Choosing Wisely: Beyond the Low Hanging Fruit

The first stages of Choosing Wisely tackled less contentious issues in its successful rollout. Now it is time to step up efforts in ambition and scope.

In April 2012, the American College of Cardiology (ACC) joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign—a groundbreaking initiative that addresses unnecessary tests and procedures by promoting conversations between physicians and patients about what care is appropriate for their condition. Along with eight other medical specialty societies, the ACC released a specialty-specific list of “Five Things Physicians and Patients Should Question” based on current evidence about management and treatment options. Since then the number of participating societies has grown exponentially and an increasing number of related tools have been developed.

In a perspective article in the New England Journal of Medicine, Morden and colleagues offered their assessment of the ABIM Foundation’s Choosing Wisely campaign. In their analysis, they noted that there are at least three factors to be admired in the Choosing Wisely concept.

First, the campaign calls for a conversation between the patient and healthcare provider when any of the procedures on the lists appear to be indicated or requested. This reinforces the primacy of the physician-patient relationship and the desirability of patient input into diagnostic and therapeutic decisions.

Secondly, the lists of low-value procedures were  developed by physicians through their medical specialty societies. They are not generated externally by payers, regulators or government agencies. This lends a degree of credibility to the recommendations that  otherwise would be lacking.

Third, the entire exercise suggests that physicians, through their specialty societies, are willing to look at available diagnostic or therapeutic options and voluntarily eschew at least five of those which are of low value.

The authors also raise three points of criticism with this initial rollout of Choosing Wisely. The services included in the Choosing Wisely lists vary widely in terms of their potential impact on care and spending. Additionally, several participating societies suggested only low-impact items. Finally, some societies generally named other specialties’ services as low value, and did not suggest services that were in their own area of expertise.

There were several notable exceptions to these criticisms. The American College of Radiology listed only imaging procedures in its five. The American Gastroenterological Association named three endoscopic procedures, and the ACC, American Society of Echocardiography, American Society of Nuclear Medicine and the Society of Cardiovascular Computed Tomography all named procedures within the field of cardiac imaging.

The authors called for more public education, for the creation of quality indicators to codify the suggestion of Choosing Wisely, for incorporating these recommendations into the maintenance of certification (MOC) framework, for public reporting at the physician-group, regional or hospital level, and for “more numerous and more courageous lists” to be developed to move Choosing Wisely forward.

It is our opinion that the Morden article is an excellent summary and critique of Choosing Wisely. It provides an informed perspective on the current state of the campaign. We agree with the authors’ assessments of the positive aspects of the program, and we believe that the criticisms are fair and balanced.

Choosing Wisely was the first attempt at this process by any of the professional societies, so it is probably understandable that they first would name the easy choices. Member approval of the recommendations is a requisite for these organizations, and consensus is most easily achieved with the “low hanging fruit.” Future rounds will be more challenging for everyone. While it is disconcerting that some of the organizations did not look inwardly at all and only pointed to procedures done by others, it is encouraging that the gastroenterologists identified three endoscopic procedures of questionable value in spite of the potential financial impact to their members.

We agree with the conclusion that “more numerous and more courageous” efforts should follow, but it is not necessarily true that future attention should be limited to discrete, and relatively short lists. In fact, the ACC has been supporting an analogous, but much more extensive, program since 2005. Currently, we have 966 clinical scenarios published in 10 Appropriate Use Criteria (AUC) documents, which essentially guide cardiologists and primary care physicians in making wise choices for 18 diagnostic and therapeutic procedures from exercise treadmill testing to bypass surgery. This is “Choosing Wisely” aimed directly at practicing physicians.

Also, it is worth noting that ACC already is implementing many of Morden et al’s suggested action items for our AUCs and for our Choosing Wisely list. These include converting recommendations into performance measures, some of which have been endorsed by the National Quality Forum and included in the Physician Quality Reporting System, collecting data in our registries, and linking these activities to MOC Part IV.  We also have partnered with ABIM to develop teaching modules to model effective patient communications and we are working to integrate this information into consumer medical information by creating and publishing mobile applications and other resources.

We do not, however, concur with any suggestion to involve payers in the selection of Choosing Wisely procedures. Including payers would contradict the spirit of the Choosing Wisely program, which is intended to be a physician-led effort that is founded in professionalism. Professionals are self-regulating; they are scholarly experts with a specialized body of information, and they have a fiduciary responsibility to those they serve. In our opinion, payers do not have a place in this self-regulating process.

For healthcare reform to be ultimately successful in achieving the triple aim of improved patient experience of care, healthier communities and lower costs, physician leadership will be required. The Choosing Wisely campaign and efforts such as the ACC’s AUC demonstrate that physicians are stepping up to meet that challenge.

Dr. Zoghbi is director of the Cardiovascular Imaging Institute at Methodist Hospital in Houston; Dr. Drozda is director of Outcomes Research at Sisters of Mercy Health System in St. Louis; Mr. Allen is director of the ACC’s Translating Research into Practice program; and Dr. Oetgen is a professor at Georgetown University School of Medicine in Washington, D.C.