Choosing Wisely campaign not yet associated with reduced low-value testing

1. For seven of the original Choosing Wisely campaign recommendations to reduce low-value testing, there was no clinically significant change in the use of these tests in the immediate years after the initiation of the campaign.

2. In statistical measures, there was a decrease in two of the seven, and an increase in two of the seven noted, but the clinical effect was negligible.

Evidence Rating Level: 2 (Good)

Study Rundown:  The Choosing Wisely campaign, initiated in 2009 and expanded in 2012, is a physician-driven effort to curb health care costs. It is a constellation of recommendations from a variety of specialties about the judicious use of tests, imaging, and treatment that are low-value. While most guidelines are geared specifically towards practitioners, the Choosing Wisely campaign is meant for both clinicians and patients. This study was meant to determine if there were any early effects from these recommendations in curbing the cost of health care in low-value situations. The results showed that for seven of the original recommendations made by the Choosing Wisely campaign, there was no clinically significant change in use of these tests in the immediate years after the initiation of the campaign. In statistical measures, there was a decrease in two of the seven, and an increase in two of the seven noted, but the clinical effect was negligible.

While the study did benefit from a large number of insurance claims from which data were obtained, using only a single insurance company’s claims may have confounded the results. Furthermore, benefits of the campaign may not be realized for many years after its initiation, especially since these overhauls take time to gather traction, so the study may have been conducted too early. Also, the claims data may not entirely capture the particular clinical situations in which tests were ordered, whether appropriately or inappropriately.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely

In-Depth [retrospective cohort]: This retrospective study used data from Anthem-affiliated Blue Cross and Blue Shield medical and pharmacy claims. Of the many recommendations present in the Choosing Wisely campaign, seven of the original ones from 2012 were examined in this study. The seven recommendations were as follows: imaging for headaches with uncomplicated conditions, cardiac testing with no cardiac history or symptoms, preoperative chest x-rays without any history or physical findings, low back imaging without any red flag symptoms, human papillomavirus testing in women under age 30, antibiotics in acute sinusitis, NSAID usage in setting of certain chronic conditions (hypertension, heart failure, or chronic kidney disease). The metrics for these services were evaluated over the course of at least 10 quarters, starting in 2010.  The aforementioned recommendations were made in the 2012.

After analysis, there was a statistically significant decrease in the amount of head imaging for uncomplicated headaches (from 14.9% to 13.4%; trend estimate 0.99; 95% CI, 0.98-0.99) and for cardiac testing in absence of cardiac disease (from 10.8% to 9.7%; trend estimate 0.99; 95% CI, 0.99-0.99). For the remaining five recommendations, there was no significant decrease. In fact, there was a statistical increase in the HPV testing amongst women under 30 (from 4.8% to 6.0%; trend estimate 1.01; 95% CI, 1.00-1.01) and in NSAID use amongst patients with aforementioned chronic conditions (from 14.4% to 16.2%; trend estimate 1.02; 95% CI, 1.01-1.02).

Image: PD

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