'Choosing Wisely' Turns 5, With Mixed Results

Miriam E. Tucker

October 25, 2017

WASHINGTON — The Choosing Wisely campaign can claim some successes in reducing inappropriate medical care, but, at the same time, there's much work left to do in reversing long-ingrained habits, speakers agreed at a forum held on the occasion of the campaign's fifth birthday.

During the 3-hour symposium, Choosing Wisely: Opportunities and Challenges in Curbing Medical Overuse, experts discussed the accomplishments of the American Board of Internal Medicine (ABIM)-led campaign, and where they believe it is headed. The event was sponsored by the journal Health Affairs, which published online October 24 two papers related to the campaign, one on physician awareness and views about Choosing Wisely and the other on the program's past, present, and potential future.

The Choosing Wisely campaign, in which participating medical specialty societies create lists of specific steps clinicians can take to reduce overuse of medical resources, began in 2012 with nine medical societies issuing 45 recommendations. Today, over 80 medical specialty societies have issued over 500 recommendations.

Commonly cited examples include "Avoid prescribing antibiotics for upper respiratory infections," from the Infectious Diseases Society of America; "Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam," from the American College of Radiology; and "Offer prostate-specific antigen screening for detecting prostate cancer only after engaging in shared decision making," from the American Urological Association.

"The Choosing Wisely campaign represents a practical expression of the core mission of the ABIM Foundation, to improve healthcare by strengthening medical professionalism," Richard J. Baron, MD, president and chief executive officer of the American Board of Internal Medicine and ABIM Foundation, said in his introductory remarks.

He continued, "how you get from the aspiration to do the right thing to actually changing behavior to front-line conversations and front-line actions…that's what Choosing Wisely is all about."

Initially, each participating society was tasked with producing a list of "five things" that were being done too often and that should be questioned, Dr Baron recounted. "It was basically the guideline process turned on its head. Instead of trying to identify all the things you had to do, what are some of the things that maybe you shouldn't be doing?"

Physician Awareness Remains Flat

Alexander J. Mainor, research project coordinator at Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, presented his new finding that despite continued publicity and physician outreach efforts, in 2017 only about one in four clinicians is aware of the campaign, not a significant change from 2014 (21% to 25%).

The majority of physicians who were aware of Choosing Wisely found the campaign's patient and physician materials to be helpful. But there was a slight, nonsignificant increase since 2014 in the percentage who reported difficulty in having conversations about avoiding low-value services, from 42% to 46% in 2017.

When the researchers asked physicians why they continued to provide services deemed to be low-value, they listed malpractice concerns most often, followed by "dealing with uncertainty," and "patient demand." 

However, Mainor pointed out that such concerns don't align with the literature on what is actually driving the practices and their impact. For example, Mainor and lead author Carrie H. Colla, PhD, note in their paper that there is little evidence that patients are demanding these low-value services, or that not offering them increases the risk for malpractice suits.

"In terms of future research, it's important to try to disentangle physician perceptions of the drivers of low-value care versus what's actually showing up in the empirical research because there's a definite disconnect." 

Los Angeles County: A Success Story

Eric Wei, MD, Interim Chief Quality Officer, Los Angeles County and University of Southern California Medical Center, explained why he became involved and brought his institutions into the campaign. "No matter how you measure low-value care, whether it be the $200 billion annually to our health care system, delays in care due to backlogs, false positives, incidental findings leading to more unnecessary care, or actual harm to patients due to errors, side effects, and bad outcomes to the tune of thirty thousand deaths a year, we simply cannot afford not to address this critical issue."    

He added that this situation is even more pronounced in the safety net setting, where resources are limited. For instance, if everyone with back pain is scheduled for magnetic resonance imaging, that creates long backlogs and harms people who truly need time-sensitive diagnoses such as for cancer.

In a collaboration between Los Angeles County Department of Health Services, UCLA, and Consumer Reports, an initiative to reduce preoperative testing for cataract surgery involved physician champions showing ophthalmology clinicians the data that such testing — typically full laboratory panels, chest x-rays, and EKGs — rarely if ever changed outcomes or management of cataract patients. Instead, such unnecessary measures often lead to more visits, greater costs, and delays to surgery.

"Pre-operative testing for cataract surgery epitomizes low-value care. [The procedure] doesn't require anesthesia and only takes 15 minutes on average," Dr Wei noted.

Their results were dramatic. The intervention began in October 2015, and by April 2016 the amount of preoperative laboratory testing, EKGs, and chest-x-rays had dropped by about 80%, while the median wait time for surgery was reduced from 245 days in the year prior to just 64 days after. "So on average patients received 6 months of improved vision. That's something you can take home."  

Other safety-net hospitals in California have begun similar initiatives, he said.

Choosing Wisely : The Next 5 Years

In introducing her Health Affairs article on the future of Choosing Wisely, Eve A. Kerr, MD, Newburgh research professor of internal medicine, University of Michigan Medical School, and director of the Veterans Affairs Center for Clinical Management Research, Ann Arbor, said she was "impressed by the uptake and the growth of the Choosing Wisely campaign in just the last five years" particularly insofar as they have the potential to accomplish what "guidelines haven't been able to do and performance measures can't…. But, we still have some work to do."

In the paper, Dr Kerr and colleagues highlight remaining challenges and suggest potential solutions:      

  • Strong methods for developing recommendations: Societies have been using various methods, and their recommendations haven't always focused on the most important processes. To solve the problem, the ABIM Foundation and/or other organizations should work to incentivize societies to work together to codify their approach and consolidate recommendations.

  • Innovative Intervention Methods: Common interventions don't always assess drivers of overuse, and rarely focus on broader culture change and patient-centered outcomes. Funders should encourage targeting the root causes of low-value services, leverage existing behavioral science frameworks, and pursue cultural change among clinicians and patients via awareness campaigns.

  • Meaningful evaluation techniques for the campaign lists: Many published studies use weak designs, and rarely assess unintended consequences or patient-reported outcomes. Funders should require robust evaluation methods within new studies and encourage collaboration between stakeholders and researchers to strengthen methods.

  • Collaborative dissemination: Choosing Wisely campaigns are often focused on single institutions. Payers, state societies, and health systems should establish funds and infrastructure to share approaches, data, and results.

"I think we still have fundamental work to do to get the word out about Choosing Wisely. I think it's had different impact in different specialties," Dr Kerr told Medscape Medical News in an interview.

She noted that the specialty societies that queried their members about what measures to include in the list appear to have had more success. "I think if you do more bottom up and not all top-down you'll start engaging doctors more."

Examining overuse is at least as important as many of the performance measures to which physicians are currently subjected, she believes. "I'm not saying it's easy, but I think that banding together and saying you're measuring us a lot on what we're doing too little of, but let's also look at what we do too much of, and how can we change that so we'll have a balanced approach."      

And, she added, "As a primary care doctor, ordering fewer MRIs won't affect my bottom line, but it's the right thing to do for my patients." 

Dr Wei is a Choosing Wisely grantee. Dr Kerr has received grants from Choosing Wisely, PCORI, the VA, and NIH. Mr Mainor's work was supported by ABIM Foundation and Agency for Healthcare Research and Quality.

Health Affairs. Published October 24, 2017. Abstract, Abstract

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