A periodic series in Updates from the Field, “Research Roundup” highlights recently published research related to Choosing Wisely®. (Note: Some articles require subscription.)
Clinicians’ Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain-Knowing Is Not Enough (Sears, JAMA Internal Medicine, December 2016): The authors surveyed a national random sample of VA nonresident clinicians about a hypothetical scenario involving a 45-year old woman with nonspecific low back pain and no red flag symptoms who requested a CT or MRI scan. (Numerous specialty societies have released Choosing Wisely recommendations against imaging in those circumstances.) Only 3.3 percent of respondents thought the patient would benefit from the scan; 77 percent said they worried that imaging would lead to future unnecessary tests or procedures. But 76 percent said they would worry that they couldn’t refer the patient to a specialist without a scan, 58 percent would worry the patient would be upset if they didn’t agree to the imaging, and 27 percent said they’d worry that refusing imaging could leave them vulnerable to a malpractice claim. Only 15 percent said they worried that following the Choosing Wisely recommendation against imaging in this situation would be difficult for them to follow, but 63 percent said they thought it would be difficult for patients to accept the recommendation. The authors called for “efficient patient education interventions” and greater attention to referral requirements.
Choosing Wisely: Opportunities for Improving Value in Cancer Care Delivery? (Rocque, Journal of Oncology Practice, November 2016): This study found that adherence to a set of nine Choosing Wisely recommendations from the American Society of Clinical Oncology (ASCO) and the American Society for Radiation Oncology (ASTRO) ranged from 39 to 94 percent at 12 institutions within the University of Alabama at Birmingham Health System Cancer Community Network. Significant variability was noted across the centers for all recommendations, with as much as an 89 percent difference. The authors reported that patient characteristics were similar for patients receiving recommended and nonrecommended care, suggesting that the variability was clinician-driven. They estimated that if concordance increased to 95 percent for all nine measures, it would result in a $19 million reduction in total cost of care per quarter.
Quality and Value-Focused Decision Making in Heparin-Induced Thrombocytopenia: The Impact of the American Society of Hematology’s Choosing Wisely Initiative (Baranwal, Blood, December 2016): Authors found that the number of HIT (heparin-induced thrombocytenia) tests ordered per patient declined significantly after release of the American Society of Hematology Choosing Wisely recommendation against testing and treating patients with low pretest probability of HIT. The study compared 140 patients who were admitted before the release of the recommendation and 140 who were admitted after publication. Although the number of tests fell substantially, the authors found that physician adherence to the 4T scoring system designed to measure probability of HIT had not increased, and called for more efforts to improve quality of care.
Low-Value Service Use in Provider Organizations (Schwartz, Health Services Research, November 2016): This study found that the use of low-value services in provider organizations varied substantially across organizations, and that an organization’s likelihood of providing low-value services was highly consistent over time. The authors reported that the data was consistent with the concept that systems shape the practice patterns of their affiliated physicians. The study was based on Medicare data from 2007–11, which predates Choosing Wisely, but the low-value services included a number that are covered by specialty society recommendations, such as routine preoperative stress tests, imaging for uncomplicated headache and imaging for nonspecific low-back pain.