PHM groups issue Choosing Wisely® recommendations

SHM members involved from the start


The Choosing Wisely® Pediatric Hospital Medicine (PHM) recommendations were published in January 2021. The initial Choosing Wisely® PHM recommendations were released in 2012 and the 2021 recommendations were the result of an extensive and years-long process. The Choosing Wisely® campaign, an initiative led by the American Board of Internal Medicine, was developed to enhance clinician-patient conversations, promoting care that is evidenced based, free from harm, and truly necessary.

Dr. Bobby Casey, Joe DiMaggio Children's Hospital, Hollywood, Fla.

Dr. Bobby Casey

The campaign has been embraced by the entire medical community, with more than 70 professional medical societies releasing recommendations. With its emphasis on high value care and eliminating medical waste, it is no surprise that the Choosing Wisely® campaign has found a home in a pediatric hospital medicine community that prides itself on those very traits. This article sheds light on the recommendation development process and identifies challenges and opportunities for implementation across the country.

The Choosing Wisely® process started with the selection of a committee. This group comprised nine members, with equal representation from all three societies affiliated with PHM: the Society of Hospital Medicine (SHM), the American Academy of Pediatrics’ Section on Hospital Medicine (AAP SOHM), and the Academic Pediatric Association (APA). Members of the committee intentionally represented a wide spectrum of practice variability, geography, and clinical experience.

The SHM members of the group were: James O’Callaghan, MD, FAAP, SFHM, pediatric hospitalist at Seattle Children’s Hospital and clinical professor of pediatrics at the University of Washington School of Medicine; Vivian Lee, MD, clinical pediatric hospitalist at Children’s Hospital of Los Angeles and associate professor of pediatrics at USC Keck School of Medicine; and Francisco Alvarez, MD, pediatric hospitalist at Lucile Packard Children’s Hospital, Palo Alto, Calif., and clinical associate professor of pediatrics at Stanford (Calif.) University.

Dr. James O'Callaghan of Seattle Children's Hospital

Dr. James O'Callaghan

According to Dr. O’Callaghan, it was important that the Choosing Wisely® recommendations come from the broader PHM community, reflecting the community’s priorities.

The committee started the process by asking the broader PHM community to submit ideas for consideration, via SHM’s HMX and the AAP SOHM listserv. The PHM community responded with more than 400 submissions.

Dr. Francisco Alvarez, Stanford (Calif.) University

Dr. Francisco Alvarez

Dr. Alvarez said the committee organized and trimmed the initial submissions, removing redundancy, into approximately 200 distinct recommendations. After initial literature review, the committee focused on approximately 70 recommendations. At that point, each member undertook an extensive literature review of the topics.

Once every potential recommendation had received a thorough review, Dr. Lee said, the committee underwent a modified Delphi process to evaluate the list. In this process, each member ranked the recommendations on validity – a measure of the quality of evidence supporting a topic – and feasibility – a measure of the PHM community’s ability to influence compliance.

Dr. Vivian Lee, Children's Hospital of Los Angeles

Dr. Vivian Lee

At the end of this objective process, Dr. O’Callaghan said, the committee chose the five recommendations that received the highest total scores. While there were spirited discussions regarding the data available for each recommendation, all three SHM members of the committee agreed that the objective process played itself out.

Now that the Choosing Wisely® recommendations have been published, the PHM community is challenged to implement these recommendations to spur change for the care of hospitalized children throughout the country. Given the variety that exists in PHM, specifically in practice settings, it may be a daunting task. Dr. O’Callaghan said that differing opinions among physicians in a group may be a challenge to implementing change. “These recommendations allow for those conversations” to take place, he said. Dr. Lee said she hopes these recommendations provide a national panel opinion of the evidence to help support hospitalists in management discussions with others in a hospital – such as subspecialists or emergency department physicians – to increase high value care.

Since the nature of hospital medicine is one of collaboration, these recommendations will allow pediatric hospitalists to lead change throughout their hospitals and health care systems. However, it may not be a quick task. Dr. Alvarez estimates it may take 10-15 years until these recommendations are fully implemented throughout the country. However, there is reason to be optimistic, as the initial PHM Choosing Wisely® recommendations from 2012 have been broadly accepted and now represent national standards of care.

While the road ahead may be long and filled with challenges, the path forward has been clearly delineated, and the PHM community is grateful for the work done by members of the Choosing Wisely® Pediatric Hospital Medicine committee.

Dr. Casey is a pediatric hospitalist at Joe DiMaggio Children’s Hospital in Hollywood, Fla., and a member of the Society of Hospital Medicine’s Pediatric Special Interest Group’s Executive Council.

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