Why Hospitalists Should Heed Choosing Wisely Recommendations

Without widespread patient education, overutilization will likely continue; a recent survey sponsored by the Choosing Wisely campaign found about half of physicians admitted they would order a test they know is unnecessary if the patient is insistent.⁴

Variable Outcomes

While there are many reasons to celebrate the success of the campaign, there is some concern that the Choosing Wisely campaign may have unintended consequences. Although a major driver in the success of the program is the fact that the lists have been created and endorsed by physician societies, a sort of “self-governance,” with no influence or impact from payers, critics of the program note the variability that each list has on the actual practice or revenue of the physician groups enacting the lists.

For example, a recent New England Journal of Medicine (NEJM) essay notes that the list produced by the American Academy of Orthopedic Surgeons does not include procedures that are high volume and variably valuable (such as knee arthoplasty) but does include over-the-counter medication use and low-volume procedures (such as needle lavage for knee osteoarthritis).5 Some societies list specialty services that need to be curbed but neglect to mention their own.

And, although the campaign specifically states on its website that the “recommendations should not be used to establish coverage decisions or exclusions,” some are legitimately concerned that these Choosing Wisely lists might very well be used by payers and/or quality reporting bodies to determine payments. This is undeniably tempting: How can practitioners argue against public display and reimbursement schemes being tightly tethered to their performance on metrics that they themselves have deemed unnecessary? As the NEJM editorial summarizes, these efforts should be embraced as long as there is thoughtful discussion about inclusion criteria, exclusion criteria, and measurement beforehand.⁵

In Sum

Despite concerns, the impact of the Choosing Wisely campaign has been widespread and impressive. The full extent to which this will have an impact on utilization and healthcare cost remains to be seen, but this yeoman’s attempt to reduce waste by providers is long overdue. Whether the program will be used for unintended purposes, such as public reporting, financial penalties, or incentives for performance, is still unknown, but physician groups should be paying close attention to the lists that we can impact, and we should pledge to be good stewards of the finite healthcare resources available to our patients.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Choosing Wisely Campaign. Available at: http://www.choosingwisely.org. Accessed May 11, 2014.
2. Choosing Wisely Consumer Partners. Available at: http://www.choosingwisely.org/partners. Access May 11, 2014.
3. Choosing Wisely Grantees. Available at: http://www.choosingwisely.org/grantees. Accessed May 11, 2014.
4. Choosing Wisely & Consumer Reports. Available at: http://consumerhealthchoices.org/wp-content/uploads/2014/03/ChoosingWiselyAndConsumerHealthChoices.pdf. Accessed May 11, 2014.
5. Morden ME, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value services. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1314965. Accessed May 11, 2014.