Research Roundup—October 2016
A periodic series in Updates from the Field, “Research Roundup” highlights recently published research related to Choosing Wisely®. (Note: Some articles require subscription.)
Changes in Antiemetic Overuse in Response to Choosing Wisely Recommendations (Encinosa, JAMA Oncology, September 2016): This study reviewed the prevalence of antiemetic use before and after the release of the American Society of Clinical Oncology’s 2013 Choosing Wisely recommendation against the overuse of expensive antiemetics in patients with low risk of chemotherapy-induced nausea and vomiting (CINV). The authors found that patients had 7 percent lower odds of overuse in the six months following the recommendation. After the initial six months, however, the overuse of low-risk intravenous chemotherapy agents rose again, by 7.4 percent, with a sustained decrease among only one of five risk groups studied. The authors wrote that the results “create the concern that voluntary measures to reduce anti-emetic overuse may have limited effectiveness” and suggested that financial incentives for physicians, accompanied by patient engagement and education, may be necessary to reduce overuse.
Perceived Barriers to Implementing Individual Choosing Wisely Recommendations in Two National Surveys of Primary Care Providers (Zikmund-Fisher, Journal of General Internal Medicine, September 2016): The authors surveyed primary care physicians (some in private practice, others at the Veterans Administration) in 2013 and 2014 about their familiarity with 12 Choosing Wisely recommendations relevant to primary care. They also asked whether the recommendations were difficult to follow and/or would be difficult for patients to accept. Sixty percent of private practice doctors and 37 percent of those at the VA had some familiarity with Choosing Wisely. A majority of physicians in both practice settings judged five recommendations to be easy to follow and for patients to accept. Forty percent of physicians anticipated that patients would find four recommendations—related to antibiotics for sinusitis, imaging for low back pain, benzodiazepines for older adults and brain imaging for syncope—difficult to accept. The authors noted that the concerns about patient reaction were most pronounced in areas that related to symptomatic conditions and wondered whether physicians were anticipating barriers that either do not exist or could be overcome. Many physicians noted patient requests for tests and treatments, number of tests and treatments recommended by specialists, and lack of time for shared decision-making as barriers to reducing overuse.
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 thryroid nodules, and oxycodone/acetaminophen combination and cyclobenzaprine therapy for patients with acute low-back pain treated with Naproxen).