncomplicated pneumonia.	51	92 (12)	8 (1)	0 (0)	0 (0)
13	Do not prescribe acetylsalicylic acid as a primary prevention to all diabetic patients.	50	85 (11)	15 (2)	0 (0)	0 (0)
14	Do not request chest X-rays at the end of treatment as a control for uncomplicated pneumonia with good clinical outcome.	50	85 (11)	15 (2)	0 (0)	0 (0)
15	Do not routinely request urine cultures for all patients, except for asymptomatic pregnant women.	50	85 (11)	15 (2)	0 (0)	0 (0)
16	Do not routinely prescribe lipid-lowering medications to patients older than 75 years of age, without considering comorbidities and life expectancy.	49	77 (10)	23 (3)	0 (0)	0(0)
17	Do not perform routine preoperative cardiac evaluation tests in asymptomatic patients before low-risk surgical procedures.	49	77 (10)	23 (3)	0 (0)	0 (0)
18	Do not request a sinus x-ray for the diagnosis of acute rhinosinusitis.	48	77 (10)	15 (2)	8 (1)	0 (0)
19	Do not prescribe proton-pump inhibitors to prevent acute mucosal injury in patients without risk factors.	48	84 (11)	8 (1)	0 (0)	8 (1)
20	Avoid requesting routine pre- and post-capillary glycemic measurements for insulin adjustments.	47	69 (9)	23 (3)	8 (1)	0 (0)
21	Avoid requesting daily blood gas analysis in an intensive care unit for patients without acute respiratory failure.	47	69 (9)	23 (3)	8 (1)	0 (0)
22	Do not request complementary cardiological exams (ergometric test and echocardiogram) for asymptomatic patients.	46	61 (8)	31 (4)	8 (1)	0 (0)
23	Do not request urinalysis for the diagnosis of urethritis or cystitis in non-pregnant women in case of emergency care.	45	54 (7)	38 (5)	8 (1)	0 (0)
24	Avoid routinely requesting complementary exams for a check-up, without clinical correlation.	43	77 (10)	0 (0)	0 (0)	23 (3)

Medical clinic recommendation	Hits n (%)	Misses n (%)
Do not request upper gastrointestinal endoscopy for patients below the age of 50 with recent-onset dyspepsia and no warning signs.	98 (100.0)	-
Avoid prescribing multiple tests to inpatients whose results will not influence therapeutic management.	95 (97.0)	3 (3.0)

Medical clinic recommendation	Nonexposed to CW campaign (N=110)		Exposed to CW campaign (N=98)		⁺P-value
Medical clinic recommendation	Hits n (%)	Misses n (%)	Hits n (%)	Misses n (%)
Avoid routinely requesting complementary exams for a check-up, without clinical correlation.	45 (40.9)	65 (59.1)	93 (94.9)	5 (5.1)	0.001