Evaluating the Effectiveness of the Choosing Wisely Initiative

Can you briefly describe what brought about the need to launch the Choose Wisely initiative?

The ABIM Foundation’s mission is to advance medical professionalism. This includes the idea that physicians are in the best position to take responsibility for appropriate utilization of limited health care resources. Yet, there is a growing recognition that much of what is done in health care — some estimate up to 30% — is wasteful and does not benefit patients. Working with medical specialty societies and Consumer Reports, the ABIM Foundation created the Choosing Wisely campaign to support conversations between patients and physicians on the appropriate use of services and to support clinician leadership in identifying areas of waste. 

How does the Choosing Wisely initiative function to reduce wastefulness and unnecessary care within the medical community?

The ABIM Foundation and Consumer Reports are partners in the Choosing Wisely campaign. The ABIM Foundation works with leading medical specialty societies that develop lists of tests and treatments they say are overused and should be discussed by clinicians and patients. Consumer Reports, working with society partners, creates patient-friendly materials and disseminates them through a bevy of consumer group partners, such as the National Business Group on Health and AARP.

Has the Choosing Wisely campaign been effective since it launched in 2012? Has any research been done to measure its impact?

There are many ways to measure the effectiveness of the Choosing Wisely campaign. For example, we could look at the number of society partners — starting with nine, and growing to more than 75. We could look at the more than 400 journal articles that have been published about the campaign and society recommendations. We know clinicians and patients are accessing the information at the Choosing Wisely website, with more than 2 million visits per year. 

Beyond those numbers, we know there are many examples of how the campaign is being implemented at the practice level. For example, at Cedars Sinai, 180 recommendations are included in their electronic health records (EHR) system and provide clinicians with alerts about their appropriateness. Approximately 300 alerts are sent per day, with two-thirds in the ambulatory setting, and one-third in the hospital setting. As of January 2015, they report improvements in quality of care, including a 31.5% decrease in the rate of new orders for benzodiazepines for patients over age 65 within two months of the alert going live. Virginia Mason in Seattle focused on reducing inappropriate prescriptions for antibiotics by conducting chart reviews and developing a phone protocol that connected patients requesting appointments for acute respiratory symptoms to nurses, who helped manage symptoms without an office visit. As a result, they reduced inappropriate prescribing by more than half—from 41.8% in 2011 to 18.6% in 2014. 

Another good example is a recent study by Colla, et al, in the American Journal of Managed Care that reported 97.1% of primary care physicians surveyed said Choosing Wisely recommendations were viewed as legitimate sources of guidance, and 75.1% said they agreed or somewhat agreed that the campaign empowered them to reduce their use of unnecessary tests and procedures. There are many other examples available on the Choosing Wisely website.

What types of resources does the campaign offer to physicians?

The Choosing Wisely campaign was designed to encourage clinician and patient conversations about avoiding unnecessary care — and the lists published by societies are a good starting point. But we know these conversations aren’t always easy for clinicians, so we worked with Drexel University College of Medicine and society partners to develop a suite of communications modules that demonstrate specific skills that can aid them in these discussions. For example, a clinician may learn how to respond to patient concerns when a particular test or treatment isn’t warranted, or check to ensure a patient understands an agreed upon treatment plan before leaving the office.

The ABIM Foundation also leads an active learning network comprised of more than 110 leaders from hospitals and health systems that regularly shares best practices and ideas on how to implement specialty society recommendations in their institutions. We welcome interested clinicians to join the network, so they can learn how to implement Choosing Wisely in their own practice.

Consumer Reports also distributes materials developed in partnership with specialty societies to physicians’ offices to support them in conversations with their patients. 

How has the program been received by physicians?

The Choosing Wisely campaign has been well-received among clinicians because it is based on professional principles and respects their autonomy and mastery. It provides information about what care may not be needed but leaves the ultimate decision up to clinicians and patients based upon informed conversations. We recently launched a new component called “Choosing Wisely Champions” that recognizes clinicians that are making significant contributions to advancing the campaign and 20 societies have initially agreed to participate in this program. The American Geriatrics Society has already awarded two Choosing Wisely Champions, including Ariel Green, MD, who said, “I was instantly attracted to working on Choosing Wisely from the minute I heard about the opportunity.” 

Are there any barriers to widespread acceptance of the Choosing Wisely philosophy?

While Choosing Wisely and its ideals have been widely embraced by clinicians and institutions, there can be barriers to actualizing the campaign in practice. EHR systems are not always designed in ways that support clinicians in deciding what care is not needed; for example, some include standardized order entry sets that may contain multiple tests a particular patient may not need. A fee-for-service payment system traditionally incentivized delivery of more care—fortunately there are newer models being tested that recognize value over volume. And finally, we know clinicians face many demands in their practice, and time with patients is usually shorter than they’d like. Despite these barriers, about two-thirds of physicians say they feel they have a great responsibility to make sure their patients avoid unnecessary tests and treatments, and 58% say they are in the best position to address the problem of overuse. Through resources like communications skills modules and sharing best practices, we are supporting clinicians in achieving this goal. 

What sorts of associations have encouraged participation in Choosing Wisely?

Choosing Wisely has been successful thanks to our great partners, including more than 75 medical specialty societies, that have published lists of overused or unnecessary tests and treatments. Consumer Reports has been a critical partner with their efforts to educate patients and build a coalition of consumer groups. We’ve also been fortunate to receive two rounds of funding from the Robert Wood Johnson Foundation, including our current grant of $4.2 million that supports seven initiatives across the country focused on reducing utilization of unnecessary tests and treatments, including a 20% reduction of inappropriate prescribing of antibiotics.

What are your hopes for the Choosing Wisely campaign? What does the future of the program look like?

My ultimate hope is that the ideals of Choosing Wisely become ingrained in the culture of medicine, and I am optimistic given the campaign’s bright future that we can make that happen. I envision continued expansion of projects aimed at implementing Choosing Wisely and a growing number of systems and physicians adopting the campaign and contributing to the movement. I also am excited by several state-wide efforts that I think could serve as a model for others to follow. One example is the Connecticut Choosing Wisely Collaborative, a diverse multi-stakeholder group that promotes widespread adoption of the campaign as a vehicle for health care improvement in the state. Another example is the Washington State Choosing Wisely Task Force, which unites and coordinates 24 health care organizations to implement strategies aimed at reducing inappropriate care identified by Choosing Wisely societies. 

Is there anything else you’d like to add?

The Choosing Wisely campaign is still relatively young, having launched just a little more than 4 years ago. While we’ve been heartened by its positive reception and adoption at institutions across the country, we know there’s still a lot of work to be done. It’s also been gratifying to see it spread internationally, with nearly a dozen countries having created campaigns based on the US Choosing Wisely campaign and its ideals, such as Australia, Italy, the UK, and Switzerland. We are thankful to our many partners for joining us in Choosing Wisely and look forward to continuing to spread this important movement.