Most developed countries over the last few decades have seen a rapid escalation in national spending on health care, and its sustainability has become a controversial issue, worldwide. While the problem is well known, the strategies to solve it are still widely debated. A welcome advance in discussions for cost containment is the recent shift of focus away from rationing and towards waste avoidance. As highlighted by Berwick and Hackbarth, in the US spending on interventions unbeneficial to patients amounts to around 30% of the total budget, waste being a major driver of cost increases . As overuse of medical resources is not only a leading factor in the high level of spending on health care but also a source of risk to patients , current efforts focus on achieving appropriateness in medicine by reducing unnecessary tests and procedures.
In 2009 the American Board of Internal Medicine (ABIM) Foundation launched a campaign called Choosing Wisely with the goal of promoting a national dialog on avoiding wasteful or unnecessary medical tests, treatments and procedures. Choosing Wisely, as described in the website of the ABIM Foundation should “help providers and patients engage in conversations to reduce overuse of tests and procedures, and support patients in their efforts to make smart and effective care choices” . The campaign was inspired by findings reported in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine in a paper “Medical Professionalism in the New Millennium: A Physician Charter”, . The fundamental principles of this charter are the primacy of patient welfare, patient autonomy, and social justice as well as the professional responsibilities of physicians, the commitment to improving quality and access to care, advocating the just and cost-effective distribution of finite resources and the importance of maintaining trust by managing conflicts of interest. The charter’s commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures. Later, Howard Brody advanced a proposal calling for physicians to lead the effort in identifying waste to be eliminated . According to Brody “a Top Five list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes”. In addition, Grady and Redberg, in their “Less is More” series of articles further articulated the need to dispel the myth that “if some medical care is good, more care is better” .
Choosing Wisely: birth and evolution of the campaign
Beginning in 2009, the National Physicians Alliance, founded by the ABIM Foundation, involved three primary care specialties in a project aiming to develop “Top Five” lists as “specialty-specific enumerations of five achievable practice changes to improve patient health through better treatment choices, reduced risks, and where possible, reduced costs” . In 2012, the initial effort was expanded and launched as the choosing wisely campaign, with lists from nine specialty societies and a patient-education component led by consumer reports . Thereafter, many other scientific societies joined the initiative and, in a paper published in 2014, 25 US specialty societies were reported to have identified the practices prone to overuse in their area. The most common service types listed by these societies were: 29% of listed items target radiology; 21% cardiac testing; 21% medications; 12% laboratory tests or pathology; and 18% other services .
The campaign creators pinpointed individual patients’ needs as the top priority, preserving the pre-eminence of physician’s judgment, patient choice, and the therapeutic dyad. The initiative was not intended to undermine the patient-doctor relationship, as past efforts to reduce health care overuse have tended to do. The US and Canada served as the testing grounds for the campaign, which soon became global, the Netherlands, England, Japan, Italy, Australia, New Zealand, Germany, Wales and Denmark launching similar initiatives. The campaign in Italy, originally entitled “Doing more does not mean doing better” , was launched by doctors, other health care professionals, patients, and citizens, and was eventually called Slow Medicine (Figure 1), with the aim of promoting “measured, respectful and equitable care “(www.slowmedicine.it). This movement focuses on improving the concept of appropriateness in medicine, and highlighting the problems of overtesting, overdiagnosis, and overtreatment, also with respect to guidelines recently released by the Italian Ministry of Healthcare.
The Local Health and Social Care facility (ULSS 16) of Padova has promoted an initiative based on the concepts underlying the Choosing Wisely campaign and under the auspices of Slow Medicine. This involves a series of meetings, and scientific initiatives also conducted through a specifically developed website (www.labuonasanita.it), which has received substantial interest from physicians, healthcare operators and other stakeholders, including patients and patient associations, as demonstrated by the remarkable and growing number of accesses per month.
Choosing Wisely: myth or effective tool?
Unlike other initiatives to reduce health care costs, the Choosing Wisely campaign is rooted in the advancement of medical professionalism. Its specialty society lists are intended to spur closer conversations between physicians and patients about what care is truly needed. To be effective the “Top Five lists” should comply with the following: (a) recommendations should be evidence-based; (b) tests and procedures should be commonly requested, and must be under the control of specialty; and (c) the development and monitoring process should be transparent. However, as highlighted by Grady et al. “although many professional societies have published ‘top-five’ lists, most have not detailed the methods by which the list was created. In some cases, the lists were developed without much input from frontline practitioners, using a process that was not transparent and without clear criteria for inclusion on the list” . In addition, the campaign currently lacks a mechanism, to evaluate its influence on clinical practice and/or any appraisal of whether additional efforts are necessary .
Rosenberg and colleagues performed a retrospective analysis of several low-value services selected in the “Top Five Lists” to quantify the trends on the earliest recommendations of the Choosing Wisely campaign. The results demonstrate that two services declined: there was a decrease in imaging for headache (from 14.9% to 13.4%) and cardiac imaging (from 10.8% to 9.7%). However, the use of antibiotics for sinusitis remained stable, and there were no statistically significant changes observed in the use of imaging for low back pain or preoperative chest X-rays. Two practices actually showed usage trends opposite to the recommendations in Choosing Wisely: there was an increase in the use of non-steroidal anti-inflammatory drugs (NSAID) in selected conditions (from 14.4% to 16.2%) and human papillomavirus (HPV) testing in younger women (from 4.8% to 6.0%) . One of the limitations of the study was that the trend analysis was based on quarterly data starting from 2010 to the third quarter of 2013 while the recommendations were published and released in the second quarter of 2012. This short observation period may have compromised the ability to detect practice changes later in the reporting period, or afterwards. In addition, the analysis was based on administrative claims data, which do not capture the clinical circumstances leading to the ordering of a service, and are subject to coding inaccuracies. Finally, the lack of changes in the frequency of the use of low-value services after the publication of Choosing Wisely recommendations might have been affected by changes in the nature and size of the target population over time and by the evidence that some procedures (e.g. HPV testing) or treatments selected by specialty societies are relatively rare. In an accompanying editorial, Gonzales and Cattamanchi highlight the evidence that awareness of guidelines is not enough to change clinicians’ behavior . Importantly, David H. Howard and Cary P. Gross called for further research to generate evidence to distinguish between low and high value care, stressing that “in the absence of this evidence, healthcare system leaders and administrators may have difficulty convincing frontline physicians to change practice patterns” .
Lessons from the Choosing Wisely campaign
There are two principal ethical arguments for waste avoidance and appropriateness improvement. First, no patient should be deprived of useful medical services, even if they are expensive, as long as money is not wasted on useless interventions . Second, useless tests and treatments are potentially harmful and “primum non nocere” is the stronger argument for eliminating non-beneficial medicine.
As elimination of wasteful, non-beneficial tests and interventions is ethically mandated, the question shifts to implementation. The main advantages of the Choosing Wisely campaign with respect to other approaches are: (a) the principles driving the campaign include improving patients’ access to high-quality care, practicing evidence-based care, advocating for the cost-effective distribution of finite resources and improving the physician-patient relationship; (b) physicians and their specialty societies are involved in identifying the most relevant (Top Five) low-value tests and treatments; (c) some low-value practices are to be identified through multidisciplinary work, particularly as most tests or interventions delivered by a discipline affect the practice of other physicians and professionals.
Current drawbacks are the lack of harmonization and transparency of the method used by any specialty society for developing and revising the Top-Five lists, and the paucity of data evaluating the impact of these list(s) on health care delivery and patient outcomes.
In addition to the need for collecting data over a longer timeframe, other opportunities for improving the effectiveness of the campaign should be found. These could include improved educational programs, targeting both clinicians and patients, to clarify the purpose and rationale of the campaign, employing incentives to promote adoption of the recommendations, and embedding changes in the EMR that would help discourage the choice of test or treatment options that are considered low value.
The Choosing Wisely campaign might also wish to address the reality that underutilization may be as big a problem as overutilization in health care today, especially in regard to diagnosis. The recently released document by the Institute of Medicine (now renamed National Academy of Medicine) on Improving Diagnosis in Health Care (http://nas.edu/improvingdiagnosis) highlights that the diagnostic process is “a complex and collaborative activity that unfolds over time and occurs within the context of health care work system. The diagnostic process is iterative, and as information gathering continues, the goal is to reduce diagnostic uncertainty...”. Most failures in the diagnostic process spring from lack of communication and errors at the boundaries between different healthcare facilities and operators. For example, it has been demonstrated that most laboratory-associated errors do not occur in the analytical phase but in the pre- and post-analytical steps and are due to defects in requesting the right test, collecting the right sample and/or interpreting and using laboratory information [15, 16]. In addition, according to available literature, the landscape of inappropriate testing in laboratory medicine varies systematically in relation to the clinical setting, test volume, and measurement criteria. In a recently published meta-analysis, the rates of underutilization (44.8%) were found to be higher than those for overutilization (20.6%) and overutilization measured using subjective criteria was nearly twice as high as for objective criteria .
In summary, the available data highlights current difficulties in identifying the true low-value diagnostic tests (and interventions), and the need to set out the Top-Five lists(s) based on criteria consensually established by different health care operators with the involvement of patients.
The campaign should raise awareness in all physicians that projects aiming to improve quality and reduce costs call for a multimodal approach , close cooperation between different specialty societies and professionals, effective education of both providers and patients, and the evaluation of the initiative’s efficacy over time. While some drawbacks and open questions have been reported, we must be aware that the Choosing Wisely campaign, a challenge for medical professionals and physicians, is a promising tool for reducing waste in the healthcare system.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
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ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243–6.)| false 10.7326/0003-4819-136-3-200202050-00012
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