By Lori Solomon, Editor, Diagnostic Testing & Emerging Technologies
An initial assessment shows that the Choosing Wisely campaign is not having a large impact on changing use of low-value services, according to a paper published online Oct. 12 in JAMA Internal Medicine. While this evaluation only included one laboratory metric, the authors suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice.
The Choosing Wisely campaign consists of more than 70 lists produced by specialty societies of medical practices (tests, services, or medications) or procedures of minimal clinical benefit to most patients. Since the campaign began pilots in 2009, more than 400 recommendations have been produced.
The current study was the largest attempt to date to quantify the frequency and trends of some of the earliest Choosing Wisely recommendations. The researchers retrospectively analyzed nationwide commercial health plan (Anthem-affiliated Blue Cross and Blue Shield health care plans) population-level data of medical and/or pharmacy claims for approximately 25 million members across the United States. The services included in seven selected recommendations were assessed quarterly over a 2- to 3-year span.
The seven selected recommendations included: four recommendations relating to diagnostic imaging (imaging tests for headache with uncomplicated conditions, cardiac imaging for members without a history of cardiac conditions, and preoperative chest x-rays with unremarkable history and physical examination results, and low back pain imaging for members without red-flag conditions); age guidelines for cervical cancer screening (human papillomavirus [HPV] testing for women younger than 30 years; and two recommendations related to inappropriate medication use (antibiotics for acute sinusitis and prescription nonsteroidal anti-inflammatory drugs [NSAIDs] for members with select chronic conditions [hypertension, heart failure, or chronic kidney disease]).
The researchers found that two recommendations were tied to declines—use of imaging for headache (decrease from 14.9 percent to 13.4 percent) and cardiac imaging (decreased from 10.8 percent to 9.7 percent). Two services had increases, counter to recommendations: use of NSAIDs in select conditions (increase from 14.4 percent to 16.2 percent) and HPV testing in younger women (increased from 4.8 percent to 6.0 percent). The other recommendations did not have significant changes in use.
The authors note that even though the changes were "desirable" and statistically significant for headache and cardiac imaging, the changes were "modest," the effect sizes "marginal," and the clinical significance is "uncertain."
"Simple publication of recommendations—such as the Choosing Wisely lists—is insufficient to produce major changes to practice," write the authors led by Alan Rosenberg, M.D., from Anthem (Indianapolis, Indiana). "Our mixed results highlight the need for interventions beyond the current level of promotion, such as data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives."
The authors additionally say specialty societies need to focus Choosing Wisely lists on procedures with a high baseline frequency of use. The researchers say they initially looked at an additional cervical cancer screening recommendation— Papanicolaou tests for women younger than 21 or with hysterectomy for noncancer disease, but existing use was so infrequent it was "unsuitable" for trend analysis.