Choosing Wisely®, and overuse more generally, continues to attract considerable attention from researchers writing in peer-reviewed journals. This is the first of a periodic series in Updates from the Field that will highlight recent research that those who are interested in Choosing Wisely may find useful. (Note: Some articles require subscription.)
Neurology Choosing Wisely Recommendations: 74 and Growing, Neurology Clinical Practice: In this study, a team of neurologists looked beyond the five Choosing Wisely recommendations from the American Academy of Neurology (AAN) to explore recommendations from other societies that are relevant to neurology practice. The team discovered 69 such additional recommendations from 30 different specialty societies, with significant contributions in the areas of general neurology and the cognitive, stroke and headache disciplines. The authors pointed to 12 recommendations that were offered by multiple societies, such as the use of imaging for low back pain, and called for a focus on intervention approaches designed to reduce overuse in those areas. They also noted areas of neurology for which there were few (epilepsy, multiple sclerosis) or no (movement disorders, neuromuscular disease) recommendations, which could be fertile ground for future specialty society input. The authors have added the list of relevant recommendations to the AAN website and wrote that they would update the list annually.
Physician Response to Patient Request for Unnecessary Care, American Journal of Managed Care, by Sapna Kaul, et al.: This study based on a 2009 poll of practicing primary care physicians explored the extent to which they agreed to patient requests for unnecessary specialty referrals and brand-name drug prescriptions when generics were available. Although the study predates the launch of Choosing Wisely, it provides important context for continuing efforts to reduce unnecessary care. Overall, 51.9 percent of primary care physicians reported they sometimes or often gave unnecessary referrals upon a patient’s request, and 38.7 percent said they sometimes or often agreed to requests for a brand-name medication. In both cases, family physicians and internal medicine doctors were more likely to agree to such requests than pediatricians. Physicians who met with representatives from drug and device companies were more likely to report agreeing to both kinds of requests; physicians with higher concentrations of uninsured patients and patients with Medicaid reported that they were less likely to agree to either request. Older physicians and physicians in solo or two-person practices were also more likely to prescribe brand-name drugs. Among other suggestions, the authors suggested providing physicians with real-time support, including making available the specialty society lists and patient education materials that have been created as part of the Choosing Wisely campaign.
Undermeasuring Overuse—An Examination of National Clinical Performance Measures, JAMA Internal Medicine (October 2015) by Erika H. Newton, et al.: Researchers identified all outpatient and emergency department process measures contained in major national measure programs and clearinghouses as of mid-2012 and analyzed whether the measures addressed overuse, underuse or misuse. Their findings demonstrated that underuse measures dominated the field, with 91.6 percent of the measures targeting underuse and only 6.5 percent targeting overuse. (The remaining 2.7 percent addressed misuse.) As the authors pointed out, the preponderance of underuse measures threaten to “foster a culture of ‘more is better’ and inadvertently encourage overuse,” since performance on clinical measures can influence how physicians and institutions are evaluated and compensated.
Update on Medical Practices That Should Be Questioned in 2015, JAMA Internal Medicine, Daniel J. Morgan, et al. (November 9, 2015): The authors highlighted the 10 articles published in 2014 that were most likely to influence medical overuse. The highlighted studies found that the following interventions either offered no benefits or carried risks that outweighed any benefits:
- CT scans of the head;
- screening for asymptomatic carotid stenosis;
- screening for pelvic examinations in asymptomatic women;
- screening for thyroid cancer;
- renal artery vascularization for renal artery stenosis;
- the use of paracetamol and acetaminophen for treating low back pain;
- perioperative aspirin for patients undergoing noncardiac surgery; and,
- medications to raise high-density lipoprotein cholesterol levels.
Other cited studies found that opioids were overused for postoperative pain control and that most diagnoses are made based on the taking of medical histories and physical examinations, not through diagnostic tests.