AOTA’s Top 5 Choosing Wisely^® Recommendations

Health care spending in the United States continues to grow at an unsustainable rate. In 2015, spending increased 5.8%, to reach $3.2 trillion, or $9,990 per person. As a share of the nation’s gross domestic product, health spending accounted for 17.8% (Morgan et al., 2016).

A critical component of addressing this issue is eliminating wasteful spending without reducing quality and appropriate care. According to Morgan et al. (2016), the overuse of health care, which can include providing treatment that is duplicative, not indicated, or inappropriate, is increasingly recognized as a problem in clinical care. In their systematic review, Morgan et al. noted that the number of articles on medical overuse nearly doubled from 2014 to 2015, indicating that awareness of overuse is increasing. A panel of the Institute of Medicine (2013) estimated in a September 2012 study that $690 billion was wasted in U.S. health care annually. These excess costs included unnecessary and inefficiently delivered services and did not include fraud.

Choosing Wisely^® is an initiative of the American Board of Internal Medicine (ABIM) Foundation that aims to encourage meaningful conversations between health care practitioners and clients to ensure that appropriate and quality care is being provided; specifically, the aims of this initiative are to promote interventions and assessments that are

• Supported by evidence,

• Not duplicative of other tests or procedures already received,

• Free from harm, and

• Truly necessary.

The overarching goals of this initiative are to

• Support efforts to help clients make smart and effective health care choices,

• Promote effective use of health care resources, and

• Help improve the quality and safety of health care in the United States.

The Choosing Wisely campaign was launched in 2012 by ABIM and Consumer Reports^® and now includes 75 health care provider organization partners that have published almost 500 recommendations (ABIM Foundation, 2019; Wolfson et al., 2014). Currently, active Choosing Wisely campaigns exist throughout North America, South America, Europe, Scandinavia, and Asia.

The American Occupational Therapy Association (AOTA) made a commitment to join this initiative in 2016. By partnering with Choosing Wisely, AOTA recognizes the importance of avoiding procedures and interventions that are unnecessary, duplicative, and inconsistent, while providing quality health care that is appropriate and cost effective. Starting in Summer 2016, AOTA and volunteer leaders initiated a three-phase process to develop, publish, and disseminate the “5 Things Patients and Providers Should Question” (ABIM Foundation, 2018) recommendations. This article describes in detail the process and results of AOTA’s Choosing Wisely campaign.

Led by Project Champion Glen Gillen, at Columbia University, AOTA conducted a three-phase project to develop the final Choosing Wisely recommendations of services that occupational therapy practitioners should not provide on the basis of limited evidence for effectiveness or for potential harm. In addition, the overall approach is based on several key considerations, including involving and gaining approval from AOTA’s Board of Directors (BoD), soliciting AOTA member input, proceeding with full transparency about the process, ensuring recommendations are supported by evidence, and gaining final approval from ABIM.

Phase 1 included developing a Choosing Wisely team and project plan as well as reaching out to AOTA members to build awareness and support.

The AOTA Evidence Team designed and managed the project to develop and disseminate the list of Choosing Wisely recommendations. The team represents staff from Professional Affairs, Public Affairs, and Business Operations and includes the Research Methodologist of AOTA’s Evidence-Based Practice Project. The team was made aware of this initiative from general member inquiries and an environmental scan and literature review about Choosing Wisely. The team contacted ABIM and held an initial conference call to learn more about the project.

The Evidence Team completed a SWOT (strengths, weaknesses, opportunities, and threats) analysis and developed a project proposal that was shared with AOTA’s Executive Management Group (EMG), which includes the Executive Director and Chief Officers. This document was refined and used for initial discussion with AOTA’s BoD in November 2016 to gain support for the project. Before embarking on the campaign, the Evidence Team carefully evaluated the goals of Choosing Wisely for consistency with the team’s mission of developing, disseminating, and translating evidence-based practice information, resources, and products to

• Inform clinical decision making to improve occupational therapy practice,

• Leverage the value of occupational therapy interventions with external audiences,

• Share with clients for informed decision making,

• Provide foundational materials for academic and continuing education programs,

• Guide the development of clinical research projects, and

• Provide a valuable AOTA member benefit.

The Evidence Team continues to manage the project in terms of resource development and refinement, and a subgroup of this team serves on the Choosing Wisely Team. The team updates AOTA’s EMG on an ongoing basis, and the EMG provides input on critical items and key decision points. In addition, updates and input also have been solicited and provided from AOTA’s BoD on an ongoing basis.

As the national professional association representing the interests and concerns of occupational therapy practitioners and students of occupational therapy, it was critical to the project to enlist a member champion to be the face of the initiative, engage member involvement and support, provide guidance on the project, and lead the development of the Choosing Wisely recommendations for AOTA.

AOTA reached out to Glen Gillen, a highly accomplished clinician, academician, researcher, and champion of evidence-based practice within the field to lead this project. Gillen was selected for his scholarly work, including numerous original publications and serving as the editor of the definitive textbook on stroke rehabilitation for occupational therapists, now in its fourth edition (Gillen, 2016). He has received numerous awards and invited lectureships, including the Eleanor Clarke Slagle Lectureship (Gillen, 2013). He is widely acknowledged as a leader in the field of occupational therapy nationally and internationally and a strong advocate and proponent of evidence-based practice.

Transparency and building member awareness and support were essential to ensure a member-driven initiative. To achieve this, the Choosing Wisely Team conducted a series of presentations to AOTA leadership groups and members. Presentations included an explanation of the importance and value of AOTA participation in the Choosing Wisely campaign as well as the project plan and opportunities for member participation. Time also was set aside for questions, discussion, and idea generation.

A town hall session about Choosing Wisely was held at the 2017 AOTA Annual Conference & Centennial Celebration (Gillen, 2017b), and the campaign was presented at key leadership group meetings. Subsequent presentations and discussions were held by means of conference calls with AOTA leadership groups, committees, and commissions (see Appendix 1 for a list of these groups). Information about the campaign was disseminated more widely to AOTA membership via social media, AOTA print and online publications (AOTA, n.d.; Gillen et al., 2017), and the posting of a presentation recorded on AOTA’s website (Gillen, 2017a). There was also an online form on AOTA’s website for members to provide contact information to receive updates about the campaign. Fifty-one members indicated interest in receiving periodic updates about the campaign.

Phase 2 involved multiple steps to iteratively prioritize occupational therapy items generated by AOTA staff and members for the Choosing Wisely campaign.

An online member survey was conducted to generate ideas for occupational therapy services to consider. The survey was promoted during presentations about the campaign and disseminated to the broader AOTA membership via AOTA publications, social media, and other online outlets. Participants responded to the prompt, “Based on your clinical expertise and knowledge of the occupational therapy evidence, please list up to 5 occupational therapy interventions that you feel SHOULD NOT be included in practice.”

The survey was open from March to June 2017 and yielded 328 responses. These were collated and analyzed into grouping of topics, and duplicates and items outside the scope of occupational therapy practice were removed. The final result of this process was a list of 62 items.

The 62 items were provided to AOTA Special Interest Section (SIS) volunteer leaders representing major practice areas to rank the top items on the basis of the following established criteria from Choosing Wisely:

• The service is relevant to occupational therapy practice and, if included on the list, would positively impact the profession and client care.

• There is evidence to demonstrate that the service offers no benefit to most clients, and in some circumstances may be harmful.

• The service is not cost effective.

• The service is not truly necessary.

• The service is not duplicative of other services already received.

After the SIS review, 12 items remained. The project team conducted literature reviews of these items to address the requirement for Choosing Wisely that the proposed items be based on research evidence. During this process, literature was hand searched, and content experts were contacted for suggestions of supporting literature. The recommendation and supporting statements for all 12 items were developed. The list of items and supporting evidence were in turn shared with the AOTA BoD and other experts in the areas for review.

The next step was to again solicit member input of the 12 remaining items with the goal of selecting the top 5. A second survey was disseminated to the AOTA membership by means of AOTA publications, social media, and online outlets. Participants were asked to select up to 5 occupational therapy services from the list of 12 items that occupational therapy practitioners should not provide. The survey was open from October to November 2017. This survey yielded 4,860 responses that were analyzed by the Choosing Wisely Team in terms of how members ranked the items and the comments they provided to explain their conclusions.

This survey resulted in the final 5 recommendations. The project team developed brief evidentiary statements for each recommendation that describe the evidence behind the recommendation as well as a description of appropriate interventions. With input from content experts, each recommendation also included citations for supporting evidence. The final 5 recommendations and supporting evidence were presented to the AOTA BoD for final approval in February 2018. After gaining that approval, the materials were submitted to the ABIM Choosing Wisely Foundation for review by two clinician reviewers, one from the field of occupational therapy and one from another discipline. Minor edits were suggested and revisions made. ABIM then sent the AOTA recommendations to their members of specialty societies and health care providers for review. There were no further revisions recommended. With permission from ABIM, and in advance of final publication, the final draft list of 5 recommendations was shared with attendees during a session at the April 2018 AOTA Annual Conference & Expo (Gillen, 2018).

Finally, Phase 3 included publication and implementation of a communications plan. AOTA’s “5 Things Patients and Providers Should Question” was published on ABIM’s Choosing Wisely website on June 4, 2018. The publication was disseminated to AOTA members, nonmembers, external stakeholders, and the media by means of AOTA publications, social media, a press release, and other online outlets. In addition, supplemental materials (Richardson, 2018a, 2018b, 2018c, 2018d, 2019) were developed to help colleagues and clients understand the importance of the initiative as well as support clinicians as they implement the recommendations into their practice and share the recommendations with colleagues. This phase is under way and ongoing.

The following 5 AOTA recommendations were approved and published on the Choosing Wisely website:

Purposeful activities—tasks that are part of daily routines and hold meaning, relevance, and perceived utility such as personal care, home management, school, and work—are a core premise of occupational therapy. Research shows that using purposeful activity (occupation) in interventions is an intrinsic motivator for clients. Such activities can increase attention, endurance, motor performance, pain tolerance, and engagement, resulting in better client outcomes. Purposeful activities build on a person’s ability and lead to achievement of personal and functional goals. Conversely, non-purposeful activities do not stimulate interest or motivation, resulting in reduced client participation and suboptimal outcomes.

Many children and youth are affected by challenges in processing and integrating sensations that negatively affect their ability to participate in meaningful and valued occupations. Processing and integrating sensations are complex and result in individualized patterns of dysfunction that must be addressed in personalized ways. Interventions that do not target the documented patterns of dysfunction can produce ineffective or negative results. Therefore, it is imperative to assess and document specific sensory difficulties before providing sensory-based interventions such as Ayres Sensory Integration^®, weighted vests, listening programs, or sensory diets.

The exclusive use of physical agent modalities (PAMs; e.g., superficial thermal agents, deep thermal agents, electrotherapeutic agents, mechanical devices) as a therapeutic intervention without direct application to occupational performance is not considered occupational therapy. PAMs provided with a functional component can lead to more positive health outcomes. PAMs should be integrated into a broader occupational therapy program and intervention plan in preparation for or concurrently with purposeful activities or interventions that ultimately enhance engagement in occupation.

Use of an overhead pulley for individuals with a hemiplegic shoulder resulting from a stroke or other clinical condition is considered too aggressive and should be avoided because it presents the highest risk of the client developing shoulder pain. Gentler and controlled range of motion exercises and activities are preferred.

To improve occupational performance, cognitive-based interventions should be embedded in an occupation relevant to the client. Examples of cognitive-based interventions include awareness approaches, strategy training, task training, environmental modifications, and assistive technology. The use of cognitive-based interventions not based on occupational performance will result in suboptimal client outcomes.

Appendix 2 includes the references for “5 Things Patients and Providers Should Question.”

As a partner in Choosing Wisely, AOTA has a responsibility to update its list regularly to ensure that the recommendations reflect the best and most current evidence. AOTA will annually review its Choosing Wisely recommendations, conducting a literature review and consulting member experts to consider whether changes to the list are needed. If changes are required, the items will be updated, amended, or withdrawn. In addition, there is the potential for AOTA to develop additional Choosing Wisely items. Any changes will be communicated to the ABIM Choosing Wisely Foundation and AOTA members.

The continued growth in health care costs and the prevalence of inefficient or medically unnecessary health care services have led policymakers and payers to reform payment models to focus on paying for quality health care services instead of the past focus on quantity of services. In 2010, the Patient Protection and Affordable Care Act (Pub. L. 111-148) initiated reforms to try to move Medicare toward incentivizing higher quality services. Congress has continued this trend through passage of the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 118-135), which requires the submission of standardized data across postacute care settings to better measure quality and the implementation of the Quality Payment Program for Medicare B services provided through the Physician Fee Schedule. Moreover, upcoming changes to the payment methods used to reimburse home health agencies and skilled nursing facilities mean that reimbursement will be based more on client characteristics and not on the intensity of therapy services.

All of these changes mean occupational therapy practitioners must demonstrate their value through positive client outcomes, delivered in an efficient manner across all health care settings. AOTA’s participation in Choosing Wisely is an important demonstration to health care decisionmakers that occupational therapy practitioners are committed to providing high-quality, efficient care. Occupational therapy practitioners need to be able to demonstrate the distinct way in which occupational therapy enhances quality and provides value. A major theme that resulted from the development of the Choosing Wisely list is the importance of occupation-based practice.

According to AOTA’s Distinct Value Statement, “Occupational therapy’s distinct value is to improve health and quality of life through facilitating participation and engagement in occupations” (AOTA, 2015a). Although productivity standards and other external forces may make it difficult to provide services that are occupation based, occupational therapy practitioners must incorporate purposeful and meaningful occupations into services to produce optimal outcomes and demonstrate the distinct value of occupational therapy.

The Occupational Therapy Code of Ethics (AOTA, 2015b) also supports the mission of the Choosing Wisely campaign. Principle 1, Beneficence, states that “occupational therapy personnel shall demonstrate a concern for the well-being and safety of the recipients of their services” (p. 2). Related standards of conduct include

• “Provide appropriate evaluation and a plan of intervention for recipients of occupational therapy services specific to their needs.” (p. 2)

• “Use, to the extent possible, evaluation, planning, intervention techniques, assessments, and therapeutic equipment that are evidence based, current, and within the recognized scope of occupational therapy practice.” (p. 2)

Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions; instead, they are meant to spur conversation about what is appropriate and necessary treatment. Because each client’s situation is unique, providers and clients should use the recommendations as guidelines to determine an appropriate treatment plan together.

AOTA is proud to have taken part in the Choosing Wisely initiative. The rigorous process to develop, publish, and disseminate the “5 Things Patients and Providers Should Question” was undertaken with a goal of ensuring a grassroots, member-centered resource. Through the different phases and data collection points, the data from member feedback were refined, and items were prioritized. The Choosing Wisely Team and AOTA members, SIS leaders, and the BoD rigorously conducted the refining of the items. The result is a list of evidence-based, high-priority items. The development of the final list meets the objective and criteria for the Choosing Wisely campaign and is built on rigorous methods, transparency, and inclusion.

AOTA’s “5 Things Patients and Providers Should Question” is meant to start a dialogue within the occupational therapy profession. It is a reminder that there is always room for improvement in everyday practice. It is the perfect time for clinicians to examine their practice, for academicians to think about what is included in curricula, and for researchers to examine their priorities.

Next steps for AOTA’s Choosing Wisely campaign will focus on the dissemination of this information to clients, practitioners, other health care professionals, and stakeholders. AOTA is supporting efforts for occupational therapy practitioners to not only apply the findings from the initiative to their practice but also to share the recommendations with their colleagues and start a dialogue about the necessity of practice improvement, whether it be in the workplace, conferences, social media, or other forums.

We acknowledge and thank Marian Arbesman, Heather Parsons, Christina Davis, and Hillary Richardson for their participation in AOTA’s Choosing Wisely^® initiative.

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