After five years, Choosing Wisely has gained significant momentum as more medical societies have made Choosing Wisely recommendations and hospitals and clinics across the U.S. have incorporated the recommendations into their care protocols.

This article will provide an overview of Choosing Wisely, discuss the rationale for the campaign, provide a snapshot of Choosing Wisely today, feature local Choosing Wisely initiatives, and highlight useful resources for providers and patients. The next issue of Rx for Prevention will feature Choosing Wisely recommendations on preventive care for women.

More Care is Not Always Better Care

  Credit: University of Michigan Center for Value-Based Insurance Design  www.vbidcenter.org

Choosing Wisely challenges the cultural norm that more care is always better care and strives to reduce the use of low-value care. In addition to sometimes causing harm, unnecessary care is wasteful and inefficient. The Institute of Medicine estimated that $750 billion spent on health care in the U.S. in 2009 was unnecessary.¹ This equates to approximately 30% of U.S. health care spending.² As physician decisions account for more than 80% of all health care expenditures, physicians need to be part of the solution.³

Physicians are aware of the problem of unnecessary care. In a 2011 article in the Archives of Internal Medicine Less is More series, 42% of the primary care physicians surveyed reported believing that patients in their own practice received too much care.⁴ In addition surveys using hypothetical scenarios found that over a third of physicians said they would agree to a patient request for a test —even when they knew the test was not necessary.^5,6

 

 

What is Choosing Wisely?

Choosing Wisely provides physicians with resources and tools to help address this problem of unnecessary care. The ABIMF invites specialty medical societies to create lists of five (or more) things that physicians and patients should question. The recommendations must be evidence based. In order to create the list of tests, procedures, and treatments that should not be routinely used, the societies must use a transparent process to select care within their purview that is either used frequently and/or that carries significant costs. Each professional society’s Choosing Wisely list includes their recommendations, the rationale, methodology and sources of evidence. The lists for providers, as well as patient-focused materials (created by Consumer Reports), are on the Choosing Wisely website and phone app.

In addition to making recommendations on patient care, Choosing Wisely aims to “promote conversations between providers and patients by helping patients choose care that is supported by evidence, not duplicative of tests or procedures already received, free from harm, and truly necessary".⁷ To encourage these discussions, the campaign produces resources for patients such as cards and videos with 5 Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure and communications skills training modules for physicians (see resources section).   

Choosing Wisely at 5 Years

Since the campaign began in 2012, Choosing Wisely has grown significantly in content, scope, and practice. Almost 80 specialty medical societies have created more than 500 recommendations. Several other professions (nursing, dental, and physiotherapy) are now partners with Choosing Wisely and the campaign has expanded to 19 countries. Choosing Wisely recommendations are being implemented by individual clinicians, group practices, and health systems. Patients and consumers are learning about Choosing Wisely though community groups, clinicians, health systems, and employers. Choosing Wisely has a growing on-line presence with the website reporting nearly 1.5 million visits a year. In addition, Consumer Reports staff routinely add Choosing Wisely information to the health-related Wikipedia pages, in recognition that Wikipedia is major source of online health information.

Choosing Wisely in Los Angeles

The most striking impact of Choosing Wisely can be seen when large practices or health systems implement Choosing Wisely recommendations. Here are two local instances of implementation of Choosing Wisely.

Los Angeles County + USC Medical Center:  The Los Angeles County Department of Health Services collaborated with UCLA and others on an ABIMF grant to implement Choosing Wisely recommendations. They began in 2015 by eliminating routine preoperative visits and testing prior to cataract surgery. As a result, in addition to a large reduction in unnecessary testing, the average wait time for cataract surgery was reduced by six months.⁸

Cedars-Sinai Hospital: On a much larger scale, Cedars-Sinai embedded 180 Choosing Wisely recommendations, as well as patient materials, into the electronic medical record in 2013. Alerts were programmed to request that providers reconsider orders that might be unnecessary.⁹ Implementing Choosing Wisely recommendations across the entire Cedars-Sinai health system saved $6 million in the first year.  It was also reported that patients of physicians who followed all the Choosing Wisely alerts had fewer medical complications and left the hospital sooner.¹⁰

Locally on the consumer facing side, the Los Angeles County Department of Public Health (DPH) created the Health Care Consumer Protection Unit to reduce harms from needless tests and treatments and to help individuals make informed health choices. The DPH Health Care Consumer Protection Unit includes Choosing Wisely messages and health education materials on its consumer website.

Resources

For providers: In addition to the society lists of recommendations, the Choosing Wisely  website has tools to help incorporate Choosing Wisely into practice, Updates from the Field, opportunities to join Choosing Wisely networks, and online interactive learning modules (see below). Practices in LA County that are interested in implementing Choosing Wisely may contact the DPH Health Care Consumer Protection Unit to facilitate introductions to the Choosing Wisely team at ABIMF.

For patients: Handouts, and materials in other formats encourage patients to talk to their provider about frequently ordered tests (such as pre-operative screening), treatments (such as antibiotics), and the management of conditions (such as back pain, sinusitis, pink eye, and headache). They explain when tests or treatment might be needed, steps that patients can take to improve their health, and list other resources. The handouts can be incorporated into electronic health systems. In addition to material on specific issues, Consumer Reports has created tips to help consumers communicate with their doctor, including 5 Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure [see below].

Return on Investment

A common concern of physicians about implementing Choosing Wisely is the time it takes to engage patients in conversations about unnecessary care. In “Updates from the Field” a primary care physician describes how, in the long run, engaging in these conversations is a good investment:¹¹

“Choosing Wisely gave me a lot of confidence in my ability to tell patients that I’m working on their behalf to reduce unnecessary care,”

“Doctors think it takes so much more time to talk patients out of something they want, and that agreeing to order a test makes everyone happy. But I’ve found that those conversations are not usually that time-consuming; and once you have a conversation about one unnecessary test, if you have a relationship with your patients, they understand why you’re not ordering a different test. And when you don’t order a test, you save the post-visit time you would have spent reviewing the results.”

Dr. Eric Barbanel, Crystal Run Healthcare, New York State

Conclusion

The overuse of medical resources is not only costly, but can lead to undesirable side effects and unwarranted harm. The Choosing Wisely specialty society lists and resources can help physicians reduce overuse while providing care that is both evidence-based and patient-centered.

Online Learning Modules

References

1. Best Care at Lower Cost - The Path to Continuously Learning Health Care in America Report Brief September 2012. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2012/Best-Care/BestCareReportBrief.pdf.
2. Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med. 2012 Sep;23(6):495-8.
3. Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund. 2009; Apr 27 http://www.commonwealthfund.org/publications/commentaries/2009/apr/change-the-microenvironment.
4. Sirovich BE, Woloshin S, Schwartz LM. Too Little? Too Much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011 Sep 26;171(17):1582-5.
5. Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802.
6. PerryUndem Research/Communication for ABIM Foundation. Unnecessary Tests and Procedures In the Health Care System. What Physicians Say About the Problem, the Causes, and the Solutions. May 1, 2014. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf.
7. Choosing Wisely Website: About Us. Retrieved August 25, 2017 from http://www.choosingwisely.org/about-us/.
8. Eye-Opening Results at LAC+USC Medical Center, Updates from the Field, January 12, 2017 http://www.choosingwisely.org/resources/updates-from-the-field/eye-opening-results-at-lacusc-medical-center/
9. Cedars-Sinai Alerts Its Docs to Choosing Wisely, Updates from the Field, June 5, 2014. http://www.choosingwisely.org/resources/updates-from-the-field/cedars-sinai-alerts-its-docs-to-choosing-wisely/.
10. California Hospitals and Health Systems Report Promising Outcomes in Effort to Reduce Unnecessary Care That Can Harm Patients and Drive up Spending. May 1, 2017. https://www.cedars-sinai.edu/About-Us/News/News-Releases-2017/California-Hospitals-and-Health-Systems-Report-Promising-Outcomes-in-Effort-to-Reduce-Unnecessary-Care-That-Can-Harm-Patients-and-Drive-up-Spending.aspx.
11. Choosing Wisely at Crystal Run Healthcare, Updates from the Field, August 7, 2014. http://www.choosingwisely.org/resources/updates-from-the-field/choosing-wisely-at-crystal-run-healthcare/.