The Choosing Wisely initiative and laboratory test stewardship
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Diagnosis 2019; 6(1): 15–23
Review
Geoffrey S. Baird*
The Choosing Wisely initiative and laboratory test
stewardship
https://doi.org/10.1515/dx-2018-0045
Received June 27, 2018; accepted August 6, 2018; previously
Introduction
published online September 6, 2018
One undeniable hallmark of medical care in the US is that
Abstract: The United States Choosing Wisely initiative was it is expensive. According to 2016 data from the Organiza-
started in 2012 by the American Board of Internal Medicine tion for Economic Cooperation and Development, the US
Foundation and focused on reducing medical resource spends substantially more per capita than any of the 35
overutilization. Since its inception in the US, similar countries it surveys, beating out the second place country
efforts have arisen in at least a dozen countries. Strongly (Switzerland) by nearly 25% [1]. Put another way, other
patient-focused, and in fact started in collaboration with wealthy countries spend half as much per person on
the consumer magazine Consumer Reports, the effort has healthcare as the US does, on average. However, the US
resulted in a collection of greater than 500 recommenda- has fewer physician consultations per capita than most
tions from over 80 US professional societies intended to comparable countries [2]. This implies that when a US
inform both patients and doctors about medical practices patient visits their doctor, what occurs at that visit must,
whose necessity should be questioned or discussed. Tar- on average, cost substantially more than it would in most
gets of recommendations include practices that lack a other wealthy nations, either due to increased utilization
basis in scientific evidence, practices that may be duplica- of services or pharmaceuticals, or increased prices for
tive of other care already received, practices that may be those services, increased administrative costs or some
harmful and practices that are simply unnecessary. While combination of these and other factors. More frustrat-
critiques have been levied against the Choosing Wisely ingly, the US does not seem to be purchasing much value
initiative over its intent, methods and efficacy, it is clear with these expenditures, as healthcare outcomes of the US
that many of its recommendations have been adopted by lag well behind many developed nations [3].
large medical practices, and several positive outcomes, When confronted with the large cumulative expendi-
i.e. reductions in perceived waste, have been reported in ture on healthcare in the US, one might be tempted to ignore
relation to many of the recommendations, including those the role laboratory tests play in driving costs because the
specifically targeting laboratory tests. The future success overall percentage of healthcare dollars going to labora-
of Choosing Wisely will likely hinge on whether or not tory testing sits at around 4% of US national healthcare
significantly positive and durable outcomes can be dem- expenditure [4]. However, those in the laboratory profes-
onstrated, especially at a time where there is increasing sion recognize the fallacy of this argument almost imme-
pressure to drive down costs in medical care while con- diately, because while laboratory tests are collectively,
comitantly increasing quality. and often individually, quite inexpensive, they provide a
substantial fraction of the objective data that is used in
Keywords: Choosing Wisely; demand management;
medical decision-making, and they therefore likely play a
test utilization.
substantial role in driving other non-laboratory costs [5].
A clear example of this is a prostate-specific antigen (PSA)
test, which is individually inexpensive (the US govern-
mental insurance program Medicare’s reimbursement in
the author’s region at the time of this writing is USD $22.71
*Corresponding author: Geoffrey S. Baird, MD, PhD, Associate for a single PSA test), but which could lead to a biopsy,
Professor and Interim Chair, Department of Laboratory Medicine,
prostatectomy, chemotherapy or radiation therapy, the
University of Washington, Box 357110, 1959 NE Pacific Street,
Seattle, WA 98195, USA, Phone: +206-598-6137,
cumulative costs of which may exceed the initial test cost
Fax: +206-897-4312, E-mail: gbaird@u.washington.edu. by over 1000-fold. Alas, quantifying this magnification
https://orcid.org/0000-0001-9064-6558 effect is challenging. While it has been stated, quoted
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Download Date | 2/26/19 9:04 PM16 Baird: Choosing Wisely
Table 1: International Choosing Wisely internet addresses. societies [9]. The effort was based on two precepts: Com-
plexity Theory, in which a process was allowed to develop
Country Web Link organically so that an “emergent design” arose in a context
United States www.choosingwisely.org of minimum constraints, and Self-Determination Theory,
Canada www.choosingwiselycanada.org in which the autonomy of each individual special society
Italy www.choosingwiselyitaly.org was supported so that they could work in their own pre-
Japan www.choosingwisely.jp
ferred way and only join the overall initiative when ready.
Switzerland www.smartermedicine.ch
Australia www.choosingwisely.org.au Although it would have been very difficult to document, it
New Zealand www.choosingwisely.org.nz is likely that some specialty societies that otherwise might
Germany www.klug-entscheiden.com have resisted participation in the Choosing Wisely initia-
United Kingdom www.choosingwisely.co.uk tive chose to join eventually because so many other socie-
Brazil proqualis.net/choosing-wisely-brasil
ties had joined that their absence would be noticed, akin
Israel www.choosingwisely.org.il
Wales www.choosingwisely.wales.nhs.uk
to “peer pressure”. With these mechanisms in place, the
individual specialty societies began to generate recom-
mendations based on only a few rules: recommendations
should pertain to tests and treatments that are costly and/
and cited for more than a decade that laboratory tests
or used frequently, recommendations should be evidence-
influence approximately 70% of medical decisions, this
based, recommendations should pertain to decisions that
notion, often proffered as fact, is actually a surmise made
are within the control of the specialty and recommenda-
by a single clinical pathologist that has taken on a life of
tions should be developed and approved using a transpar-
its own, despite the fact that it has no basis in any rigorous
ent process.
study or evidence (Dr. Rod Forsman, personal communi-
As one can imagine, some of the later criticisms of
cation and this [6]). While the true average impact of all
Choosing Wisely (to be discussed below) stem directly
laboratory tests on all medical decisions is thus unknown,
from this rather loose structure. The process Choosing
as nearly a third of outpatient visits, approximately half of
Wisely allows for recommendation generation is much
emergency department visits and essentially all inpatient
less rigorous than what is in place in essentially any
visits are associated with laboratory testing, it must be the
process that generates official medical practice guide-
case that laboratory testing has an effect on healthcare
lines, which is one reason that Choosing Wisely generates
decisions that is far larger than its proportion of expendi-
“recommendations” rather than “guidelines”.
ture [7].
The relative lack of evidence of laboratory testing’s
role in overall health care overutilization and concomi-
tant over-expenditure notwithstanding, it seems entirely Choosing Wisely’s laboratory
rational to surmise, along with Dr. Forsman, that labo-
ratory tests have an outsized effect in driving medical
test-focused recommendations
decision making, and also to assume that optimizing lab-
While the American Society for Clinical Pathology (ASCP),
oratory test utilization will be beneficial to patients and
an organization focused entirely on pathology and labo-
our economy. It is with these ideas in mind that several
ratory testing, has been involved in the Choosing Wisely
of the specialty societies engaged in Choosing Wisely in
initiative since 2013 and has made 20 recommendations
2012–2013 began to develop recommendations, many of
(Table 2), as of this writing 71 recommendations relating to
which dealt specifically with the topic of laboratory test
laboratory tests have been made by other specialty socie-
overutilization. Since that time, many other international
ties as well (Table 3).
Choosing Wisely efforts have arisen [8], as indicated in
The laboratory test recommendations made to date
Table 1, adding to these US recommendations.
are mostly non-controversial, and to those involved in
the field of laboratory test stewardship in any capacity,
they mostly appear to be the proverbial “low-hanging
The Choosing Wisely process fruit”. For example, certain recommendations, such as
the ASCP’s recommendation to avoid frozen sections if
Significant thought was put into the process by which the the results will not affect immediate management, are
Choosing Wisely initiative would solicit or encourage rec- little more than common sense, and the Society of Hos-
ommendations to be made by the participating specialty pital Medicine and Critical Care Societies’ collaborative
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Table 2: ASCP Choosing Wisely recommendations as of June 2018.
Do not use sputum cytology to evaluate patients with peripheral lung lesions
Do not order red blood cell folate levels at all. In adults, consider folate supplementation instead of serum folate testing in patients with
macrocytic anemia
Do not repeat hemoglobin electrophoresis (or equivalent) in patients who have a prior result and who do not require therapeutic
intervention or monitoring of hemoglobin variant levels
Do not test for protein C, protein S, or antithrombin (ATIII) levels during an active clotting event to diagnose a hereditary deficiency because
these tests are not analytically accurate during an active clotting event
Do not order a frozen section on a pathology specimen if the result will not affect immediate (i.e. intraoperative or perioperative) patient
management
Do not perform fluorescence in situ hybridization (FISH) for myelodysplastic syndrome (MDS)-related abnormalities on bone marrow
samples obtained for cytopenias when an adequate conventional karyotype is obtained
Do not request serology for Helicobacter pylori. Use the stool antigen or breath tests instead
Do not test for amylase in cases of suspected acute pancreatitis. Instead, test for lipase
Do not routinely order expanded lipid panels (particle sizing, nuclear magnetic resonance) as screening tests for cardiovascular disease
Do not routinely perform sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma because these
tests do not improve survival
Don’t order multiple tests in the initial evaluation of a patient with suspected thyroid disease. Order thyroid-stimulating hormone (TSH), and
if abnormal, follow up with additional evaluation or treatment depending on the findings
Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T
Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency
Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio (INR) and does not respond to vitamin K therapy
Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive
protein (CRP) to detect acute phase inflammation
Don’t use bleeding time test to guide patient care
Only order methylated septin 9 (SEPT9) to screen for colon cancer on patients for whom conventional diagnostics are not possible
Avoid routine preoperative testing for low risk surgeries without a clinical indication
Don’t perform low-risk HPV testing
Don’t perform population based screening for 25-OH-vitamin D deficiency
recommendations to avoid daily routine inpatient labo- commonly, even though the evidence for their use may be
ratory testing address a problem that almost everyone in weak or nonexistent. In making these recommendations,
medical practice agrees is wasteful. One might question the ASCP has indicated that its experts believe that stop-
the utility of recommendations like this, as they appear ping these testing practices is safe, and likely beneficial
only to be admonitions to remember the obvious, and to patients. Thus, these types of recommendations often
as calls for enhanced vigilance regarding laboratory test find utility as the bases of large system-wide initiatives in
utilization are notoriously ineffective. Additionally, the health care systems.
basis of these recommendations lies not in evidence but Although unusual, some recommendations duplicate
rather in logic, as no one would design a clinical trial to or conflict with other recommendations. This is unusual
assess the efficacy of needless frozen sections or routine because the recommendation generation process involves
tests ordered without any indication. Nonetheless, these communication with other professional societies and
recommendations may still have value in supporting an review of other existing recommendations, so professional
appeal to a higher authority when a contentious situation societies can be aware of conflicts and adjudicate them
arises, i.e. a pathologist may benefit in crafting a hospital prior to publication. PSA testing, mentioned previously,
policy discouraging needless frozen sections or routine is one such area, as the American Academy of Family
daily laboratory testing by citing Choosing Wisely. Physicians recommends against routine use of PSA as a
Other laboratory test recommendations, like ASCP’s cancer screening test and the American Society of Clinical
recommendation to avoid routine vitamin D screening, Oncology recommends against screening asymptomatic
routine preoperative testing workups and thrombophilia men with less than 10 years of life expectancy, but the
workups during acute clotting events address issues American Urological Society uses positive language in rec-
that are significant but controversial to some clinicians. ommending, “Offer PSA screening for detecting prostate
Selected practitioners do prefer to order these tests quite cancer only after engaging in shared decision making”.
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Download Date | 2/26/19 9:04 PMTable 3: All non-ASCP Choosing Wisely recommendations designated by the initiative as focused on “lab” services.
18
Source Recommendation
AMDA – The Society for Post-Acute and Long-Term Care Medicine Don’t obtain a Clostridium difficile toxin test to confirm “cure” if symptoms have resolved
AMDA – The Society for Post-Acute and Long-Term Care Medicine Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years
AMDA – The Society for Post-Acute and Long-Term Care Medicine Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract
American Academy of Allergy, Asthma and Immunology Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy
American Academy of Allergy, Asthma and Immunology Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of
immunoglobulin E (IgE) tests, in the evaluation of allergy
American Academy of Dermatology Don’t routinely use microbiologic testing in the evaluation and management of acne
Baird: Choosing Wisely
American Academy of Dermatology Don’t use skin prick tests or blood tests such as the radioallergosorbent test (RAST) for the routine evaluation of eczema
American Academy of Family Physicians Don’t routinely screen for prostate cancer using a prostate specific antigen (PSA) test or digital rectal exam
American Academy of Nursing Don’t routinely repeat labs hemoglobin and hematocrit in the hemodynamically normal pediatric patients with isolated
blunt solid organ injury
American Academy of Ophthalmology Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications
American Academy of Pediatrics Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteriuria
American Academy of Pediatrics Don’t perform screening panels for food allergies without previous consideration of medical history
American Academy of Pediatrics – Section on Endocrinology Avoid ordering LH and FSH and either estradiol or testosterone for children with pubic hair and/or body odor but no other
signs of puberty
American Academy of Pediatrics – Section on Endocrinology Avoid routinely measuring thyroid function and/or insulin levels in children with obesity
American Academy of Pediatrics – Section on Endocrinology Avoid ordering vitamin D concentrations routinely in otherwise healthy children, including children who are overweight or
obese
American Academy of Pediatrics – Section on Endocrinology Avoid ordering screening tests looking for chronic illness or an endocrine cause, including CBC, CMP, IGF-1, thyroid tests,
and celiac antibodies, in healthy children who are growing at or above the third percentile for height with a normal growth
rate (i.e. not crossing percentiles) and with appropriate weight gain
American Association for the Study of Liver Diseases Don’t repeat hepatitis C viral load testing outside of antiviral therapy
American Association of Blood Banks Don’t perform serial blood counts on clinically stable patients
American College of Medical Genetics and Genomics Don’t order APOE genetic testing as a predictive test for Alzheimer disease
American College of Medical Genetics and Genomics Don’t order MTHFR genetic testing for the risk assessment of hereditary thrombophilia
American College of Medical Genetics and Genomics Don’t order HFE genetic testing for a patient without iron overload or a family history of HFE-associated hereditary
hemochromatosis
American College of Medical Genetics and Genomics Don’t order a duplicate genetic test for an inherited condition unless there is uncertainty about the validity of the existing
test result
American College of Medical Genetics and Genomics Don’t order exome or genome sequencing before obtaining informed consent that includes the possibility of secondary
findings
American College of Medical Toxicology and The American Don’t perform hair or nail testing for “metal poisoning” screening in patients with nonspecific symptoms
Academy of Clinical Toxicology
American College of Medical Toxicology and The American Don’t order tests to evaluate for or diagnose “idiopathic environmental intolerances,” “electromagnetic hypersensitivity”
Academy of Clinical Toxicology or “mold toxicosis”
American College of Medical Toxicology and The American Don’t order heavy metal screening tests to assess non-specific symptoms in the absence of excessive exposure to metals
Academy of Clinical Toxicology
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American College of Obstetricians and Gynecologists Don’t screen for ovarian cancer in asymptomatic women at average risk
American College of Rheumatology Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam
findingsTable 3 (continued)
Source Recommendation
American College of Rheumatology Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease
American College of Rheumatology – Pediatric Rheumatology Don’t repeat a confirmed positive ANA in patients with established JIA or systemic lupus erythematosus (SLE)
American College of Rheumatology – Pediatric Rheumatology Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses
American College of Rheumatology – Pediatric Rheumatology Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam
findings
American College of Rheumatology – Pediatric Rheumatology Don’t order autoantibody panels unless positive antinuclear antibodies (ANA) and evidence of rheumatic disease
American Society for Colposcopy and Cervical Pathology Don’t perform vaginal cytology (Pap test) or HPV screening in women who had hysterectomy (with removal of the cervix) for
reasons other than high-grade cervical dysplasia (CIN 2/3) or cancer
American Society for Colposcopy and Cervical Pathology Don’t perform cervical cytology (Pap tests) or HPV screening in immunocompetent women under age 21
American Society for Reproductive Medicine Don’t perform prolactin testing as part of the routine infertility evaluation in women with regular menses
American Society for Reproductive Medicine Don’t obtain follicle-stimulating hormone (FSH) levels in women in their 40s to identify the menopausal transition as a
cause of irregular or abnormal menstrual bleeding
American Society for Reproductive Medicine Don’t obtain a karyotype as part of the initial evaluation for amenorrhea
American Society for Reproductive Medicine Don’t perform immunological testing as part of the routine infertility evaluation
American Society for Reproductive Medicine Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation
American Society for Reproductive Medicine Don’t perform a postcoital test (PCT) for the evaluation of infertility
American Society for Reproductive Medicine Don’t perform advanced sperm function testing, such as sperm penetration or hemizona assays, in the initial evaluation of
the infertile couple
American Society of Anesthesiologists Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk
surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss
(or fluid shifts) is/are expected to be minimal
American Society of Clinical Oncology Don’t perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to
live less than 10 years
American Society of Hematology Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT
American Society of Hematology Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major
transient risk factors (surgery, trauma or prolonged immobility)
American Society of Nephrology Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms
American Urogynecologic Society Avoid using synthetic or biologic grafts in primary rectocele repairs
American Urological Association Don’t obtain urine cytology or urine markers as a part of the routine evaluation of the asymptomatic patient with
microhematuria
American Urological Association Offer PSA screening for detecting prostate cancer only after engaging in shared decision making
American Urological Association Don’t diagnose microhematuria solely on the results of a urine dipstick (macroscopic urinalysis)
American Urological Association Don’t order creatinine or upper-tract imaging for patients with benign prostatic hyperplasia (BPH)
Commission on Cancer Don’t initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan
Critical Care Societies Collaborative – Critical Care Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions
Endocrine Society Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients
Baird: Choosing Wisely
Endocrine Society Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function
HIV Medicine Association Avoid unnecessary CD4 tests
HIV Medicine Association Avoid quarterly viral load testing of patients who have durable viral suppression, unless clinically indicated
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HIV Medicine Association Don’t order complex lymphocyte panels when ordering CD4 counts
1920 Baird: Choosing Wisely
These are not entirely contradictory recommendations,
Don’t obtain routine blood work (e.g. CBC, liver function tests) other than a CEA level during surveillance for colorectal cancer
Don’t perform maternal serologic studies for cytomegalovirus and toxoplasma as part of routine prenatal laboratory studies
Don’t do an inherited thrombophilia evaluation for women with histories of pregnancy loss, intrauterine growth restriction
but they certainly reflect different interpretations of the
Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein
Don’t offer noninvasive prenatal testing (NIPT) to low-risk patients or make irreversible decisions based on the results of
published literature and cost-benefit analyses of PSA
Don’t perform urinalysis, urine culture, blood culture or C. difficile testing unless patients have signs or symptoms of
Don’t routinely order testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency for patients who are not
testing, and they likely also reflect biases and maybe even
Don’t routinely test for CMV IgG in HIV-infected patients who have a high likelihood of being infected with CMV
financial motives of different groups of physicians, as
urologists are likely to see a financial return from screen-
Don’t order serum aneuploidy screening after cfDNA aneuploidy screening has already been performed
ing strategies that drive referrals. That no formal process
exists to resolve such inconsistencies is a drawback of the
Choosing Wisely approach.
Finally, another class of recommendations worth con-
Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability
sidering includes those that deal with proprietary tests,
such as ASCP’s recommendations dealing with meth-
infection. Tests can be falsely positive leading to over diagnosis and overtreatment
ylated septin 9 and nuclear magnetic resonance lipid
assays. These recommendations, by virtue of their push
Avoid testing for a Clostridium difficile infection in the absence of diarrhea
Don’t screen low risk women with CA-125 or ultrasound for ovarian cancer
to decrease test utilization, could conceivably adversely
affect the profitability of specific laboratories or holders of
intellectual property. Other recommendations, such as the
one discouraging large immunoglobulin E (IgE) allergy
testing panels made by the American Academy of Allergy,
Asthma and Immunology (AAAAI), ostensibly threaten to
reduce the utilization of tests that can generate substan-
thrombosis (DVT) in the setting of a known cause
tial revenue for some clinical laboratories. The Choosing
Wisely initiative has no plan to deal with these situations,
where the recommendations of a specialty body would be
(IUGR), preeclampsia and abruption
predisposed due to race/ethnicity
expected to penalize one or a very few individuals or labo-
ratories financially. However, as the initiative moves into
the future and novel diagnostic tests continue to be devel-
oped at a fast pace, one can expect this thorny issue to
arise frequently, and formal recognition of this issue may
this screening test
Recommendation
become important.
Overdiagnosis and Choosing Wisely
One of the critical concepts underlying the Choosing
Wisely initiative is the idea of overdiagnosis. Welch
et al. has authored numerous studies documenting the
Society of Hospital Medicine – Adult Hospital Medicine
problem of overdiagnosis [10, 11], which he defines as
the diagnosis of a disease that will never cause symp-
Society for Healthcare Epidemiology of America
toms or death during a patient’s lifetime. An example of
overdiagnosis is the small, indolent prostatic carcinoma
Infectious Diseases Society of America
discovered through PSA testing and concomitant biopsy
Society for Maternal-Fetal Medicine
Society for Maternal-Fetal Medicine
Society for Maternal-Fetal Medicine
Society for Maternal-Fetal Medicine
in a 78-year-old male with a 4-year life expectancy due
Society of Gynecologic Oncology
to coronary artery disease. While the patient truly has
Society for Vascular Medicine
Society of Surgical Oncology
cancer, it should be apparent that the diagnosis of cancer
HIV Medicine Association
HIV Medicine Association
does not help this individual in any way, as he is likely to
Table 3 (continued)
die of some other cause before the cancer, even untreated,
would likely cause any symptoms or death. Many physi-
cians would advise against giving this patient a PSA test
Source
in the first place, so as to avoid this overdiagnosis and all
of the expensive and potentially dangerous follow-up that
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the overdiagnosis could engender. This is the underlying although questionably causal, relationship could be
logic of the Society for Post-Acute and Long-Term Care observed between Choosing Wisely and ordering prac-
Medicine’s Choosing Wisely recommendation to avoid not tices. However, other services that Choosing Wisely rec-
just prostate cancer screening, but also breast and colo- ommended against actually increased, such as human
rectal cancer screening in individuals with life expectan- papilloma virus testing in young women, and other
cies shorter than 10 years. services recommended against remained common and
In addition to this PSA example, several other Choos- unchanged in frequency, such as preoperative chest X-rays
ing Wisely recommendations explicitly try to prevent [12], so the positive effect observed in the two imaging cat-
overdiagnosis in areas other than cancer. The AAAAI’s egories may have been a statistical fluke or an isolated
recommendations against large immunoglobulin G and effect that was not applicable to other areas. Another
IgE allergy panels and IgE testing without a history con- study in 2015, however, showed a much more positive
sistent with IgE-related food allergy is clearly rooted in the effect of Choosing Wisely. In this study [13, 14], inspired
propensity of these tests to yield several questionable pos- by the Canadian and US Choosing Wisely campaigns, the
itive results, or overdiagnoses, that have no clinical conse- testing requisition for the Canadian province of Alberta
quence. For example, if a patient who enjoys strawberries was changed so that vitamin D testing was not permitted
is being evaluated for a nut allergy and an IgE against a without the ordering physician providing an indication of
strawberry antigen is discovered due to large IgE panel medical necessity. This intervention led to a 92% reduc-
testing, it is unlikely that this patient has a serious risk for tion in vitamin D testing and an estimated $4 million USD
anaphylaxis from strawberries. Neither the inconvenience in projected annual monetary savings. The contrasting
of strawberry avoidance nor the expense of any therapeu- results of these two studies indicate that passive adoption
tic intervention aimed at inducing tolerance to strawber- of Choosing Wisely recommendations is weak and maybe
ries would be warranted. While this seems logical, it has nonexistent, but that targeted implementations of recom-
been, in the author’s experience, rather challenging to mendations can be highly effective.
communicate this risk of testing to ordering providers and A 2017 US study [15] assessed multiple interventions
laboratories successfully, especially when financial incen- undertaken at a large military hospital aimed at reduc-
tives support the decision to test. ing unnecessary laboratory testing, primarily related to
Choosing Wisely recommendations targeting daily routine
testing. Interventions included modifications of repetitive
Efficacy of Choosing Wisely inpatient orders for routine tests and displaying laboratory
test costs (US Medicare reimbursement rates) to ordering
At its inception, the Choosing Wisely initiative promised providers, both of which were found to lead to sustained
many benefits. It had the potential to increase awareness, reductions in routine test ordering, by 19.4% and 15.3%,
amongst patients and providers alike, of the problem respectively. This study demonstrates the power of using
of resource overutilization in medicine. It also held the multiple, linked interventions coupled with computerized
promise to reduce, directly or indirectly, some of the order set modifications to effect lasting change in ordering
practices that were called out in its many recommenda- behaviors, and also evidence that a targeted effort to imple-
tions. Finally, one might have hoped that it would have ment Choosing Wisely recommendations can succeed.
some positive effect on the so-called triple aim of health- Another study, from the Netherlands [16], similarly
care, which is to improve the patient experience of care, focused on Choosing Wisely recommendations by choos-
improve the health of populations and reduce the cost of ing to implement processes inspired by the American
healthcare. Whether or not Choosing Wisely has done any College of Rheumatology’s antinuclear antibody (ANA)
of these things has been debatable, in large part due to testing recommendation. Through a combination of edu-
the fact that the initiative does not include explicit aims cation and provision of non-individualized feedback
focused on measurement or monitoring of efficacy. None- on test ordering patterns, the authors reported a signifi-
theless, the peer-reviewed literature now contains several cant decrease in ANA test orders from the targeted rheu-
studies of Choosing Wisely’s efficacy in targeted areas. matologists, significant decreases in repeat ANA test
A 2015 study demonstrated that services provided to orders and decreased variation in test ordering practices
members of a large US insurer followed trends that were between rheumatologists at one site in the study. While
partially in accord with Choosing Wisely recommenda- small (the study only included 29 total rheumatologists)
tions, namely those concerning imaging for headache and only focused on patients who actually received ANA
and cardiac imaging, indicating that a temporally related, tests, it demonstrates that education paired with feedback
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can be a successful strategy for reducing test utiliza- recommendations. A study comparing Choosing Wisely
tion. One weakness of this study is that it was not able to US recommendations to German S3 Guidelines [20]
demonstrate that the reduction in ANA test volumes was found that of the different participants’ “Top Five” rec-
entirely due to reductions in unnecessary tests. ommendations in 2015, only 131 of 412 were found to be
“trustworthy” according to assessments used to grade
evidence-based guidelines. Only 75 recommendations
Criticisms of Choosing Wisely had equivalents in the German guidelines, but several
others were found to have sufficient evidentiary support
Criticisms of Choosing Wisely are rooted in the historical cited in the recommendation text. This analysis does
perspective that the initiative began only a few years after not reach a surprising result, as Choosing Wisely never
the passage of the US Affordable Care Act, also known as intended its recommendations to rise to the standards
“Obamacare”. This was a time of great focus on healthcare expected of formal clinical guidelines, but the question
economics, as well as significant disagreement between remains as to what clinicians and patients should do with
political parties in the US regarding how to solve problems the 281 recommendations that did not meet criteria for
in the US healthcare system. At its core, Choosing Wisely trustworthiness.
presented (and still presents) a political target for propo- As to the effectiveness of Choosing Wisely, the lack of
nents and beneficiaries of the current fee-for-service based compelling evidence of passive adoption of recommenda-
US healthcare system, as lowering healthcare costs comes tions has been cited above. The best evidence in support
with a necessary side-effect of lowering the revenue of of Choosing Wisely would be comprehensive studies of
those who perform the services and receive the fees. Other implementation and outcomes across many sites, but
critics have warned that Choosing Wisely recommenda- while frameworks have been proposed for monitoring the
tions are difficult to follow and could interfere with the success of the initiative [21], perhaps one of the most inci-
doctor-patient relationship [17], that patients may not be sive criticisms of Choosing Wisely is that so little has actu-
able to understand the recommendations [18], and that ally been done to date to measure the overall effect of all of
the entire initiative is about saving money and not about the campaign. Taking a cynical position, the existence of
patient care [19]. One might also wonder how enforce- the Choosing Wisely “Champions” program within the ini-
able simple recommendations could ever be, and likewise tiative (http://www.choosingwisely.org/success-stories/
question the effectiveness of recommendations that no champions/) may paradoxically reflect this problem, as
one is required even to read, much less follow. While peer the initiative’s focus on local success stories could partly
pressure may have induced several professional societies be due to the paucity of evidence of a more global benefit.
to participate in the program, it is unclear whether or not The fairest assessment of this issue, however, is probably
peer pressure alone might also curb test overutilization by that the initiative is still young, that local successes are
the members of those same professional societies. While still successes and that quality improvement takes time
no attempt to refute any of these arguments will be made and effort. While little exists today to demonstrate a global
here, it is important to understand the criticisms in the benefit from Choosing Wisely, there have been many
context of Choosing Wisely’s origin in the US. The US’s undeniable and meaningful positive changes effected on
outsized healthcare expenditures, the US citizenry’s dis- local scales that are clearly tied to the initiative.
comfort with the thought of “less is more” and ignorance
of the fact (or unwillingness to believe) that US healthcare
is not actually the best in the world, the lack of a cen- Conclusions
tralized healthcare model in the US, the related lack of a
single central review body in the US that has the authority The US Choosing Wisely initiative represents a new tactic
to assess the efficacy and utility of medical practices and in a decades-long struggle to control the overutilization of
the US’s current political climate that explicitly prioritizes medical tests and procedures. Through use of a patient-
neither evidence nor expertise in decision-making all focused website and an underlying model that is flexible
work together against initiatives in the US that would seek and that encourages wide participation and commonsense
to reduce healthcare services even when trusted groups recommendations, the initiative aims to support doctors,
say that those services are unnecessary. patients and healthcare systems in their efforts to reduce
Besides criticisms aimed at the purpose of the ini- the quantity of unnecessary medical care delivered in the
tiative, additional criticisms of Choosing Wisely have US. Success stories abound, with individuals and health-
been aimed at the methodology used to create the care systems demonstrating substantial savings derived
Unauthenticated
Download Date | 2/26/19 9:04 PMBaird: Choosing Wisely 23
from reductions in overutilization when targeted interven- 5. Gass Kandilov AM, Pope G, Kautter J, Healy D. The national
tions are undertaken. Other studies indicate modest or no market for Medicare clinical laboratory testing: implications for
payment reform. Medicare Medicaid Res Rev 2012;2:E1–21.
discernible improvements in utilization, indicating that
6. Hallworth MJ. The ‘70% claim’: what is the evidence base? Ann
there is significant variation in the effectiveness of passive Clin Biochem 2011;48:487–8.
adoption of Choosing Wisely recommendations. As is often 7. Ngo A, Gandhi P, Greg Miller W. Frequency that laboratory
the case with quality improvement projects undertaken tests influence medical decisions. J Appl Lab Med AACC Pub
within an organization, the overall outcome benefits of 2016;3:1–5.
8. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr
Choosing Wisely will be difficult to demonstrate because
EA, et al. ‘Choosing Wisely’: a growing international campaign.
randomized and controlled experiments are simply unfea- BMJ Qual Saf 2015;24:167–74.
sible. Nonetheless, it is hard to imagine how an effort tar- 9. Wolfson D, Suchman A. Choosing Wisely®: a case study of
geted simply at raising awareness among physicians and constructive engagement in health policy. Healthc (Amst)
patients of common sense approaches to rational utiliza- 2016;4:240–3.
tion of services in healthcare cannot be regarded as an 10. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst
2010;102:605–13.
overall good, and indeed as another helpful addition to the
11. Welch HG, Prorok PC, O’Malley AJ, Kramer BS. Breast-cancer
laboratory test stewardship toolbox. tumor size, overdiagnosis, and mammography screening effec-
tiveness. N Engl J Med 2016;375:1438–47.
Author contributions: The author has accepted responsi- 12. Rosenberg A, Agiro A, Gottlieb M, Barron J, Brady P, Liu Y, et al.
bility for the entire content of this submitted manuscript Early trends among seven recommendations from the Choosing
Wisely campaign. JAMA Intern Med 2015;175:1913–20.
and approved submission.
13. Naugler C, Hemmelgarn B, Quan H, Clement F, Sajobi T,
Research funding: None declared. Thomas R, et al. Implementation of an intervention to reduce
Employment or leadership: The author is a clinical advisor population-based screening for vitamin D deficiency: a cross-
for Avalon Healthcare Solutions. The author is a member sectional study. CMAJ Open 2017;5:E36–9.
of the American Society for Clinical Pathology’s Choosing 14. Ferrari R, Prosser C. Testing vitamin D levels and Choosing
Wisely Effective Test Utilization Steering Committee. Wisely. JAMA Intern Med 2016;176:1019–20.
15. Sadowski BW, Lane AB, Wood SM, Robinson SL, Kim CH. High-
Honorarium: None declared.
value, cost-conscious care: iterative systems-based interven-
Competing interests: The funding organization(s) played tions to reduce unnecessary laboratory testing. Am J Med
no role in the study design; in the collection, analysis, and 2017;130:1112.e1–.7.
interpretation of data; in the writing of the report; or in the 16. Lesuis N, Hulscher ME, Piek E, Demirel H, van der Laan-Baal-
decision to submit the report for publication. bergen N, Meek I, et al. Choosing Wisely in daily practice: an
intervention study on antinuclear antibody testing by rheuma-
tologists. Arthritis Care Res (Hoboken) 2016;68:562–9.
17. Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bern-
stein SJ, Kerr EA. Perceived barriers to implementing individual
References Choosing Wisely. J Gen Intern Med 2017;32:210–7.
18. Volpp KG, Loewenstein G, Asch DA. Choosing wisely: low-value
1. OECD (2018). Health spending (indicator). Available at: https:// services, utilization, and patient cost sharing. J Am Med Assoc
doi.org/10.1787/8643de7e-en. Accessed: 15 June 2018. 2012;308:1635–6.
2. OECD Health Data: Health care utilisation, OECD Health Statistics 19. de Boer MJ, van der Wall EE. Choosing wisely or beyond the
(database). Available at: https://doi.org/10.1787/health-data-en. guidelines. Neth Heart J 2013;21:1–2.
Accessed: 29 Oct 2014. 20. Horvath K, Semlitsch T, Jeitler K, Abuzahra ME, Posch N,
3. Papanicolas I, Woskie LR, Jha AK. Health care spending in the Domke A, et al. Choosing Wisely: assessment of current US top
United States and other high-income countries. J Am Med Assoc five list recommendations’ trustworthiness using a pragmatic
2018;319:1024–39. approach. BMJ Open 2016;6:e012366.
4. Konger RL, Ndekwe P, Jones G, Schmidt RP, Trey M, Baty EJ, et al. 21. Bhatia RS, Levinson W, Shortt S, Pendrith C, Fric-Shamji E,
Reduction in unnecessary clinical laboratory testing through Kallewaard M, et al. Measuring the effect of Choosing Wisely: an
utilization management at a US Government Veterans Affairs integrated framework to assess campaign impact on low-value
Hospital. Am J Clin Pathol 2016;145:355–64. care. BMJ Qual Saf 2015;24:523–31.
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