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Disappointing Results Seen Thus Far for Choosing Wisely

By Scott Harris, MedPage Today  
   October 15, 2015

Researchers find that, for seven treatment and testing services listed by the Choosing Wisely campaign as usually unnecessary, use of two had indeed declined, but use of the other five either did not change or had increased. From MedPage Today.

This article originally appeared in MedPage Today.

The Choosing Wisely campaign was designed as a starting point of sorts for a new approach to clinical decision-making and, according to new findings, it may be just that: a starting point.

Authors of a study published Monday in JAMA Internal Medicine found that, for seven treatment and testing services listed by the Choosing Wisely campaign as usually unnecessary, use of two had indeed declined, but use of the other five either did not change or had increased.

The investigators -- all affiliated with Anthem, the big health insurer, and led by Alan Rosenberg, MD, the firm's vice president of clinical pharmacy and medical policy -- recommended new measures to effect meaningful change in physician knowledge and behavior.

Created in 2012 by the American Board of Internal Medicine Foundation and now involving more than 50 medical societies, the Choosing Wisely campaign began as a way to help raise awareness and reduce the use of wasteful and unnecessary medical procedures and treatments. Many, though not all, of the services are related to diagnostic imaging.

"Population-level analysis showed both desirable and undesirable modest trends in use of low-value services," Rosenberg and colleagues wrote. "The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice. Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives."

Rosenberg and colleagues analyzed insurance claims data for seven medical services deemed by Choosing Wisely stakeholders to have relatively low clinical value:

  • Imaging tests for headache with uncomplicated conditions
  • Cardiac imaging without a history of cardiac conditions
  • Pre-operative chest X-rays with unremarkable history or examination results
  • Low back pain imaging without red-flag conditions
  • Human papillomavirus (HPV) testing for women younger than 30 years of age
  • Antibiotics for acute sinusitis
  • Prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with select chronic conditions such as hypertension or heart failure

At least 10 quarters of claims data were assessed for each service, through the third quarter of 2013. Starting points for data collection ranged from 2010 to 2011 because of varying data availability.

Rosenberg and colleagues revealed statistically significant declines in two of the services. The percentage of imaging for headaches with uncomplicated conditions decreased from 14.9% to 13.4% for a relative reduction of 10.1%, and the percentage of cardiac imaging in the absence of cardiac disease (using a 5% random sample) decreased from 10.8% to 9.7% for a 10.2% relative reduction.

Three of the services remained essentially the same. Pre-operative chest X-rays rose very slightly from 91.3% to 91.5%, for a relative change of 0.2%. The percentage for low back pain imaging held steady at 53.7%. Use of antibiotics for acute sinusitis saw a mild decrease from 84.5% to 83.7%, or a relative reduction of 0.9%.

Two of the services actually increased in use during the examined timeframes. The percentage of HPV testing in women younger than 30 went up from 4.8% to 6%, for a 25% relative increase. The use of prescription NSAIDS by patients with one or more of the previously identified chronic conditions rose from 14.4% to 16.2%, meaning a 12.5% relative increase.

An accompanying editorial co-written by Cary P. Gross, MD, of Yale University School of Medicine, and David H. Howard, PhD, of Emory University in Atlanta, asserted that clinical decision-making is just one piece of the puzzle when it comes to reducing unnecessary tests or treatments, and that more targeted research, including in comparative effectiveness, would help by definitively determining which treatments or services were low-value.

"A comprehensive initiative to fund trials comparing established medical treatments with less costly alternatives should complement ongoing efforts to reduce low-value care through physician stewardship and innovations in health care," Gross and Howard wrote. "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?'"

This article originally appeared in MedPage Today.

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