Nutrition Support Blog: Choose Wisely
June 8, 2012
In one of my favorite Indiana Jones movies, a villain who is trying to select the real Holy Grail hidden among counterfeit chalices is told to “Choose Wisely…” When the evildoer drinks from the wrong cup and meets his gristly and graphic end, the knight guarding the Grail turns and says quietly, “He chose poorly.” While real life decisions tend to be a bit more mundane than an adventure movie, healthcare is facing challenges that could ultimately lead to a meltdown befitting a nefarious movie foe. Physicians and physician groups are realizing that we all have a responsibility to limit unnecessary tests and procedures, before we reach the point where essential medical care is rationed or unavailable.
A national program initiated by the American Board of Internal Medicine called the “Choosing Wisely®” campaign is working to identify specific tests or procedures commonly used within various specialties that are not always necessary. The American Academy of Allergy, Asthma & Immunology (AAAAI), The American Academy of Family Physicians (AAFP), The American College of Cardiology (ACC), The American College of Physicians (ACP), The American College of Radiology (ACR), The American Society of Nephrology (ASN), American Society of Clinical Oncology (ASCO), and The American Society of Nuclear Cardiology (ASNC) have all become supporters of the “Choosing Wisely®” campaign. Check out the website for more information: http://choosingwisely.org/
As I read through the lists prepared by each specialty of “Five Things Physicians and Patients Should Question,” I realized that there are similar tests and practices in the world of nutrition, and that there is no reason why nutrition clinicians and societies should not be a part of this campaign. The practice of checking serum proteins such as albumin or prealbumin (and even transferrin in some places), as a marker of nutrition status or nutritional adequacy are some obvious candidates. Lab tests for serum proteins are not free, and the best available evidence is that they are not valid markers of nutrition status in acutely ill patients (see our September 1, 2011 blog). The other practice that needs to be checked is the use of more expensive specialty formulas that do not have adequate data to support improvements in patient outcome. Certainly nutrition support practitioners are on-board with the need to avoid parenteral nutrition in patients where enteral is feasible, and I think it would be great to have, “Avoid unnecessary PN” as the number 1 item on our list of “Five things...” for all physicians to see.
We may not (yet) be officially involved with the “Choosing Wisely®” campaign, but making sound clinical decisions based on good data is also sound fiscal policy, besides, who says we have to wait to be asked? There is no better time to educate your staff on avoiding unnecessary tests or expensive formulas without efficacy data. We all need to be responsible for avoiding unnecessary medical expenses before our healthcare system is rolled over by a giant boulder of debt, and we realize too late that we “Chose poorly.”
“Since our problems have been our own creation, they also can be overcome.”
- George Harrison