Study analyzes use of 7 low-value services in Choosing Wisely campaign

An analysis of seven clinical services with minimal benefit to patients identified as part of the Choosing Wisely campaign found significant declines in two services: the use of imaging for headaches and cardiac imaging in low risk patients, according to an article published online by JAMA Internal Medicine.

Reducing the use of unnecessary medical procedures and treatments is important in controlling health care expenditures. Choosing Wisely includes more than 70 lists of about 400 recommendations of frequently used medical practices or procedures that are of minimal clinical benefit to patients.

Abiy Agiro, Ph.D., of HealthCore, Wilmington, Del., and coauthors examined the frequency and trends of some of the earliest Choosing Wisely recommendations from 2012 using medical and pharmacy claims from Anthem-affiliated Blue Cross and Blue Shield health care plans for about 25 million members.

The authors identified seven services: imaging tests for headache with uncomplicated conditions; cardiac imaging for members without a history of cardiac conditions; preoperative chest x-rays with unremarkable history and physical examination results; low back pain imaging without red-flag conditions; human papillomavirus (HPV) testing for women younger than 30; antibiotics for acute sinusitis; and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with select chronic conditions (hypertension, heart failure or chronic kidney disease).

The authors found:

• Use of imaging for headache decreased from 14.9 percent to 13.4 percent
• Cardiac imaging decreased from 10.8 percent to 9.7 percent
• Use of NSAIDs increased from 14.4 percent to 16.2 percent
• HPV testing in younger women increased from 4.8 percent to 6.0 percent
• Antibiotics for sinusitis remained stable decreasing only from 84.5 percent to 83.7 percent
• Use of pre-operative chest x-rays (ending utilization 91.5 percent) and imaging for low back pain (53.7 percent utilization throughout the study) remained high with no significant changes.

Although four of the seven had statistically significant changes, which is unsurprising given the large sample size, the clinical significance is uncertain, the authors note.

The authors acknowledge limitations because the study was based on administrative claims data that do not adequately capture the clinical circumstances that led to the service being ordered so the recommendation may be appropriate for an individual patient

"The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice. Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies and financial incentives," the authors conclude.

(JAMA Intern Med. Published online October 5, 2015. doi:10.1001/jamainternmed.2015.5441. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: The authors made conflict of interest disclosures. Research support was provded by Anthem. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures.

In a related commentary, Ralph Gonzales, M.D., M.S.P.H., and Adithya Cattamanchi, M.D., M.A.S., of the University of California, San Francisco, write: "As we have described, frameworks exist to guide delivery systems and clinician groups in developing and testing strategies to facilitate reducing the ordering of low-value tests and treatments. Further efforts to compel delivery systems to commit to Choosing Wisely are needed to leverage the grassroots/front-line cultural shifts that the campaign has stimulated before the impact wanes."

(JAMA Intern Med. Published online October 5, 2015. doi:10.1001/jamainternmed.2015.5987. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures.

Viewpoint: Producing Evidence to Reduce Low-Value Care

In a related Viewpoint, David H. Howard, Ph.D., of Emory University, Atlanta, and Cary P. Gross, M.D., of the Yale University School of Medicine, New Haven, Conn., write: "A comprehensive initiative to fund trials comparing established medical treatments with less costly alternatives should complement ongoing efforts to reduce low-value care through physicians stewardship and innovations in health care. There is a need for evidence that will guide decisions about clinical care. Instead of asking, "Does evidence affect practice?" we ought to be asking, "How can we produce more of it?" (JAMA Intern Med. Published online October 12, 2015. doi:10.1001/jamainternmed.2015.5453. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: The authors made conflict of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures.

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Media Advisory: To contact study corresponding author Abiy Agiro, Ph.D., call Jill Becher at 414-234-1573 or email Jill.Becher@anthem.com. To contact corresponding commentary author Ralph Gonzales, M.D., M.S.P.H., call Laura Kurtzman at 415-476-3163 or email Laura.Kurtzman@ucsf.edu.