October 24, 2017 8:00 AM

Researchers: ‘Choosing Wisely’ Off to a Strong Start, but It’s Time to Evolve

The movement to reduce overtesting and overtreatment is blossoming, but much more work is needed to cut back on low-value care.

Five years ago, a group of medical organizations did something they’d never done before: Give doctors a list of things they shouldn’t do for patients.

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The goal was to empower doctors and patients to start a conversation about avoiding unnecessary care.

Now, the momentum behind this campaign, called Choosing Wisely, has snowballed, with the list of “don’ts” growing to more than 500 items — from specific uses of blood tests and scans to particular prescription drugs and medical devices. Each recommendation is backed with a body of evidence showing that it’s unnecessary for specific patients, or that it may even cause harm.

But to truly eliminate unnecessary care, Choosing Wisely needs to evolve, says a trio of University of Michigan and Veterans Affairs researchers in a new analysis published in Health Affairs and at a briefing in Washington, D.C.

“We need to get more rigorous and more innovative,” says Eve Kerr, M.D., MPH, lead author of the paper and a longtime researcher on appropriate and low-value care. “The recommendations so far are a great start and laid the foundation, but we need to focus on using strong methods to identify ones that will make the most difference in quality and value in health care and innovate in the way we change clinical practice and culture.”

For example, after new recommendations come out, they may rarely be used, according to several studies. This shows how hard it is to help doctors stop doing things they may have done for years for patients with particular symptoms or risks.

"This is about patients and physicians having conversations to help them make the right decisions."
Eve Kerr, M.D., MPH

'An opportunity to move things forward'

Still, the campaign has succeeded tremendously in starting the conversation about low-value care, say the authors in the paper. But Choosing Wisely needs to take specific next steps to move forward.

Kerr and her colleagues suggest:

  • Prioritizing recommendations: New recommendations should focus on the most overused practices, based on clinical data, to make the biggest impact on care.

  • Consolidating recommendations: Groups of professional societies should work together to create recommendations for patients seeking care for the same complaint. For instance, many current recommendations address back pain, but were created separately without coordination among the professional societies that wrote them.

  • Evaluating efforts: Researchers should evaluate the impact of recommendations more rigorously, using methods that can truly let them see if the recommendations are making a difference and if any they led to unintended consequences. Researchers should also try to identify barriers to success. While this kind of evaluation should include cost-related impacts, cost reduction is not the key goal of Choosing Wisely.

  • Considering patient preferences: Recommendations should take into account patient priorities and preferred outcomes, front and center with guidelines and in evaluations, and make sure patients can understand the recommendations that affect them.

  • Sharing best practices: Health care and government organizations should partner with institutions making serious efforts to help their providers follow Choosing Wisely recommendations, and with researchers who can help enhance the innovation and rigor of interventions and evaluations.

“Choosing Wisely has changed the game in terms of getting people to think about health care services that don’t help people, could hurt them and add excess cost to our health system,” says Jeff Kullgren, M.D., M.S., MPH, a co-author of the paper and an assistant professor of internal medicine at U-M. “We hope that this synthesis of the evidence will point us in a clear direction for how to make our health care system more efficient.”

SEE ALSO: To Screen or Not to Screen: The Risks of Over-Imaging and Testing

The authors note that Choosing Wisely has made great inroads in awareness and provider buy-in over a short period. It represents an evolution in medical thinking, because just 20 years ago, the medical community was focused on making sure more patients got more of the types of care they needed the most, such as regular blood sugar tests for people with diabetes.

That’s still important, says Kerr, but now “we need to also focus on making sure patients don’t get care they don’t need. This is about patients and physicians having conversations to help them make the right decisions.”

Says co-author Sameer Saini, M.D., M.S., “The key is to get the right care to the right patient at the right time.

“But changing the behavior of patients, providers and health systems is not easy. We need to be more thoughtful about how we design programs and interventions to reduce the use of low-value care and be more rigorous and complete in how we assess whether these programs actually worked. At the same time, we need to think about how we will sustain what has been achieved once a program ends. Doing this well is going to require that clinicians, health system leaders and researchers work together.”

Kerr, a professor of internal medicine at U-M and director of the VA Center for Clinical Management Research, heads the Michigan Program on Value Enhancement. Based at IHPI and Michigan Medicine, U-M’s academic medical center, it’s an effort to implement many of the recommendations about appropriate care laid out by the authors of the new paper.

Kullgren, who specializes in studying consumer behavior around the use of health services, notes that Consumer Reports has done a good job of creating materials aimed at patients for each of the Choosing Wisely recommendations.

He has even used them in his own research, which is funded by the Donaghue Foundation and seeks to assess the impact of having providers make specific commitments to apply the Choosing Wisely guidelines for diabetes care, sleep medication and prostate cancer screening in their own practices. He is also holds a Career Development Award grant from the VA to bring behavioral economics approaches to clinical care practice.

“How we go about changing the hearts and minds of patients, as well as doctors, still holds a lot of unknowns,” Kullgren says. “We have an opportunity to move things forward.”

The authors received funding from the Department of Veterans Affairs. Kerr serves on the steering committee for Choosing Wisely International, which is bringing the Choosing Wisely approach to many countries.