In 2012, the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports formally launched the Choosing Wisely campaign in order to reduce the utilization of diagnostic tests and treatments that provide no meaningful benefit to patients.1 After widespread acceptance in the house of medicine and many consumer groups and with expansion of the program internationally, the question remains, is this just a “feel-good program,” or will this program have any true impact on utilization?
Explore This IssueACEP Now: Vol 35 – No 02 – February 2016
Despite the success of raising awareness and gaining buy-in for this program, the early data suggest that little impact has been made in curbing utilization in the areas noted in the 70 lists containing approximately 400 recommendations.2 Emergency medicine is no exception. ACEP was cautious yet agreed to participate and provided a total of 10 recommendations. However, it seems that this simply isn’t enough. Choosing Wisely and its participating specialty societies have been talking the talk, but now it’s time to walk the walk.
Although garnering widespread support for this program must have had its challenges, it seems the real challenges lie ahead. Just like any practice update, simply knowing what is right is very different from incorporating that information into clinical practice. When you ask physicians to “choose wisely” and those choices include changing the way they practice and interact with their patients, you’ve reached the crossroads of knowing and doing. In other words, knowledge translation is where the rubber hits the road and where Choosing Wisely may have blown a tire.
To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications. —Louis Pasteur
Pasteur’s quote, cited in a 2006 article about knowledge translation, defines exactly what Choosing Wisely aspires to be. The article further defined translation as to “synthesize research findings and convert them into a form applicable to a target population or audience in the context of the conditions in which its members live and interact.” Brownson and colleagues reported an average of 17 years for 14 percent of original “discovery” to actually reach practice.3
Can we wait 17 years to implement these recommendations? I doubt it. This campaign provides an opportunity to remedy overutilization, which is largely under our control. Failing to bring these recommendations to the bedside will only result in additional well-intentioned, but ill-informed, bureaucratic intervention to reduce spending on health care in the United States.
Choosing Wisely in Action—or Not
In a study published in October 2015, 25 million members of Anthem-affiliated BlueCross and BlueShield plans were assessed over a two- to three-year period through 2013. Medical and pharmacy claims were assessed for the following seven Choosing Wisely recommendations2:
- Imaging tests for uncomplicated headache
- Cardiac imaging without history of cardiac conditions
- Low back pain imaging without red-flag conditions
- Preoperative chest X-rays with unremarkable history and physical examination results
- Human papillomavirus (HPV) testing for women younger than 30 years
- Use of antibiotics for acute sinusitis
- Use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease
The first two, imaging for headache and cardiac imaging, showed a small decline from 14.9 percent to 13.4 percent and 10.8 percent to 9.7 percent, respectively. Two recommendations, prescribing NSAIDs for certain conditions and HPV testing for women younger than 30 years, showed increased utilization. Antibiotics for sinusitis remained stable, while preoperative chest X-rays and imaging for low back pain remained high without a statistically significant change.2 The data cannot confirm a cause-and-effect relationship, and with such a large sample size, the small changes noted could simply be due to chance. However, it certainly suggests that more work is needed to ensure that providers are actively engaged with this campaign. Although two of these recommendations, antibiotics for sinusitis and imaging for low back pain, have also been submitted by ACEP, much of the data sample precedes ACEP’s involvement. Even if we evaluated utilization following ACEP’s submissions, should we expect different results? I don’t think so. It has been difficult for all involved to move the knowledge translation needle for Choosing Wisely.