Assessment and study of knowledge and practice across different settings in Lebanon based on the recommendations of the American Society of Hematology Choosing Wisely campaign (ASK-PADS study)
Authors: Antoine N. Saliba, Hassan Moukhadder, Hassan Beydoun, Afif Harb, Rania Farhat, Hussein Abou Ghaddara, Ali T. Taher
Journal: American Journal of Hematology (2018)

The Choosing Wisely campaign was started in 2012 by the American Board of Internal Medicine with the aim of improving awareness about the avoidance of wasteful or unnecessary medical tests and interventions (24 April 2015; http://www.choosingwisely.org/). The American Society of Hematology (ASH), for example, has published a list of 10 recommendations that every physician and patient should consider, regarding the diagnosis and treatment of certain hematological conditions (Supporting Information Appendix A; 24 April 2015; http://www.choosingwisely.org/). The impact of Choosing Wisely is likely to be greater in countries with economic and political instability where healthcare services are still not as well organized. Because the majority of the global population resides in low- to middle-income countries (LMIC), it is especially important to explore the theoretical effects of introducing Choosing Wisely campaigns into LMIC. In LMIC, prioritization of medical care and just allocation of services would not only decrease healthcare costs but also allow for redistribution of resources, which might be very limited in certain locations or time periods. The home institution for this study endorses the practice of medicine based on the highest standards governed by guidelines of care followed in the United States. In the absence of updated national guidelines in Lebanon, physicians at our institution follow guidelines set by American expert societies. In this article, our aim is to critically explore the knowledge and practice of Lebanese physicians—family physicians, internists, and hematologists/oncologists—regarding the ASH Choosing Wisely recommendations, while using the Lebanese setting as a potential prototype for other LMIC in terms of awareness about Choosing Wisely. We also aim at comparing the reported practice by these physicians to their knowledge and comparing the knowledge and practice of physicians working at our home institution with those of other physicians practicing in the Lebanese community regarding the Choosing Wisely recommendations set by ASH. This study was exempted from review by the Institutional Review Board (IRB). All questionnaires were anonymous. Within our home institution, questionnaires (Supporting Information Appendix B), including 10 knowledge questions and 10 questions about medical practice, were distributed by direct personal approach to 53 internal medicine residents, 6 family medicine residents, 6 hematology/oncology fellows, 2 attending family physicians, and 15 attending physicians from different internal medicine specialties (11 internal medicine and 4 hematology/oncology). The questions were based on the 10 ASH Choosing Wisely recommendations and were validated by face-to-face interviews with six physicians (internists, hematology/oncology specialists, residents physicians) from our institution and surrounding community practices prior to distribution of the questionnaires to respondents. No areas of potential misinterpretation were identified during the validation process. Questionnaires usually took 5-10 min and were filled in the presence of a research coordinator while ensuring full confidentiality with blinding of the research coordinator to the answers. Oral consent was solicited from every participant; all participants were asked to read a brief consenting script. Outside the premises of our home institution, general practitioners were approached and asked to fill out the same questionnaire mostly at national meetings for general practitioners. All samples were convenience samples. Each question is divided into two parts with the first one testing knowledge and the second assessing practice patterns. In other words, the first part tests whether the participant knows the actual answer and the second part whether they would do the right thing in practice. A knowledge score was calculated by counting the total number of correct answers. A practice score was calculated by counting the total number of right decisions that clinicians would make in practice. Stratified analysis of the associations between these scores and respondent characteristics was carried out according to specialty (internal medicine vs. family medicine or general practitioners), type of practice (university-based vs. community-based), level of training for residents (postgraduate year, resident vs. fellow), and years of experience. Among nonhematology/oncology internal medicine physicians, only the mean practice score (and not the mean knowledge score) differed significantly between the participating resident and attending groups (4.55 for resident and 3.60 for attending physicians, P = .025). The knowledge score was not significantly different between the nonhematology/oncology internal medicine housestaff group and the nonhematology/oncology internal medicine attending physician groups. The practice score of nonhematology/oncology internal medicine housestaff group was statistically significantly superior to the nonhematology/oncology internal medicine attending physician group (5.56 vs. 4.95, respectively). Nonhematology/oncology internal medicine housestaff had a statistically significantly higher knowledge score when compared with their corresponding practice score. This difference was not statistically significant in the nonhematology/oncology internal medicine attending physician group. Among participating attending staff, the mean knowledge and practice scores were significantly higher for hematology/oncology when compared with other specialties (7.80 vs. 5.18, P < .001, and 6.90 vs. 4.07, P = .001; Table 1). Among nonhematology/oncology specialists, the knowledge and practice scores were higher for those practicing in university hospitals when compared with those running community-based clinics (5.31 vs. 2.75, P = .002 and 4.19 vs. 1.75, P = .027, respectively). The trend toward higher knowledge scores in resident physicians when compared with attending physicians may be attributed to the fact that the residency training curriculum includes hematology/oncology. Attending physicians in other nonhematology/oncology internal medicine specialties could be unaware of the most recent recommendations and practice guidelines in hematology/oncology. A similar interpretation can be used to explain the statistically significant differences in both practice and knowledge scores between the hematology/oncology and nonhematology/oncology attending physician groups. Within the housestaff group, practice scores were significantly lower than knowledge scores. The higher knowledge and practice scores in university-based physicians vs. community-based physicians may be related to the fact that university hospitals are more stringent about adherence to guidelines established by expert medical societies, with the systematic dissemination of these principles among the attending staff practicing within their premises through structured continuing medical education sessions. The trend toward higher knowledge scores when compared with practice scores was consistent among the different groups studied including hematology/oncology specialists. One possible explanation is that attending physicians are subject to scrutiny of quality of delivered care and are always threatened with malpractice litigation. These factors collectively serve as barriers to implementation of the principles of Choosing Wisely. In addition, clinicians in our setting often feel compelled to accommodate patients' requests for tests and interventions they know are unnecessary, as suggested by data in the literature.3, 4 The discussions in healthcare delivery in Lebanon are partially governed by the increasing strain on the system to serve a continuously expanding population with the influx of immigrants from surrounding areas of conflict. Healthcare planning still focuses on finding the funds to maintain current practices rather than ensuring that providers follow cost-effective practices. A few elements of change, in a the polarizing and unsteady political environment like Lebanon's, are: changing physician attitudes (such as fear of missing a possible diagnosis or malpractice concerns), encouraging and empowering physicians to conduct challenging conversations aiming at discussing with patients the clinical utility of specific investigations or interventions, establishing reimbursement incentives, and spreading public awareness that doing more does not always mean doing what is better to the patient.5 Physicians are strongly encouraged to consider the ASH Choosing Wisely recommendations in their clinical practice, teaching of trainees, and planning of future research prospects. The cross-sectional design and the convenience sampling in our study limit both the control over selection bias and the analysis of knowledge and practice trends over time. The study serves as a basis for future larger prospective cohort studies or interventional studies exploring different educational approaches in hematology/oncology. The authors have no relevant conflicts of interest to disclose. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.