A Lever and a Place to Stand

“Choosing wisely” – a simple phrase, covering all manner of situations. Nowhere is carefully considered decision-making more important than in medical care, where even the smallest error can have grave consequences. But not every “unwise decision” in healthcare is an error; sometimes, it’s a question of less-than-optimal resource use, which itself feeds downstream consequences like hospital blood draw-induced anemia, false positive results, or incidental findings that may never have affected a patient’s health if not discovered and pursued during other investigations. Such is the dilemma of unnecessary testing. An extra complete blood count here or erythrocyte sedimentation rate there is unlikely to prove severely damaging, but each test comes with a cost, both to patient comfort and to the laboratory’s resources.

Such considerations gave rise to the eponymous “Choosing Wisely” campaign – a movement intended to encourage better decisions about medical services by primary care physicians, specialists, and patients, who together are best positioned to change the status quo. In 2010, an article in the New England Journal of Medicine outlined medical professionals’ ethical responsibility to contribute to reducing unnecessary testing and proposed a “Top Five” list of the most expensive and overused tests in each specialty (1). A year later, another paper estimated that – even using the most conservative estimates – waste in just six categories amounted to at least US$558 billion per year, more than one-fifth of total healthcare expenditures (2). In the same year, the Choosing Wisely campaign was launched. Featuring Top Five lists from nine specialties, the goal was to raise awareness about overutilization and encourage medical professionals to take steps to prevent it. In medicine, more is not always better – and Choosing Wisely places the lever for change firmly in doctors’ hands and encourages patients and physicians to discuss when tests and treatments may not be needed.

A shift in perspective

Since its launch, the movement has grown to include a wide range of specialties, and a correspondingly wide range of testing recommendations. The American Society for Clinical Pathology, for instance, has a “Top 20” list of “things physicians and patients should question.” Their recommendations include aspects such as not ordering population-based vitamin D screening, avoiding routine preoperative testing for low-risk surgeries, and not using the bleeding time test to guide patient management (3). To some physicians, some of these may seem obvious. After all, one-third or more of the UK’s population exhibits vitamin D deficiency in the winter (4), but not all require immediate medical intervention – so why subject them to testing? Others may be less intuitive; for instance, doctors may hesitate to perform even low-risk surgery without first establishing a patient’s complete blood count, clotting times and general health. But when these tests influence care in fewer than three of every 100 patients, neither the stress nor the cost may be worthwhile.

These are the kinds of changes to patient care that Choosing Wisely has spent the past five years working to normalize. What began as an idea in 2011, with just a few societies and recommendations, has now grown into a movement with over 80 societies issuing over 500 recommendations about services that may not be necessary in every instance. One factor that has really helped drive the success of the campaign among doctors is the support of the American Board of Internal Medicine (ABIM) Foundation in establishing relationships with professional societies, health systems, researchers, and funders. And although Choosing Wisely and the ABIM Foundation might not be well-known names among the general public, the campaign has another powerful partner – Consumer Reports. Their involvement has helped to bring the campaign to patients by producing reports, brochures and videos to educate patients on utilization management and how to discuss it with their doctors. Furthermore, the campaign has spread to nearly 20 countries – so despite its United States origins, it’s now a truly global phenomenon. In just five years, Choosing Wisely is becoming a household name – and, as a result, the need to decrease unnecessary medical services has become an accepted imperative.

Proving itself in patient care

Choosing Wisely recommendations have been tested in, and incorporated into, many health systems. The increase in traction is due to the guidelines’ success on the ground; most health systems that have promoted Choosing Wisely have found that utilization of unneeded services has decreased and conversations about those services has increased. One study showed that, among primary care physicians, those familiar with the campaign tended to be more cost-conscious than colleagues unfamiliar with it, and tended to make less use of low-value services (5). Individual health systems have seen great success in implementing the guidelines. California’s Cedars-Sinai Health System, for instance, reduced multiple metrics (including inappropriate blood transfusions, vitamin D testing and human papillomavirus testing) by at least 20 percent over a year of adherence to Choosing Wisely guidelines (6). The University of Utah decreased its lab cost per patient per day from US$138 to $123 with no increase in readmission rates, and the University of Vermont Medical Center reduced lab tests on patients with end-stage renal disease by 72 percent and the ordering of complete blood counts and basal metabolic panels on adult inpatients by 48 percent.

There’s little doubt, then, that the Choosing Wisely recommendations are helping to optimize patient care. The challenge now is how to spread effective interventions to other health systems. Changing routine behaviors and practices is difficult in any profession – and that can keep physicians ordering unnecessary tests and procedures, and prevent the transition to newer, more streamlined approaches to patient care. Even when physicians agree with the campaign’s recommendations, they may think their patients expect certain tests, or they may be uncertain about when to order them for specific patient indications. And that’s why a new paper, which takes a look at the movement’s history and the promise it sets up for the next five years (7), acknowledges that we need to continue to develop and test innovative behavior change strategies for both physicians and patients. According to lead author Eve Kerr, Professor of Internal Medicine at the University of Michigan and Director of the VA Center for Clinical Management Research, Ann Arbor, USA, there is no single best way to disseminate Choosing Wisely recommendations to physicians – or to educate them about better test utilization. Instead of seeking a Holy Grail answer, Kerr believes we need to understand what drives inappropriate ordering and try to design our interventions and educational approaches to address those issues. Is it uncertainty about the best course of action? Concern about patient expectations? Worries about financial losses? Simply not agreeing with a recommendation? Perhaps it is something else altogether.

How you can help

Pathologists can work within their institutions to spread the Choosing Wisely recommendations they endorse. How? Kerr says one way is to develop rules and policies about when not to perform certain tests, even when ordered. Pathologists can take steps toward implementing such rules by working with health system leadership to explain the need for them and outline how they can improve overall patient outcomes and cost savings. Another recommendation is to provide ordering clinicians with feedback about when and why tests might not be indicated for particular patients or populations. In some fields, doctors can order a full battery of tests without thinking about whether or not they are all necessary – thyroid panels, for instance, or workups for coagulopathy. Partnering with the primary care doctors and specialists who do the bulk of ordering is a great path for reducing this kind of overutilization.

The tremendous growth in medical societies, health systems, and even states espousing the Choosing Wisely campaign in just these first five years has laid a solid foundation for next steps. Pathologists can help move the campaign forward by working within their own institutions and partnering with researchers to trial innovative approaches to decreasing unnecessary testing. It’s this kind of collaborative work – involving pathologists, primary care physicians and researchers – that can ultimately lead to less expense, less testing, and a better healthcare experience for our patients.