Do Societies Play It Too Safe With Choosing Wisely Lists?

Marcia Frellick

February 12, 2015

Low-value items on Choosing Wisely (CW) lists may be diverting attention from procedures that truly drive up costs, authors of a new study say. They found that although cardiac stress testing before low-risk surgeries was rarely being done before the CW effort launched, seven specialty societies included it on their lists of top procedures to watch for overuse.

To find out whether societies might be focusing on procedures that had a low baseline use, Eve Kerr, MD, MPH, from the Veterans Affairs Center for Clinical Management Research and professor of internal medicine at the University of Michigan Medical School in Ann Arbor, and colleagues looked for routine preoperative stress testing in the two largest US federally backed healthcare programs: the Department of Veterans Affairs and fee-for-service Medicaid. Dr Kerr told Medscape Medical News they chose the stress test because it appeared widely on societies' lists.

They found that the stress test was used before cataract surgery, knee arthroscopy, or shoulder arthroscopy in only 0.67% of Veterans Affairs patients and 2.14% of Medicare patients from February to December 2009, more than 2 years before the CW campaign was launched. The researchers report their findings in a research letter published online February 9 in JAMA Internal Medicine.

Campaign Aims to Reduce Costs

The American Board of Internal Medicine (ABIM) Foundation began the CW campaign in 2012 and asks specialty societies to identify overused procedures that should be avoided to improve care and cut costs.

The authors of the research letter conclude that putting procedures such as the stress test on CW lists dilutes their benefits.

"It appears that most physicians had already incorporated guidelines about appropriate preoperative stress testing into their practices before the CW recommendations became available," the researchers explain. "Although this is good news for patients, it is not helpful for a campaign that aims to improve appropriateness. Specialty societies should focus future CW recommendations on services that have high baseline rates of inappropriate care to call attention to areas where interventions can best improve quality."

As previously reported by Medscape Medical News, some experts have said there can be political and economic incentives behind the choices. For example, authors of a 2014 opinion piece published in the New England Journal of Medicine called for more "courageous" lists.

Dr Kerr suggests societies have more transparent and systematic criteria for how the procedures are chosen.

"[CW] is a very important step in improving the quality of care that patients get," she told Medscape Medical News. However, it is important to "extend the conversation to which recommendations are going to give us the biggest impact in quality of care, and I don't think that's been done yet."

That sentiment was echoed in an accompanying editor's note by Rita Redberg, MD, professor at the University of California, San Francisco, School of Medicine. "With the growing clout of the [CW] campaign, now is the time for professional societies to be bolder in identifying common interventions that add little value to our medical care."

However, Daniel Wolfson, executive vice president of the ABIM Foundation, argues that there are plenty of examples of bold targets for overuse, among them the American Society for Radiation Oncology's call for an end to the use of proton beam therapy for the treatment of prostate cancer unless the therapy is used in the context of a clinical trial.

He told Medscape Medical News that singling out one example, such as stress testing before low-risk surgery, misses the overall benefit of the program.

"This campaign was based on having important conversations and dialogue about appropriate and necessary treatment.... People are now beginning to focus on overuse as a result of this campaign," he noted.

He says the ABIM Foundation gives the societies parameters for the lists, including that items must be evidence-based, are in the control of the society, are transparent, and are frequently done. The lists are reviewed by the ABIM, but the evidence is held by the societies. The autonomy has been important to the success of the campaign, he said.

"Are we perfect at doing this? No, we've just begun. But we're getting better, and the things that are important will be implemented by the delivery systems," he said.

This study was supported in part by the Veterans Health Administration and the Agency for Healthcare Research and Quality. Dr Redberg, Dr Kerr, and Wolfson have disclosed no relevant financial relationships.

JAMA Intern Med. Published online February 9, 2015. Research letter extract, Editor's note extract


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