Choosing Wisely® Campaign Examines Unnecessary Tests and Procedures

In a fee-for-service payment system, physicians are compensated for each test and procedure, creating an environment in which they are incentivized for the volume of care they provide.

This situation has led to frustration for both patients and payers, some of whom do not always see the benefits and are burdened by rising costs. Still, as the run-up to the November elections has shown, the issue of healthcare expenditures and their effect on states and the federal government are a major issue, regardless of party affiliation.

In recent months, clinician groups have acknowledged that their profession is undergoing dramatic change and have agreed to take a closer look at how they operate, most notably with their acceptance of the Choosing Wisely^® campaign.

This initiative, spearheaded by the American Board of Internal Medicine (ABIM) Foundation, asks medical societies to identify tests and procedures that offer little or no value and/or could potentially harm patients.

Nine organizations, including the American Academy of Family Physicians (AAFP) and the American Society of Clinical Oncology (ASCO), have already published a list of “Five Things Physicians and Patients Should Question.” For instance, ASCO advises that physicians should not perform positron emission tomography, computed tomography, or radionuclide bone scans in the staging of early prostate or breast cancer at low risk for metastasis.

This fall, another 11 societies are expected to announce their list of unnecessary tests and procedures. In all, 24 medical societies and customer-focused organizations have supported the campaign.

“The aim is to start conversations between patients and physicians around the necessity of certain tests and procedures,” ABIM Foundation chief operating officer Daniel B. Wolfson said in a podcast sponsored by the Institute for Healthcare Improvement (IHI), an independent non-profit organization. “We are hoping this will cause awareness and [create] more thoughtful conversations between physicians and patients about the issue of unnecessary care.”

The project’s implementation faces challenges, particularly in re-establishing the physician-patient relationship. Amanda Kost, MD, acting assistant professor in the department of family medicine at the University of Washington, said during the podcast that physicians do not receive training on how to talk to patients about changes in testing procedures. She suggested that these issues be addressed during the first or second year of medical school so that physicians can handle these situations better.

Dr. Kost relayed a story in which a resident planned on using dual-energy x-ray absorptiometry (DEKA) screening in a patient. However, Dr. Kost told the resident that as part of the Choosing Wisely campaign, AAFP had recommended not using DEKA screening for osteoporosis in women <65 years of age and men <70 years of age who do not exhibit any risk factors of the disease.

“It is difficult to manage patient expectations,” Dr. Kost said. “As we proceed with our participation in this project, it will be interesting to see how the other training sites manage this as well.”

Another barrier is that people in the United States are bombarded with pharmaceutical and health advertisements, which condition them to seek unnecessary treatments or treatments that are not useful, according to Donald Goldman, MD, an infectious disease specialist and senior vice president at IHI. During the podcast, Dr. Goldman said he conducted a study on the attitudes on antibiotics among parents in Germany and the United States.

German parents need to be persuaded to give their children antibiotics, according to Dr. Goldman, because they prefer natural remedies for conditions such as earaches. Meanwhile, parents in the United States must be told that antibiotics typically do not work or are beneficial for an earache.

“We have to get our act together here [in the United States],” Dr. Goldman said.

Health insurers may also receive negative feedback from their members if they withhold covering tests or procedures, according to Karen Boudreau, MD, chief medical officer at Boston Medical Center HealthNet Plan. It is not easy to tell people they cannot undergo certain procedures even if they are proven to be ineffective or harmful.

“The motives behind that are not always fully appreciated,” Dr. Boudreau said during the podcast. “It can be very difficult to get that message across without it appearing to be related to some other agenda. This kind of effort, which goes across the board and is really embraced by the specialty societies [and] by the national organizations that represent physicians and other clinicians, is enormously helpful to us.”