• I don’t want to be right about Choosing Wisely, but I may be anyway

    If you don’t know what Choosing Wisely is, start with this HCT episode. If you do, then still watch it. It’s good.

    More than three years ago, I wrote this, about Choosing Wisely:

    Look, I’m all for this. I think it’s great. But it’s also important to have a little perspective. None of these recommendations were news to those of us who practice medicine and follow the literature. Seriously, try and find a physician who doesn’t know that overuse of antibiotics for sinusitis is a problem.

    The real issue, as I’ve discussed before, isn’t that doctors don’t have access to evidence. You can say that mammograms should be used less often, but when enough physicians call that “crazy” and “unethical” and label the USPSTF “idiots”, then it’s all sort of moot.

    Here’s another post worth reading. Do you think that if Choosing Wisely said tomorrow we should not use arthroscopic surgery for knee pain all of that would go away? Really? It hasn’t worked yet.

    But maybe I was wrong. It’s been years. Let’s look at the data! From JAMA Internal Medicine, “Early Trends Among Seven Recommendations From the Choosing Wisely Campaign“:

    Importance  The Choosing Wisely campaign consists of more than 70 lists produced by specialty societies of medical practices or procedures of minimal clinical benefit to patients in most situations, with recommendations regarding judicious use.

    Objective  To quantify the frequency and trends of some of the earliest Choosing Wisely recommendations using nationwide commercial health plan population-level data.

    Design, Setting, and Participants  Retrospective analysis of claims data for members of Anthem-affiliated commercial health plans. The low-value services selected were (1) imaging tests for uncomplicated headache; (2) cardiac imaging without history of cardiac conditions; (3) low back pain imaging without red-flag conditions; (4) preoperative chest x-rays with unremarkable history and physical examination results; (5) human papillomavirus testing for women younger than 30 years; (6) use of antibiotics for acute sinusitis; and (7) use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease.

    Main Outcomes and Measures  The number of members with medical and/or pharmacy claims for the included low-value services was assessed quarterly over a 2- to 3-year span through 2013. Trend changes in recommendations were evaluated across all quarters using Poisson regression with denominators as offsets.

    Such a great, simple study. They looked at claims data to see how different Choosing Wisely recommendations changed practice in terms of usage before and after they were published in 2013. The 7 recommendations were:

    1. Don’t get imaging tests for uncomplicated headache
    2. Don’t get cardiac imaging of people without a history of cardiac conditions
    3. Don’t get imaging for low back pain unless there are serious conditions warranting it
    4. Don’t get pre-op chest x-rays on otherwise healthy people
    5. Don’t test for HPV in women less than 30 years old
    6. Don’t treat acute sinusitis with antibiotics
    7. Don’t use NSAIDS in people who have hypertension, heart failure, or chronic kidney disease.

    Since they were looking at numbers of claims, they used Poisson regression. If you believe in the power of Choosing Wisely, you hope all of these went down.

    Some did. Imaging for headache went from 14.9% to 13.4%, and cardiac imaging went from 10.8% to 9.7%. But some practices saw increases, too. Inappropriate NSAID use went from 14.4% to 16.2%, and HPV testing in women under 30 went from 4.8% to 6.0%. There were no significant changes in antibiotics for sinusitis (still used almost 84% of the time), pre-op chest x-rays (still more than 90%), and low back pain imaging (still more than half of the time).

    So if you want to read this positively, you crow about the two services that went down. Of course, two went up, too. And the rest remained unaffected.

    But the bigger issue is that almost none of these changes were likely clinically significant. Those that were common before remained very common after.

    Publishing guidelines and holding press conferences isn’t enough. The accompanying editorial offers some suggestions, most focusing on the use of better implementation strategies. Me? I haven’t changed my mind in three years:

    When I really think about it, I’m forced to admit my skepticism comes from a place of cynicism. I wish that wasn’t the case, but it is. Some doctors fear lawsuits; this won’t change that. Some doctors see a subset of patients that aren’t representative of the general population, and are conditioned to believe that more tests are necessary than really are. This won’t change. Some doctors are influenced by financial incentives that subtly or overtly induce them to do more. This won’t change that either.

    Most of these efforts assume that we can change the behavior of physicians by willing them to do good. I wish that were true. If we really want to change behavior, we have to arm recommendations like these with teeth. Stop paying for stuff we know doesn’t work. Or, make people pay for it out of pocket. If we know something doesn’t work, there should be few people willing to defend using both reimbursement-limiting and consumer-directed means to reduce its use.

    @aaronecarroll

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