Choosing Wisely: setbacks and progress

Setbacks

In June 2015, the American Association of Clinical Endocrinologists, based in Jacksonville, Florida, informed its members that it was withdrawing from the Choosing Wisely campaign. The association, jointly with the Endocrine Society, had issued its top five list in 2013, including a recommendation against ordering total or free T3 tests when monitoring levothyroxine (T4) therapy.1 The association gave its membership varying reasons for its withdrawal from the campaign.

Daniel Einhorn, association president in 2013-14, told The BMJ that the association withdrew from the campaign because it disagreed with the Endocrinology Society over the recommendation regarding T3 monitoring. Einhorn said the association decided not to lend its name to projects “we don’t fully control.”

The Choosing Wisely project is also facing scrutiny about its impact. A recent study of seven campaign recommendations found no substantive change in physician practices: two of the recommendations led to slight declines, two led to increased usage despite recommendations against, and the remaining three were unchanged.2 3

Richard Baron, president of the American Board of Internal Medicine Foundation, says that it takes time for change to take place. “There are plenty of examples of local [projects]” that are having an effect, he says, pointing to Cedars Sinai Medical Center, which has incorporated 180 Choosing Wisely recommendations into its electronic health records. Alerts fire when clinicians order interventions on the lists, and it has led to statistically significant reductions in the use of antipsychotic medicines for elderly patients with dementia, butalbital for patients with migraine, and benzodiazepines as a firstline sleep aid in elderly patients.4

Turf wars and money

Additional criticism of the campaign arose with publication of a commentary in the New England Journal of Medicine that noted the lists compiled by various specialty societies tend to be uneven and that this might reflect financial self interests.5 The authors cited the American Academy of Orthopedic Surgeons recommendations against the use of a dietary supplement, heel wedges, and prolonged use of wrist immobilizers after surgery. The only orthopedic procedure the academy listed was injection knee washing with saline. Lead author, Nancy E Morden, told Kaiser Health News that when she searched the 2011 Medicare billing records she found “zero claims” for the knee washing procedure, adding, “That’s how pathetic that item is.”6

The American College of Emergency Physicians initially decided against participation in the campaign but later decided to enter after it was satisfied that it “a number of tests would meet the criteria of the ‘Choosing Wisely’ campaign” and would not “increase the physician’s liability” or “negatively impact payments for emergency physicians.”7

Similar financial concern may have had a role in the American Academy of Otorhinolaryngology’s decision to recommend against two uses of antibiotics but not to list any procedures despite substantial evidence of wide variation and overuse of tonsillectomy and tympanostomy tube placement.5

Notably absent from the American College of Cardiology list is elective percutaneous coronary intervention, which provides lucrative incomes for interventional cardiologists. A recent study shows overuse of the procedure, which many patients mistakenly believe will reduce their risk of a heart attack or death.8 Meta-analysis has shown that overuse leads to increased mortality.9

Vikas Saini, a cardiologist and president of the Lown Institute, is concerned about the failure to mention specific clinical settings and patient groups in which invasive procedures would be unwise. He says some societies had tended “to pick the low hanging fruit that was so low it was lying on the ground.” Nonetheless, he says the Choosing Wisely campaign is a “great icebreaker,” adding, “We need culture change; this is the beginning of a conversation.”

Progress and next steps

Evidence of culture change is growing. The NEJM commentary also cited organizations that did go against their financial interest in order to protect patients. These include the Society for General Internal Medicine, which recommended against the bread and butter of many internists: the annual physical exam.5

The American College of Emergency Physicians has come from behind to be a leader in the Choosing Wisely campaign; the college wasn’t satisfied with only five recommendations, which it first issued in October 2013, and went on to issue five more in October 2014.

Jeremiah Schuur, cochair of the committee work group for updating the college’s Choosing Wisely recommendations, is a longtime supporter of the campaign. Early on he decided to independently develop a top five list for emergency medicine. He assembled a panel of experts at Partners Healthcare in Boston to identify five items of “little value” that are “actionable” by emergency department clinicians.10

The “actionable” modifier is particularly important because some specialty groups have listed items that are not within their purview. For example, radiologists could cite the use of imaging studies for uncomplicated headache, but they don’t order the tests.

When the college decided to join the campaign, it invited Schuur to lead. The college used a modified Delphi consensus process, practitioner surveys, transparency, and “solid scientific foundations” to come up with items and included panelists’ disclosures regarding conflicts of interest.11 Its methods have since been lauded as a model for other societies.11

Schuur acknowledges the concerns of some doctors that failure to order interventions could lead to malpractice suits. But he says that “having the list backs up the practice of doing less. While guidelines don’t provide absolute protection, they do show that at least what you’re doing is reasonable.”

Despite the withdrawal of the American Association of Clinical Endocrinologists from the campaign, the Endocrine Society continues to stand by its participation. Robert Lash, chair of the society’s taskforce to develop the Choosing Wisely list, told The BMJ he thinks the list provides “great advice for patients and for providers.” He says he is particularly proud of the recommendation against routine use of ultrasonography in patients with abnormal thyroid function tests with no palpable abnormality of the gland since it has the potential to lead to more thyroidectomies with no reduction in thyroid cancer mortality. Routine ultrasonography has created an “epidemic” in Korea and increased thyroidectomy rates in the US and other nations.12

Other steps to improve and extend the Choosing Wisely campaign are developing. Saini reports that a project of the Lown Institute, the Right Care Alliance, is trying to overcome the problem of specialty bias by creating a multidisciplinary approach to overuse. For real change, he said, other drivers of overuse will also have to be addressed, such as fee for service incentives, and the bias among doctors and patients that to “know and do” is almost always better than watching and waiting—a cultural driver independent of financial incentives.

Schuur says the American College of Emergency Physicians has just been awarded a $3m (£2m; €2.7m) grant from the Center for Medicare and Medicaid Innovation to “help equip clinicians nationwide with tools, information and network support” to reduce avoidable interventions.

At stake are both lives and money. According to the center, 50 000 fewer patients died from “hospital-acquired conditions” and $12bn was saved from 2010 to 2013 through efforts to improve “value-based and patient-centered” care.13