'Choosing Wisely' Reduces Some Unnecessary Testing

Diana Phillips

October 15, 2015

The use of imaging for uncomplicated headache and cardiac stress imaging for low-risk patients has declined significantly during the last few years with the implementation of the American Board of Internal Medicine Foundation's Choosing Wisely campaign.

Launched in 2012, Choosing Wisely was designed to make physicians aware of commonly overused medical procedures by publishing lists of tests compiled by different medical speciality societies that are frequently used but provide minimal benefit to patients in most situations.

In an analysis of the campaign's effectiveness published online October 12 in JAMA Internal Medicine, Alan Rosenberg, MD, from Anthem Inc in Indianapolis, Indiana, and colleagues quantified the frequency and trends of some of the earliest Choosing Wisely recommendations, using national population-level data based on medical and pharmacy claims from Anthem-affiliated commercial health plans for approximately 25 million individuals. Specifically, they chose seven low-value services to assess:

  • imaging for uncomplicated headache,

  • cardiac imaging without history of cardiac conditions,

  • low back pain imaging in the absence of red-flag conditions,

  • preoperative chest X-rays with unremarkable history and physical examination results,

  • human papillomavirus testing for women younger than 30 years,

  • antibiotics for acute sinusitis, and

  • prescription nonsteroidal anti-inflammatory drugs for select chronic conditions, including hypertension, heart failure, or chronic kidney disease.

Depending on when the Choosing Wisely recommendations were issued for a particular test, the investigators collected data for each test for at least 10 calendar quarters beginning in either 2010 or 2011, up to the third quarter of 2013, analyzing usage patterns before and after the recommendations were issued for each of the tests.

During the 2- to 3-year span, cardiac stress imaging for low-risk patients without symptoms declined significantly, going from 10.8% to 9.7%, and imaging for uncomplicated headache declined significantly, going from 14.9% to 13.4%, the authors report.

Significant utilization growth was observed in human papillomavirus testing for women younger than 30 years, going from 4.8% to 6.0%, and in the prescription of nonsteroidal anti-inflammatory drugs for individuals with chronic conditions, going from 14.4% to 16.2%; no significant changes were seen in the remaining three tests.

The mixed results "highlight the need for interventions beyond the current level of promotion, such as data feedback, physician communication training, systems interventions (eg, clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives," the authors write.

The study's reliance on population-level data precluded the examination of patient-level risk differences and regional variations, both of which might warrant evaluation in future studies, according to the authors. Similarly, they note, "[i]t is possible that assessing the local implementation of Choosing Wisely recommendations at the delivery system level could be a fruitful area for future studies," as would the creation and validation of measures for Choosing Wisely recommendations.

Lack of Evidence

In one of two commentaries on the study published in the same issue of the journal, David H. Howard, PhD, from Emory University in Atlanta, Georgia, and Cary P. Gross, MD, from Yale University School of Medicine in New Haven, Connecticut, suggest that the lack of comparative effectiveness research is a barrier to discouraging use of low-value tests and procedures.

"Many of the interventions cited in the Choosing Wisely campaign were deemed low value precisely because they have not been tested in trials," Dr. Howard and Dr. Gross write.

"Although it is not feasible to conduct a trial of every service mentioned in the Choosing Wisely recommendations, the lack of high-quality evidence will hamper efforts to reduce low-value care."

In addition to ongoing efforts to reduce low-value care, trials "comparing established medical treatments with less costly alternatives" should be pursued, according to Dr. Howard and Dr. Gross. "There is a need for evidence that will guide decisions about clinical care. Instead of asking, 'Does evidence affect practice?' we ought to be asking, 'How can we produce more of it?' "

Just a “Starting Point”

In a separate commentary published in the same issue of the journal, Ralph Gonzalez, MD, MSPH, and Adithya Cattamanchi, MD, MAS, from the University of California, San Francisco, explain that awareness of guidelines or health-related information on its own is not enough to change clinician or patient behavior.

"Although there is no 'magic bullet,' sustained clinician behavior change generally requires multilevel and multifaceted strategies," they write, noting that the Choosing Wisely recommendations are only a "starting point" toward reducing wasteful medical practices. Delivery systems and clinician groups must "develop and implement strategies that make it easier for clinicians to follow Choosing Wisely recommendations."

Correction: The year the Choosing Wisely campaign was launched was incorrectly stated. We have now corrected the error.

Research support for this study was provided by Anthem. The authors and commenters have disclosed no relevant financial relationships.

JAMA Intern Med. Published online October 12, 2015. Article abstract, Howard and Gross extract, Gonzales and Cattamanchi extract

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