Choosing Wisely continued to influence scholarly journal articles and mainstream media coverage about waste and overuse in health care throughout 2016, with more than 4,000 media mentions and more than 1,500 journal articles. As the new year begins, we look back on the “Top 5” (or 6) must-read Choosing Wisely articles for patients and physicians from last year. Let us know what you think of this list and your personal favorites by tweeting us at @ABIMFoundation and using the #ChoosingWisely hashtag.
U.S. News and World Report: Are You Seeing the Doctor Too Often?
Efforts to reduce inappropriate antibiotic prescribing have largely focused on doctor and patient education, but another strategy is for patients to avoid seeing a doctor altogether in instances when unwarranted antibiotic use is common. The Society of General Internal Medicine’s Choosing Wisely recommendation, advising against annual preventive exams for asymptomatic patients, is included in this piece.
Kaiser Health News: How Tiny Are Benefits From Many Tests And Pills? Researchers Paint A Picture
Researchers are asking people to question the kind of thinking — such as misinterpretation of statistics touting significant health benefits — that can lead to patients pressuring their clinician for unnecessary tests or treatments. Researchers describe a “benefit-risk characterization theater” to help visualize how many people out of 1,000 would need to be treated with a particular test or treatment for a single person to benefit. The piece cites a survey sponsored by the ABIM Foundation, which found that three out of four physicians said unnecessary tests and procedures are a serious problem.
In late 2016, the Academy of Medical Royal Colleges published a list of 40 treatments that doctors believe bring little to no benefit to the patient. It coincides with the launch of Choosing Wisely UK and urges patients to have candid conversations with their physicians about what treatments are needed.
Peter Ubel, MD, shares his concerns that his 92-year-old father might fare better if he stays away from the doctor’s office. Dr. Ubel details several studies that show that some medical tests and procedures do more harm than good and mentions that Choosing Wisely has taken hold in several medical specialties. He does note that more needs to be done as unnecessary practices persist.
This story focuses on the launch of a new tool to help patients search price ranges of various medical procedures based on their doctor and the type of insurance they have. Several physicians are interviewed about how patients — and even experts — struggle to figure out health care costs and more transparent information is needed. Charles Kodner, MD, of the University of Louisville School of Medicine, cites Choosing Wisely as a resource that helps patients and physicians have conversations about what care is necessary.
Clinical Journals (some articles may require registration or subscription)
“Displaying Radiation Exposure and Cost Information at Order Entry for Outpatient Diagnostic Imaging: A Strategy to Inform Clinician Ordering” (BMJ Quality and Safety, January 2016)
Researchers found that displaying both radiation exposure information for CT scans and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering influenced clinician behavior at an urban safety net health system. The ratio of CTs to ultrasounds declined by 15 percent, and the ratio of MRIs to ultrasounds declined by 13 percent. More than 80 percent of clinicians said they noticed the radiation exposure information and the cost information, and reported that the radiation exposure information was more influential than cost information in determining which imaging study to order.
“Analysis of Thrombophilia Test Ordering Practices at an Academic Center: A Proposal for Appropriate Testing to Reduce Harm and Cost” (PLOS One, May 2016): A team at the University of Texas-Southwestern studied and sought to reduce the use of thrombophilia testing, which the American Society of Hematology has recommended against using in adult patients with venous thromboembolism that occurs in the setting of major transient risk factors, such as surgery, trauma or prolonged immobility. The team reviewed data on thrombophilia testing from October and November 2009 and presented the findings to the system’s Laboratory Advisory Committee, which prompted implementation of local guidelines to improve test utilization. After the guidelines had been in place for 22 months, testing was reduced by 84 percent; following an additional electronic consultation effort, tests fell further, for an overall reduction of 92 percent.
“Testing Vitamin D Levels and Choosing Wisely” (JAMA Internal Medicine, July 2016): In Alberta, Canada, laboratory leaders approached endocrinology specialists in the province to identify when a 25-hydroxy vitamin D assay was likely to be most useful. (The American Society of Clinical Pathology has recommended against performing vitamin D assays except for patients with higher-risk conditions.) A separate form was developed and issued by laboratory services that required physicians to identify the indication justifying the test, and only indications that matched clinical guidelines were approved. This intervention led to a 92 percent reduction in expected levels of vitamin D tests.
“Low-Value Health Care Services in a Commercially Insured Population” (JAMA Internal Medicine, August 2016): An analysis of insurance claims from a random sample of UnitedHealthcare customers found that in 2013, 7.8 percent received at least one of 28 low-value services. The most commonly received services included imaging for nonspecific low-back pain and imaging for uncomplicated headache, which are addressed in Choosing Wisely recommendations. The authors suggest that efforts to reduce waste could be aided by efforts to develop measures focused on overtreatment, insurance designs to discourage overuse, and programs that target groups and regions at greater risk of low-value care.
“2016 Update on Medical Overuse” (JAMA Internal Medicine, September 2016): The authors chose the 10 most influential peer-reviewed journal articles about overuse published in 2015 based on originality, methodologic quality and number of patients potentially affected. They noted that the number of articles about overuse nearly doubled from 2014 to 2015, from 440 to 821. Three of the 10 articles addressed the overuse of testing (related to colonoscopies, imaging for headache and syncope), four addressed overtreatment (anticoagulation therapy, testosterone replacement therapy, opioid treatment after overuse, and overly strict glycemic control in older adults with diabetes mellitus) and three discussed medical practices to question (overdiagnosis of clostridium difficile infection with molecular testing, serial follow-up of benign thyroid nodules, and oxycodone/acetaminophen combination and cyclobenzaprine therapy for patients with acute low-back pain treated with Naproxen).
This article notes that inappropriate imaging can cause harm and introduces the AMA STEPS Forward module as a tool that outlines steps physician can take to identify appropriate tests and facilitate shared decision-making practice while earning continuing medical education (CME) points. Author Timothy M. Smith writes: “It is important to bring radiologists and referring clinicians together to improve imaging appropriateness and streamline image ordering. This effort can be guided by an action plan found on R-SCAN, created by the American College of Radiology, and resources and recommendations on the [ABIM] Foundation’s Choosing Wisely website. ACR has contributed to Choosing Wisely a list of five imaging orders physicians and patients should question.” Physicians can also earn Maintenance of Certification (MOC) points through R-SCAN.