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Published On September 21, 2018

POLICY

Choosing Unwisely

Why is it so hard to eliminate waste, even when physicians agree on how to do it?

Eric Barbanel is passionate about cutting down on unnecessary care in his practice, and for him that begins with educating patients. “I have some who ask for an antibiotic before they even say hello,” says Barbanel, a primary care physician at Crystal Run Healthcare in Middletown, N.Y. “Every time, I explain that antibiotics are useless against a cold.”

Barbanel has been an outspoken champion of Choosing Wisely, a national campaign launched in 2012 that takes aim at unnecessary medical tests and procedures, listing the common ones and encouraging clinicians to limit their use. The initiative quickly expanded from its origin at the American Board of Internal Medicine Foundation and a handful of other medical organizations to encompass more than 80 groups. Collectively these expert panels have generated 550 recommendations about curtailing the use of various medical practices.

There’s little doubt that such an effort is needed. According to the Institute of Medicine, nearly 10% of health care spending—well over $200 billion a year—goes toward low-value care. Yet six years after the launch of Choosing Wisely, it’s struggling to make headway. A recent analysis in Health Affairs cited a study published in JAMA Internal Medicine in 2015 based on data from 25 million members of Blue Cross Blue Shield plans. Focusing on seven services on Choosing Wisely’s list, the researchers found that the use of only two of them—imaging tests for uncomplicated headaches and cardiac imaging for patients with no troubling history of cardiac conditions—had declined. Three others remained near previous levels, and the last two actually went up. Other studies have shown similarly disappointing results.

“Choosing Wisely has been really successful in getting a national conversation going,” says Jeffrey Kullgren, a research scientist in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System in Michigan and a co-author of the Health Affairs article. “This is a paradigm shift in medicine, so widespread change may take a long time.”

Moreover, some expensive and possibly unneeded practices aren’t even on the Choosing Wisely list. An analysis in The New England Journal of Medicine, for example, suggests that many knee replacements and other joint surgeries may be unnecessary, and rack up millions of dollars in costs each year. But the American Academy of Orthopedic Surgeons has not added these procedures to its section of the Choosing Wisely list.

A separate study in Health Affairs surveyed physicians about Choosing Wisely and found that awareness of the effort had grown by only 4% from 2014 to 2017. In addition, although some doctors said they continued to provide low-value care because of patient demands, most said that they delivered such services “just to be safe.” They didn’t want to risk missing a serious diagnosis or to fail to live up to the “standard of care”—the metric by which they could be judged in a malpractice case.

Despite such concerns, however, some medical organizations have found success by applying Choosing Wisely’s recommendations in a more targeted way. During the past three years, in a project funded by the Robert Wood Johnson Foundation, 14 health care systems have homed in on reducing specific items. Nearly all of those groups reduced antibiotic prescriptions for upper respiratory infections by 20% or more, for instance, and showed significant progress in cutting back on a handful of other measures.

To improve Choosing Wisely, Kullgren and his co-authors call for medical societies to work together to streamline overlapping recommendations and develop new lists that include tests and treatments that are more widely practiced. “We need a next set of recommendations that are clinically meaningful for more patients and would have a bigger bang for the buck,” Kullgren says.

Until that happens, the program will continue to rely on the dedication of practitioners and health care systems to make choices about what care is truly needed. “It’s become part of my routine to have these conversations with patients,” says Barbanel, “and when I do that, 95% of the time they get it.”