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Choosing Wisely campaign Top 5 lists focus on reduced costs vs. risks
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The American Board of Internal Medicine Foundation’s Choosing Wisely initiative recently prompted several scientific specialty societies to create “Top 5” lists of medical services that provide no overall benefit to patients in most situations. In a recent review of the lists, researchers determined that costs were the largest contributing factor for the societies’ selections.
The campaign comprises 25 societies, including: the American Academy of Allergy, Asthma and Immunology, the American Academy of Hospice and Palliative Medicine, the American Urological Association, the American Geriatrics Society, and the American Academy of Family Physicians, according to the research paper.
Steven D. Pearson, MD, MSc, and Catherine Gliwa, BA, of the department of bioethics at the National Institutes of Health, analyzed the rationales and found that of 135 services, 49 (36% were for patient diagnosis, prognosis, or monitoring; 46 (34%) for patient treatment; and 40 (30%) for population screening. Moreover, initial evidence categorization was identical for 128 (95%) services, the researchers wrote.
Steven D. Pearson
The inclusion of 102 (76%) services were justified by claims that adequate evidence demonstrated no additional benefit with greater risk, higher cost, or both, compared with other options, according to Pearson and Gliwa.
“The second most common rationale, given for 18 services (13%), was that there was insufficient evidence to evaluate comparative benefit for use of the service beyond the evidentiary boundaries of established indications, frequency, intensity, or dosage,” they said.
Data indicated that, overall, 66 (49%) of all 135 rationales mentioned greater risks for patients as a consideration for choosing the service, 33 (24%) mentioned greater costs, 21 (16%) cited greater risk and cost, and 57 (42%) did not mention either of the two.
Of the societies included in the campaign program, 60% included at least one service justified due to greater costs for service.
“Specialty societies can enhance trust in the Choosing Wisely campaign by defining more clearly the types of potentially wasteful medical care they seek to eliminate, and by providing a clear evidentiary justification for the selection of each service,” the researchers concluded.
Disclosure: See the study for a full list of relevant financial disclosures.
Perspective
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Theodore M. Freeman, MD, FAAAAI
I think Choosing Wisely is a useful campaign. The beauty of the campaign is in creating dialogue between physicians and between physicians and patients. My understanding for the drive behind the campaign is that we emphasize the quality of care delivered. It is therefore not surprising to me that evaluations of the various items chosen by the specialty societies reflect different endpoints, since quality may reflect a variety of factors. Gliwa and Pearson have pointed out that the majority (76%) chosen reflect that “adequate evidence demonstrated no additional benefit with higher risk, higher cost or both.” They come to two conclusions. First, they “believe that specialty societies should seek greater opportunities to include … services that offer only small incremental benefits at much higher prices.” Second, they state that the “societies can enhance trust… by defining more clearly the types of potentially wasteful medical care they seek to eliminate.”
I cannot disagree with their first conclusion that specialty societies should seek out services that offer small incremental benefits at much higher prices, if such exist. I would be a little more cautious with the second conclusion. Choosing Wisely seeks to reduce overused care or care that is inappropriate within a certain context of care. Some care identified may not be inappropriate in some contexts, for instance a therapy with marginal to no additional benefit in an initial presentation may be the only option after the failure of equally potent, less expensive therapy. My question to Gliwa and Pearson is whose trust are we trying to enhance? The answer should be the trust of our patients, that their best interests are always closest to our hearts as physicians. This is trust that Choosing Wisely is enhancing in its current format. If we seek to enhance trust by our administrative colleagues in Choosing Wisely as a means of controlling costs by eliminating care that might be useful in some situations, I think we are failing in our duty to our patients.
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