Early Trends Among Seven Recommendations From the Choosing Wisely Campaign

Abstract

IMPORTANCEThe Choosing Wisely campaign consists of more than 70 lists produced by specialty societies of medical practices or procedures of minimal clinical benefit to patients in most situations, with recommendations regarding judicious use.OBJECTIVE To quantify the frequency and trends of some of the earliest Choosing Wisely recommendations using nationwide commercial health plan population-level data.DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of claims data for members of Anthem-affiliated commercial health plans. The low-value services selected were (1) imaging tests for uncomplicated headache; (2) cardiac imaging without history of cardiac conditions;(3) low back pain imaging without red-flag conditions; (4) preoperative chest x-rays with unremarkable history and physical examination results; (5) human papillomavirus testing for women younger than 30 years; (6) use of antibiotics for acute sinusitis; and (7) use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease. MAIN OUTCOMES AND MEASURESThe number of members with medical and/or pharmacy claims for the included low-value services was assessed quarterly over a 2-to 3-year span through 2013. Trend changes in recommendations were evaluated across all quarters using Poisson regression with denominators as offsets.RESULTS Two services had declines: Use of imaging for headache decreased from 14.9% to 13.4% (trend estimate, 0.99 [95% CI, 0.98-0.99]; P < .001), and cardiac imaging decreased from 10.8% to 9.7% (trend estimate, 0.99 [95% CI, 0.99-0.99]; P < .001). Two services had increases: Use of NSAIDs in select conditions increased from 14.4% to 16.2% (trend estimate, 1.02 [95% CI, 1.01-1.02]; P < .001), and human papillomavirus testing in younger women increased from 4.8% to 6.0% (trend estimate, 1.01 [95% CI, 1.00-1.01]; P < .001). Use of antibiotics for sinusitis remained stable (0.8% decrease from 84.5% to 83.7%; trend estimate, 1.00 [95% CI, 1.00-1.00]; P = .16). Use of preoperative chest x-rays (0.2% decrease, ending utilization 91.5%; trend estimate, 1.00 [95% CI, 1.00-1.00]; P = .70) and imaging for low back pain (53.7% utilization throughout study; P = .71) remained high with no statistically significant changes. CONCLUSIONS AND RELEVANCEFor this population-level analysis of 7 low-value services analyzed, changes were modest but showed a desirable decrease for 2 recommendations (imaging for headache, cardiac imaging for low-risk patients). The effect sizes were marginal, however, and although 4 of the 7 lists had statistically significant changes-unsurprising given the large sample size-the clinical significance is uncertain. These results suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations.

Frequency of and variation in low-value care in primary care: a retrospective cohort study

“…17 However, a recent study that examined temporal ordering trends of Choosing Wisely recommendations in a large US commercial health plan found substantially higher rates of imaging for low back pain without red flags (53.7%). 19 This discrepancy is likely related to varying definitions of low-value care, but may also be influenced by differences in testing practices and populations. Although previous analyses have examined population-level data and regional variation, few studies have assessed rates of use at the level of primary care practices and variability in ordering across practices.…”

“…Furthermore, our study includes an entire population from a single payer, publicly funded system with no patient copayments, which is novel because most previous research on overuse has been done in the US. 16,17,19 The lower rates of cervical screening and imaging for low back pain compared with repeat DEXA scans may reflect increased penetrance of guideline recommendations and policy changes. The Ontario government amended the fee schedule to align with the guideline changes made in 2012: 20 effective January 2013, cervical cancer screening was not insured for women less than 21 or more than 70 years of age.…”

Physician Cost Consciousness and Use of Low-Value Clinical Services

“…A recent report based on claims data from a national commercial health plan used population-level data to describe the impact of the campaign over a 2-to 3-year period after its introduction. 19 Overall, modest changes in behavior related to 7 topics were noted, with imaging for headaches and testing patients at low risk for cardiac disease decreasing at a statistically significant rate. It is arguable that the 1% to 2% absolute use reduction is really clinically significant.…”

“…The Family Medicine "list of 5" low-value services of low-back pain imaging and sinusitis treatment showed no appreciable improvement in use. 19 There may, however, be greater hope for the success of interventions at a practice level. Kost et al 20 recently reported their interventions in 3 primary care residency programs.…”

Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology

“…To date more than 60 different medical professional societies have participated in the campaign by creating and promoting lists of tests and treatments that physicians and patients should question. The campaign has had a broad impact in healthcare, both by increasing awareness of overutilization [1], and in some instances by triggering changes in practice [2].…”