Choosing Wisely Lists Dominated by Cost Considerations

Healthcare costs figured highly in specialty medical societies' decision-making processes in determining what to include in their Choosing Wisely Top 5 lists, according to a research letter published in the April 9 issue of JAMA.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation to get specialty societies to develop lists of medical services that do not provide broad overall patient benefits but that still may be performed often. The goal is to phase out unnecessary use of these procedures or tests.

To learn more about how specialty medical societies were developing their Choosing Wisely lists, Catherine Gliwa, BA, and Steven D. Pearson, MD, PhD, from the Department of Bioethics, National Institutes of Health, Bethesda, Maryland, analyzed the "evidentiary rationales provided by specialty societies" when they issued their lists.

They reviewed lists from 25 participating societies who had submitted 1 or more lists by August 2013. The lists included 135 medical services. Using information provided by the societies, they categorized the societies' rationales in terms of evidence for risks vs benefits, how risks and benefits compare with alternatives, and comparative costs or cost-effectiveness among services.

For 102 services (76%), societies stated that a service was listed because "adequate evidence demonstrated no additional benefit with higher risk, higher cost, or both, compared with other options," the authors write. Of the 25 societies, 15 (60%) listed at least 1 service because of its higher costs.

The next most common rationale for inclusion on a list turned out to be insufficient evidence to make comparisons for benefits.

Diagnostics, Treatments, Screenings

The services were fairly evenly split among patient diagnostics (49, 36%), treatments (46, 34%), and population screening (40, 30%), according to the authors.

Among all 135 services, the rationales for inclusion were split among greater patient risks (66, 49%), higher costs (33, 24%), both greater risk and higher costs (21, 16%), and neither (57, 42%).

"Our data show that the issue of cost was almost always raised in the context of a service being judged as good as other options but more expensive," the authors write. They recommend that societies emphasize services that provide smaller incremental benefits at much higher prices.

They conclude, "Specialty societies can enhance trust in the Choosing Wisely campaign by defining more clearly the types of potentially wasteful medical care they seek to eliminate, and by providing a clear evidentiary justification for the selection of each service."

This research was supported by the Intramural Research Program of the National Institutes of Health.

JAMA. 2014;311:1443-1444. Abstract

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