Written by Richard Seifman, JD, MBA, NPA Board Member
“Choosing Wisely”, a concept in which the National Physicians Alliance was instrumental, held its “Opportunities and Challenges in Curbing Medical Overuse” conference, held at Health Affairs and sponsored by the Robert Wood Johnson Foundation, on October 24, 2017 in Washington D.C. Choosing Wisely, a movement only five years old, is an effort to have clinicians and patients consider together the pros and cons of different tests, procedures, and treatments. A wallet sized card can be in the hands of patients which asks five questions including “Do I really need this procedure” and “What are the risks?” This patient centered behavioral tool is simple, easy to understand, and potentially highly effective—if a health practitioner is open to dialogue.
Among the most regularly prescribed treatments which is the subject of such a conversation should be that of antibiotics. While antibiotics are applicable for bacterial but not viral infections there are many reasons clinicians prescribe antibiotics; for example, the difficultly convincing a mother with a child with a virus that just rest and liquids will suffice—she expects some form of “treatment”, however misplaced.
What we know is that the overuse or misuse of antimicrobial agents by human actions may promote the spread of antimicrobial resistance and comes from many sources. Such applications include the inappropriate use of antimicrobials in health care but far beyond the clinician, it is from raising animals and even crops which enter the food chain, poor sanitary conditions, disposal of wastes containing antimicrobials, and weak infection and prevention and control practices in health care facilities.
Indeed, the bulk of antimicrobial use in many countries occurs in the agriculture sector, particularly in livestock. According to a World Bank report, in 2010, livestock consumed at least 63,200 tons if antibiotics and probably far more, exceeding total human consumption. The point is that clinicians need to be aware of other sources of antibiotics which are indirectly provided to their patient, and that though they might consider their prescription of minor import, it is the cumulative effect of all sources which results in an individual’s antimicrobial resistance. Clinician education, culture and traditions by and large run counter to clinicians being aware of such externalities and unaccustomed to discussing such decisions with patients.
In addition to application in the United States, the Choosing Wisely antibiotic practical approach has direct and indirect relevance and benefits for international initiatives which are gaining traction in many places. In addition to the Antimicrobial Resistance efforts taken up by the United Nations General Assembly, health-related UN agencies and external donors, there is also the pandemic preparedness focus which accelerated from the South Asian Respiratory Syndrome, Ebola, and Zika, pandemics.
Further the international community is increasingly recognizing the importance of the “One Health” approach. One Health is defined as a collaborative approach across many sectors to strengthen systems to prevent, prepare, detect, respond and recover from infectious diseases (and antimicrobial resistance), that threaten human health, animal health and environmental health. Shared knowledge of the extent to which antibiotics may be reaching a patient from multiple sources will encourage clinicians to “do no harm” when making treatment decisions.
The Choosing Wisely approach is now in 19 countries in the United States, Canada, much of Western -Europe, Australia and New Zealand– as well as Brazil, the only current middle-income country with the movement. Low and middle-income countries need user-friendly tools to address a variety of health issues including AMR. The Choosing Wisely “wallet card” approach in raising awareness of the dangers from overprescribing antibiotics would be a practical instrument applicable in many low and middle income behavioral tool kit. The next five years for Choosing Wisely should include expanding the concept to developing countries.