‘Choosing Wisely’ showing mixed results

Publishing guidelines alone not enough to ensure implementation

“Choosing Wisely,” a much-publicized initiative aimed at persuading patients and their healthcare providers to cut back on wasteful or ineffective medical procedures is achieving only mixed results, according to a new study.

Piloted in 2009 and expanded in 2012 with financial backing from the ABIM Foundation, a nonprofit offshoot of the American Board of Internal Medicine, “Choosing Wisely” now includes recommendations from 70 specialty societies regarding often-performed medical practices or procedures that have been shown to provide little benefit to patients.

Related:High-value care strategies

For their study, the research team analyzed medical and pharmacy claims for about 25 million members of Anthem-affiliated Blue Cross and Blue Shield plans nationwide. They focused on recommendations for seven services that they felt were representative of the services and specialty societies participating in the campaign and had been widely disseminated. These were:

  • Imaging tests for headache with uncomplicated conditions,

  • Cardiac imaging for patients with no history of cardiac conditions,

  • Preoperative chest x-rays with unremarkable history and physical examination results,

  • Low back pain imaging for patients without red-flag conditions,

  • Human papillomavirus (HPV) testing for women under age 30,

  • Use of antibiotics for acute sinusitis, and

  • Prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with certain chronic conditions (hypertension, heart failure, or chronic kidney disease.)

The study found a mixed response to the Choosing Wisely recommendations. The percentage of patients undergoing imaging for headaches with uncomplicated conditions decreased from 14.9% to 13.4%, and the percentage receiving cardiac imaging without cardiac disease dropped from 10.8% to 9.7%.

On the other hand, the percentage of women under age 30 undergoing HPV testing increased form 4.8% to 6%, and the use of prescription NSAIDs by patients with select chronic conditions grew from 14.4% to 16.2%. Use of the other three services covered in the study-preoperative chest x-rays and low back pain imaging in the absence of red-flag conditions, and use of antibiotics for treating sinusitis-remained the same or declined slightly.

The authors note that while four of the seven recommendations in the study showed statistically significant changes, the clinical effect of the changes is uncertain. Moreover, the frequency of the most often-used services-preoperative chest x-rays, low back pain imaging, and antibiotics for treating sinusitis-either stayed the same or decreased slightly.

The latter finding, they write, “underscores the view that simple publication of recommendations….is insufficient to produce major changes to practice.” Other steps for implementing the recommendations, they suggest, might include clinician scorecards, clinical decision support in electronic health records, use of patient-focused strategies, and financial incentives.

Daniel Wolfson, executive vice president of the ABIM Foundation, says the study’s findings were not unexpected. “I think what it does is point out that education alone and promulgation of recommendations does not necessarily turn into behavioral change,” he says. "Choosing Wisely was really about changing attitudes around more always being better, and the responsibility of both patients and physicians to have conversations around the appropriateness of certain tests and procedures.”

The study, “Early trends among seven recommendations from the Choosing Wisely campaign,” appeared online first October 12 on the website of JAMA Internal Medicine.

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