Wednesday, October 1, 2014

A Critical Look at "Choosing Wisely" - But it's not Today's NEJM.

On October 2, 2014, the New England Journal published an article on reducing low value healthcare, one of the approaches being the Choosing Wisely campaign.

Unfortunately, the author did not have the time and space to cite another New England Journal article on Choosing Wisely - one that I read with enthusiastic agreement, because that earlier article encapsulated what I'd been telling colleagues and friends for a couple years as I've read press about Choosing Wisely.  The earlier article is open access and worth looking up.


The new October, 2014 article by Colla (here) discussing a range of ways to reduce low value care, from ACO's to Choosing Wisely to prior authorization - a table lists ten approaches.

While I certainly support Choosing Wisely in general, there can be a tendency to highlight relatively trivial interventions and there's no clue what's left out because not doing it would cost too much (to the specialist doing it).   This will be especially occult to laymen and journalists.

Accordingly, I took the opportunity to make my comment in the article's comment box:
Choosing Wisely may be well intended, but lacks any data on the scope of the misuse proposed, its cost, or the national savings by reducing it.   This makes the suggestions easier to prepare.  But it is unacceptable to lack any yardstick for what the suggestions would or could do.   This becomes a smokescreen.  For example, a specialty could waste $500M on unnecessary interventions, but its committee comes up with 5 unnecessary tests or procedures that no one recommends and nearly no one does, anyway.  They'll get just as much credit for tallying "five suggestions" for taking part in Choosing Wisely - as one that would take a much harder look, bites the bullet, and would really take a hit in its membership by implementing meatier suggestions.   Tactics and proposals without even a guesstimate or estimate of scale should be called out as a waste of time.
Colla's webpage at Dartmouth provides an up-to-date list of her publications, one of which was an earlier article specifically on Choosing Wisely.  And which also appeared this year in New England Journal.   Look up Morden et al. in February 2014 (here), titled:   Choosing Wisely — The Politics and Economics of Labeling Low-Value Services.

I missed this when it came out in February, and I also missed some of the press the February 2014 article triggered.  Here's a key quotation from the February Morden et al. article:

On the surface, the creation of low-value–service lists suggests that physicians are willing to make recommendations to improve health care value even against their own financial interests. The services included on the lists, however, vary widely in terms of their potential impact on care and spending. 
The American Academy of Orthopaedic Surgeons, for example, named use of an over-the-counter supplement as one of the top practices to question. It similarly listed two small durable-medical-equipment items and a rare, minor procedure (needle lavage for osteoarthritis of the knee). Strikingly, no major procedures — the source of orthopedic surgeons' revenue — appear on the list, though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion.4 Other societies' lists similarly include low-impact items.
Participating societies generally named other specialties' services as low-value.  The graph  shows the most common service types listed by the first 25 Choosing Wisely participants: 29% of listed items target radiology; 21%, cardiac testing; 21%, medications; 12%, laboratory tests or pathology; and 18%, other services. Specialists name very few of their own revenue-generating services.
At the time, in April 2014, Kaiser Health News picked up on Morden's analysis.  Kaiser's article is called, "Doctors Overlook Lucrative Procedures When Naming Unwise Treatments," here.  It was picked up by MedPageToday (the same article, here.)   For a response issued by the ABIM Foundation, see here.

According to its NEJM page, the Morden article has been cited 3 times, triggered 2 online comments, and no letters to the NEJM editor.

If I read correctly, both articles may be free at NEJM; the Morden article is also free at Pubmed Central, here.

Update:
In July 2015, the American College of Medical Genetics offered 5 "unwise" test choices through Choosing Wisely, such as "Do not order a duplicate test unless there is uncertainty about the validity of the [prior] test result."  OK, yup, good to know.  Here.