Do you ever find yourself concerned that you or your colleagues are providing tests or treatments that are unnecessary or of limited benefit? Choosing Wisely®, a campaign from the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports, aims to promote conversations between clinicians and patients to choose care that:
- Is supported by evidence
- Is not duplicative of other tests or procedures already received
- Has the lowest possible risk for harm
- Is truly necessary
The Choosing Wisely lists of "Things Providers and Patients Should Question" were created by more than 70 professional societies. These "by clinicians for clinicians" recommendations cover tests, treatments and procedures commonly encountered in a variety of specialties. Each list provides evidence physicians and patients can use in their conversations to decide whether tests and procedures are appropriate for the situation. Using Choosing Wisely lists can help you reduce low‑value and unnecessary care in your practice while becoming a better steward of health care resources. Choosing Wisely is not a set of rigid guidelines, but rather a strategy for engaging with patients and colleagues.
What defines low-value care?
Low-value care is care that either does not improve health outcomes or does so using resources that are disproportionate to the benefit that a patient derives. Simple examples include duplicative testing, too-frequent testing, interventions that have been shown to be ineffective or unnecessary, and care that patients may not have chosen had they been better informed about the risks and benefits.
Five STEPS to advancing Choosing Wisely® in your practice
- Engage your providers
- Engage your staff
- Engage your patients
- Establish an implementation plan for the practice
- Use data to understand and improve performance
Engage your providers
Center the conversation around the benefit for the patient. The national Choosing Wisely campaign has found that the issues of safety and patient-centered care resonate with physicians more than discussions of waste and cost reduction. Agree to pilot Choosing Wisely in one disease area or with one diagnosis and see how it works.
It is also important to emphasize that Choosing Wisely recommendations are conversation starters, not mandates, and that medical decision-making is based on the patient’s best interest. It is expected that physicians will sometimes deviate from clinical practice guidelines and the Choosing Wisely recommendations based on patients’ unique circumstances and the physician’s own professional judgment.
How do we begin the conversation?
Consider discussing the following with your colleagues as you look for areas that could be improved by following Choosing Wisely recommendations:
- What guidelines do we currently follow?
- Why are we concerned about inappropriate use or overuse?
- What are we measuring and how are we measuring it?
- What difference will it make to our practice and our patients if we reduce overuse of these specific tests or procedures?
- Can we eliminate sources of possible harm, such as radiation exposure, by changing our procedures?
What are the barriers to implementing Choosing Wisely? (or "Won't this increase my malpractice risk?" or "Won't this decrease patient satisfaction?") How do we overcome these barriers?
Poll your team about their concerns and address them head-on. Physicians who are especially concerned about malpractice claims may be more likely to engage in defensive practices, such as ordering unnecessary tests.1,2,3 However, unnecessary testing that leads to harm could be a source of malpractice claims.
For example, unnecessary imaging studies that are ordered unnecessarily may lead to the discovery of unanticipated findings, which can then result in further invasive testing, such as biopsies of the liver, pancreas or lung, with serious potential physical complications. This may also lead to unnecessary anxiety and depression for patients.
Physician-patient communication is the most important factor related to patient satisfaction with treatment recommendations.4 While a parent who arrives with a child with a lingering cough may expect an antibiotic, you can use Choosing Wisely patient handouts to facilitate an informed discussion on the recommended non-antibiotic approach. Anticipating these conversations will make the move to Choosing Wisely easier. The most common barriers to moving toward this type of higher-value care, as determined by a survey of 189 clinicians at Group Health Cooperative in Seattle, are5:
Perceived barrier (percent of clinicians) Solution Time constraints (45 percent) Address pressures that result from short visits to improve the physician‑patient encounter. Overcoming patient preferences/values (44 percent) Listen and respond with empathy when discussing providers' testing preferences and patient values. In many instances, communication, not ordering or prescribing, is key to patient satisfaction. Community standards (43 percent) Provide time to discuss this topic during a monthly team meeting. Include topics other than Choosing Wisely, such as immunizations. The takeaway messages could include a mixture of "do more of this" (immunizations) and "less of that" (Choosing Wisely topics). Fear of patients' dissatisfaction (41 percent) Encourage listening and demonstrating empathy, which can help you increase patient satisfaction because your patients will feel more involved in the decision‑making process. Patients’ knowledge about the harms of low‑value care (38 percent) Have patient-friendly educational materials accessible in the waiting room and exam room. Consumer Reports has developed numerous downloadable materials in partnership with the Choosing Wisely campaign. Availability of tools to support shared decision-making (37 percent) Obtain tools to educate your team on shared decision-making and to improve communication with patients.
Source: AMA. Practice transformation series: advancing Choosing Wisely®. 2016.
Engage your staff
Consider having your clinical support staff provide patients with appropriate Consumer Reports handouts when rooming patients for specific complaints (e.g., headache, upper respiratory infection, low-back pain, cervical cancer screening). For example, when the nurse or medical assistant (MA) rooms a patient who thinks they have a sinus infection, s/he can provide the patient with the Choosing Wisely handout on sinusitis. By reading the handout ahead of the physician visit, the patient may be more likely to agree to a non-antibiotic approach to treatment.
It is important to educate the care team members who often field questions from patients, including:
- Your MAs or nurses, who room patients and discuss after-visit summaries, could be trained to utilize Choosing Wisely materials as part of their professional development curriculum
- Your health coaches, who may have discussions with patients about specific treatment options and tests related to chronic disease management
While engaging your staff in the Choosing Wisely initiative, it is important to acknowledge that medical decision‑making should always be based on the patient's best interest. Clinicians can always deviate from clinical practice guidelines based on their own professional judgment. Local standards of care and other factors must be taken into consideration.
Be a better steward of health care resources #STEPSforward
Engage your patients
Much of the success of implementing Choosing Wisely hinges on your ability to engage your patients in a dialogue about the purpose of tests, treatments and procedures so they have a clear understanding of what’s necessary, what’s not and what could cause them harm. Initiate the dialogue by demonstrating empathy for your patient's desires, needs and concerns; their cues will tell you when they are ready for you to introduce decision aids or patient education as part of a conversation about low-value care.
Consumer Reports partnered with the ABIM Foundation and leading medical societies on the Choosing Wisely campaign to create patient-friendly materials that cover unnecessary medical care as well as specific topics, such as use of antibiotics for sinusitis, CT scans for headache, frequency of Pap smears, and imaging for back pain. For example, many patients with chronic heartburn use proton pump inhibitors on a regular basis but may be able to control their symptoms with lifestyle modifications and/or an acid blocker such as a histamine H2 receptor antagonist. The Choosing Wisely handout on heartburn can facilitate the discussion between provider and patient.
You may choose to print these handouts and make them available in the waiting area and in your exam rooms. If you use a patient portal, you might send targeted handouts to patients before their appointment. Select the handouts that are most applicable to your Choosing Wisely focus area here.
How can we better partner with patients and families on this initiative?
Engage patients and families early and often. Patients may be confused by conflicting information they receive from their physicians, consumer groups and medical professional societies. You may consider including questions about testing procedures and communication about tests on your patient satisfaction survey. A patient and family advisory council or patient advisory board can assist you by vetting communication materials and evaluating the rollout of your new approach. Hosting a one-time focus group where a few patients discuss these topics with the clinicians can also be valuable.
Don’t patients feel that more is always better?
Highlighting negative consequences of overuse, such as the fact that radiation is harmful and can cause cancer, is often all that is needed to balance patients' desire for more care with their desire to avoid harm. Initiating a conversation helps distinguish between a true demand for additional care and the physician’s perception of a demand that may not in fact exist. Demanding patients are memorable, but in reality they are uncommon.12
Won’t my patient satisfaction scores go down if I don’t meet patients' requests for tests or antibiotics?
Offering a patient with a mild respiratory infection a "delayed prescription" for antibiotics may help the physician make the right choice while also meeting the patient's expectations. Likewise, a patient with acute back pain who is requesting an X-ray is often more comfortable knowing that the test will be done if he or she does not improve over time. However, as mentioned previously, positive and productive communication between patient and provider has a greater impact on patient satisfaction than an antibiotic prescription or an order for more testing.4 It is important for organizations that measure patient satisfaction scores to keep this in mind and ensure that this unintended consequence does not occur.
Establish an implementation plan for the practice
Some practices may want to go beyond simply increasing awareness and making handouts available at the point of care. If your practice decides to more formally implement and systematize the Choosing Wisely initiative, then your implementation plan may be more elaborate.
Implementation could take the form of a formal educational program, as well as checklists and protocols to help standardize the new processes. You may even choose to work with your IT department to embed Choosing Wisely recommendations into clinical decision support tools within the electronic health record (EHR; with alerts, reminders and/or order sets). Be aware, however, of the unintended consequences of forcing functions and documentation of variations from the recommendations. Choosing Wisely recommendations are intended to be starting points for conversation, not rigidly imposed guidelines.
To educate your practice about Choosing Wisely, consider using the physician communication modules available at http://www.choosingwisely.org/resources/modules/. Watch the videos and learn together during a scheduled team meeting.
Use data to understand and improve performance
Tracking and reporting will help determine if implementation of the Choosing Wisely recommendations is effective in your practice. Sharing peer comparison data over time is one of the strongest interventions available for changing practice, and should be part of any strategy.
Where do we start with a data tracking initiative?
Ideas for opportunities could come from reviewing data in your EHR, pre-printed order sheets, standing orders from your team members. Target the tests you suspect may be overused, inconsistently used and/or harmful to patients.
Consider starting with clinical areas where overuse occurs frequently, such as lab testing or imaging. Another target is any area where large amounts of variation exist. Review common tests and treatments by provider, establish a baseline and then compare and contrast to identify variability. Examples include appropriate antibiotic use, X-rays for back pain or too-frequent Pap smears. Where possible, use recommendations that have tested and validated measures.
Choosing Wisely lists are a starting point for conversation, not a set of rigid guidelines.
Choosing Wisely connects patients and clinicians by focusing both communities on achieving the same goals.
Choosing Wisely recommendations are purposefully broad, allowing you to tailor them to your practice needs.
Involve patients and families in the effort—they can review educational materials, help you determine an improvement topic and test new trategies.
Make sure you anticipate unintended consequences, such as the impact on referral relationships, when you limit some tests or increase testing in other areas.
Choosing Wisely may help you find the "sweet spot" in clinical practice: not too little, not too much, but just the right amount of care.
The data strategy for evaluating Choosing Wisely effectiveness should be timely and transparent to all in the practice. Be pragmatic about the measures that will be used.
Adequate time should be allotted to define and discuss current practice patterns. Administration must be engaged to support the work of implementing and evaluating Choosing Wisely.
Advancing Choosing Wisely is possible by engaging providers, staff and patients, and committing to continue practicing evidence-based medicine. Adopting the Choosing Wisely lists will support your practice in delivering higher-quality care and minimizing potential risks to patients.
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- Carrier ER, Reschovsky JD, Katz DA, Mello MM. High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Aff. 2013;32(8):1383-1391. http://content.healthaffairs.org/content/32/8/1383.long.
- Carrier ER, Reschovsky JD, Mello MM, Mayrell RC, Katz D. Physicians’ fears of malpractice lawsuits are not assuaged by tort reforms. Health Aff. 2010;29(9):1585-1592. http://content.healthaffairs.org/cgi/pmidlookup?view=long&pmid=20820012.
- Choosing Wisely. Research Report. http://www.choosingwisely.org/about-us/research-report/. Accessed March 10, 2016.
- Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med. 2001;134(6):521-529. http://annals.org/article.aspx?articleid=714361.
- Buist DS, Chang E, Handley M, et al. Primary care clinicians’ perspectives on reducing low-value care in an integrated delivery system. Perm J. 2016;20(1):41-46. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732793/.
- Choosing Wisely. http://www.choosingwisely.org/. Accessed March 10, 2016.
- Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. http://archinte.jamanetwork.com/article.aspx?articleid=2457401.
- Rashid A. "Goldilocks Medicine:" the quest for "just right." The BMJ. http://blogs.bmj.com/bmj/2016/01/20/ahmed-rashid-on-goldilocks-medicine-the-quest-for-just-right/. Published January 20, 2016. Accessed April 25, 2016.
- The ABIM Foundation and Choosing Wisely. Unnecessary tests and procedures in the health care system: what physicians say about the problem, the causes and the solutions. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed May 4, 2016.
- Brehaut JC, Colquhoun HL, Eva KW, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med. 2016;164(6):435-441. http://annals.org/article.aspx?articleid=2494536.
- Grover M, McLemore R, Tilburt J. Clinicians report difficulty limiting low-value services in daily practice. J Prim Care Community Health. 2016;7(2):135-138. http://www.ncbi.nlm.nih.gov/pubmed/26763305.
- Back AL. The myth of the demanding patient. JAMA Oncol. 2015;1(1):18-19. http://oncology.jamanetwork.com/article.aspx?articleid=2108844.
- Choosing Wisely. Lists. http://www.choosingwisely.org/doctor-patient-lists/. Accessed March 10, 2016.
- Kost A, Genao I, Lee JW, Smith SR. Clinical decisions made in primary care clinics before and after Choosing Wisely. J Am Board Fam Med. 2015;28:471-474. http://www.jabfm.org/content/28/4/471.full.pdf+html.
- AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2013;61(4):622-631. http://onlinelibrary.wiley.com/doi/10.1111/jgs.12770/abstract;jsessionid=470DA9A8A0F42A49B5D1B569640FAFB9.f03t04.
- Pennsylvania Patient Safety Reporting System. The Five Rights: Not the Gold Standard for Safe Medication Practices. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/jun2(2)/documents/09.pdf. Published 2005. Accessed March 25, 2016.
- Consumer Reports. Choosing Wisely. http://www.consumerreports.org/cro/health/doctors-and-hospitals/choosing-wisely/index.htm. Accessed March 10, 2016.
- Consumer Reports. Choosing Wisely campaign brochures. http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials. Accessed May 6, 2016.
- Choosing Wisely. Physician communication modules. http://www.choosingwisely.org/resources/modules/. Accessed March 10, 2016.
STEPS in practice
How’s it working in Milton, PA?
At Geisinger-Milton, a primary-care practice in Milton, PA, following the Choosing Wisely methodology supports their core mission of "doing what’s right for patients." When Choosing Wisely recommendations were rolled out to all Geisinger Health System practices in 2013, this meant incorporating the recommendations into existing preventive medicine and chronic care bundles. The Geisinger-Milton practice specifically leveraged the Choosing Wisely recommendations to support ongoing efforts to decrease the number of inappropriate Pap smears, limit antibiotic use and reduce rates of routine prostate-specific antigen (PSA) screening.
The biggest challenge to fully implementing the Choosing Wisely recommendations has been in addressing overuse of antibiotics. Patients often come with the expectation that an antibiotic will "fix them," so the practice has focused on education to reframe the conversation. Posters on the clinic walls explain the risks of antibiotic overuse, and a great deal of effort has gone into teaching the care team about the risks and benefits of antibiotic use for bronchitis and upper respiratory infection.
Conversely, one of the biggest successes following implementation of the Choosing Wisely recommendations has been a decrease in sepsis cases following prostate biopsy, from three to four cases per year to one case per year. Fewer PSA screens have resulted in fewer false positives and thus fewer biopsies, which ultimately reduced the risk of post-surgical sepsis. It is also important to note that no corresponding increase in cancer mortality has been observed with this change.
Because the practice incorporated the Choosing Wisely methodology into existing protocols and procedures, there was no resistance and the process was simple—it became a natural part of the workflow. The EHR already included best-practice alerts for health maintenance topics, and parameters were modified to follow the Choosing Wisely lists. Alerts now flag specific diagnoses, orders, and procedures, such as benzodiazepine use in patients over the age of 65 and recommended screening intervals. The care team was initially notified of the updates that were made to the existing EHR alerts based on the Choosing Wisely lists; however, no additional training was required to begin following the lists.
Positivity is essential when thinking about Choosing Wisely and how to apply the lists in practice. Emphasize what to do rather than what not to do. For patients, that means refraining from saying "don’t do this" without understanding what will work for their unique situation and providing an alternative solution. Even the few negative alerts in the EHR have been reframed to position the recommendation in a positive light and help patients determine what they need to do.
Currently, the Geisinger-Milton practice has adopted approximately 30 percent of the Choosing Wisely recommendations that apply to their patient panel. Their goal is to incorporate more radiology lists to preempt preauthorization discussions. Eventually, they hope to expand to 80 to 90 percent adoption and begin working in areas not covered by their care bundles.
How’s it working in Pennsylvania?
The nearly 70 practices of the Geisinger Health System in Pennsylvania were already on the road to reducing the number of low-value procedures and treatments when the national Choosing Wisely initiative was launched in 2012 by the American Board of Internal Medicine. The efforts of the Geisinger system included following protocols and procedures to determine when to do imaging for low-back pain and when to prescribe antibiotics for sinusitis. The Choosing Wisely initiative bolstered the rationale and provided justification for some of the decisions already being made by the Geisinger system practices, and validated their existing protocols and procedures.
Once introduced, the Choosing Wisely initiative acted as a catalyst to more actively engage physicians in promoting quality and safety. The Choosing Wisely lists, which are evidence-based sets of recommendations for avoiding unnecessary tests and procedures, are trusted and respected and provide valuable and accessible starting points for quality improvement. The lists are specifically vague and provide a high-level roadmap that individual practices can refine into unique turn-by-turn directions that their specific teams can follow.
Although each practice is part of the integrated Geisinger Health System, selecting, refining, and implementing the Choosing Wisely recommendations occurs at the practice level and not as part of a larger "top-down" initiative from the system’s administration. These activities happen organically, with providers selecting the areas they’d like to work on and rolling out the changes on their own schedule. Recommendations are shared with clinicians and team members who interact with patients. Discussion focuses on "Which ones resonate? Which ones provide the most opportunity?"
After the initial selection phase, practices take advantage of the Choosing Wisely training videos that are relevant to their clinics and their specific efforts to minimize low-value care. In addition, the practices share educational materials from the Choosing Wisely and Consumer Reports websites with patients to start a dialogue about the care plan.
Choosing Wisely recommendations have been implemented over the course of three years throughout the practices and the 12 hospital campuses that are part of the Geisinger system. One of the first projects involved building a customized clinical decision support (CDS) function within the EHR system for evaluating low-back pain that follows the Choosing Wisely recommendations. Education around this CDS tool highlighted the fact that Choosing Wisely recommendations were being followed so that providers would know that the tool and its determinations were supported by evidence.
Tracking and measuring changes in procedures and treatments over time is standard. A centralized data warehouse captures both practice and hospital data. Decreases in antibiotic usage and high-end radiology usage have been observed at the practice level. On the hospital side, decreases in urinary catheter usage and blood transfusions have been documented.
While a system-wide recognition of the overuse of tests and treatments is critical to initiating change, organizational culture also plays a large role. Within the Geisinger system, the success of implementing Choosing Wisely recommendations is related to two key organizational tenets: a culture of safety and a culture of value. The decrease in the use of urinary catheters, which are often associated with healthcare-acquired infections, can be attributed to a culture of safety. The decrease in antibiotic use and radiology orders can be attributed to a culture of value.
Momentum for adopting the Choosing Wisely recommendations continues to build as the Geisinger system explores new ways to implement CDS tools for radiology and cardiac imaging. In addition, physicians within the Geisinger system are starting to use Choosing Wisely as a teaching mechanism for residents, thereby expanding its reach to the next generation of practitioners.
How’s it working in Washington?
A patient sees a TV commercial offering a cure or solution and asks about this specific treatment during his/her visit. Another patient attempts to self-diagnose and is convinced he needs a test or treatment discovered online. While these scenarios may not occur frequently, they are often interpreted by the clinician as demands for a particular product or service. Many clinicians at Group Health Cooperative (Group Health), an integrated care and financing organization headquartered in Seattle, WA, initially believed that patients would be disappointed if they did not receive the care or treatment they wanted. This left clinicians feeling trapped between perceived patient demands and the organization’s goal of minimizing low-value care.
Group Health decided to take a careful look at the patient requests they were fielding and discovered that many stemmed from a desire for an explanation of risks, benefits and alternatives rather than a demand for a specific test or treatment. Group Health has worked to help busy clinicians shift from interpreting these scenarios as "demands for services" to seeing them as partially-informed patient requests. While the first task of the clinician in these situations is to listen and demonstrate empathy, providing better information is an important part of a successful visit. They turned to Choosing Wisely® to help educate patients who may have expectations or misinformation about the service their clinician is recommending (or recommending against).
The organization adopted Choosing Wisely recommendations in specific clinical areas that were simple, mainstream and non-controversial. In primary care, they started with the clinical areas of antibiotic overuse for upper respiratory infections (URI) and the overuse of Pap tests. Antibiotic use for URI was a particularly easy win because there is professional consensus around the need to reduce antibiotic overuse. Emergency department, urgent care and neurology clinics began with the Choosing Wisely clinical area of imaging for headaches. Having a focus, rather than trying to address a myriad of targets, was important for initial implementation and sustainability.
Group Health has a significant online presence, with nearly 70 percent of patient touches occurring through the patient portal or by phone. They leveraged this resource by embedding a patient-friendly Choosing Wisely microsite co-branded with Consumer Reports. Patients can access the microsite from the Group Health patient portal or website. Many clinics also hand out printed materials from Consumer Reports Health, such as visual aids that explain the duration of URI symptoms.
Group Health also has a comprehensive approach to the use of shared decision-making for preference‑sensitive surgical conditions, such as joint replacement, back surgery, prostate surgery and benign uterine conditions. This approach uses video decision aids as a foundation for better conversations between patients and clinicians. Often patients desire less medical care after viewing the videos.
To hardwire Choosing Wisely into the workflow, practices piloted a new process that emphasized handing educational materials directly to the patient rather than just displaying them in the exam room. Medical assistants and nurses received basic suggested scripts to help them discuss the materials with patients during the rooming process. Messages with talking points about URI and antibiotic use were sent to staff to reinforce guidelines.
To address overuse of Pap tests, Group Health added an innovation to their workflow: an electronic trigger tool that flags Pap test orders that are clinically inappropriate. A note is sent to the clinician if they’ve ordered an inappropriate Pap test. This note contains a clinical pearl along with key messages to help the clinician explain to patients why a Pap test is not recommended. Clinicians receive an email within a week of ordering a Pap test too frequently. This tool provides near immediate feedback and since its introduction, Group Health has observed a 25 percent reduction in the number of Pap tests performed. Group Health hopes that Choosing Wisely approaches will be ingrained in how clinicians practice, making the use of trigger tools on certain topics unnecessary over time.
As part of implementing Choosing Wisely, clinicians also adjusted their approach to conversations with patients. They began listening with empathy and granting grace. This entails acknowledging symptoms, demonstrating empathy and asking what they can do to manage a patient’s discomfort as opposed to stating what cannot be done. At Group Health, Choosing Wisely is not viewed as a restriction on practice but as a mechanism to help clinicians focus on patient-centered and safer care.
Overall, prescribing rates are lower and patients are having better experiences in the exam room. Group Health has observed a 33 percent decrease in inappropriate Pap tests and inappropriate imaging for headache. Data is transparently reported so that clinicians can discuss the results with their peers to better understand variability.
Group Health was impressed by several of the unexpected benefits of using Choosing Wisely Consumer Reports Health materials. They felt the patient-friendly materials were better than anything they could have created themselves, which was both a surprise and a delight. They also underestimated the joy that gathering clinicians to talk about clinical medicine would bring to teams. This created a positive feedback loop and improved practice culture. Clinicians reaffirmed how satisfying it was to celebrate successes through sharing patient stories and rejoicing in individual accomplishments, holding them up as heroes to the group.
The next phase is to spread Choosing Wisely to Group Health oncology practices to support decision‑making on advanced care planning and the use of chemotherapy at the end of life. In addition, the recommendations will be used to target the overuse of imaging studies in a variety of clinical settings.
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