Choosing Wisely Brings Lots of Energy, but No Growth in Awareness

Choosing Wisely, the campaign from the ABIM Foundation to reduce low-value care, has brought 70 professional societies into the fold and sparked 500 recommendations to cut healthcare costs. But 5 years in, awareness among physicians hasn’t budged from where it was in 2014, according to results reported today in Health Affairs.

The 2017 phone survey, which a response rate of just 5.3%, found that 25% of physicians had heard about Choosing Wisely, and this rate rose to 42% when respondents heard a description of the campaign. However, these rates were not significantly higher than the 21% of physicians who had heard of the program unprompted in 2014, or the 39% who had some awareness when prompted.

Still, more than 90% of physicians believe the campaign has value, so the challenge appears figuring out how to translate the idea of Choosing Wisely into change on the ground. An accompanying commentary by Eve A. Kerr, MD, MPH; Jeffrey T. Kullgren, MS, MD, MPH; and Sameer D. Saini, MD, MS, of the University of Michigan, concludes that the survey results do not reflect the considerable reforms that Choosing Wisely has inspired; change, while slow in coming, is starting to chip away at the culture. The upcoming years require focus on high-priority areas that are clinically meaningful, affect large numbers of patients, and offer promise of substantial savings.

The findings will be presented today in Washington, DC, during a summit, “Choosing Wisely: Opportunities and Challenges in Curbing Medical Overuse,” presented by Health Affairs that will feature faculty including Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy, Harvard Medical School, who is co-editor in chief of The American Journal of Managed Care®.

Authors of the survey findings, Carrie H. Colla, PhD, and Alexander J. Mainor, JD, MPH, both of the Geisel School of Medicine at Dartmouth, write that despite widespread acceptance of the Choosing Wisely mission among professional societies, surveys reveal that “recommendations can be difficult for physicians to follow and for patients to accept.” Making the leap from seeing the value in identifying wasteful practices and eliminating them results from many things, including the perception that doctors need to avoid malpractice claims (despite the lack of evidence to support this), as well as the idea that patients demand certain tests, which is also unsupported.

Still, physicians responding to the survey overwhelming mentioned malpractice reform to eliminate wasteful tests and procedures (92%), followed by spending more time with patients (88%), and changing financial rewards (72%).

The survey authors cited former CMS Administrator Donald Berwick, MD, MPP, who said, “In healthcare, invention is hard, but dissemination is even harder,” in noting that the lag between innovation and use in practice is not limited to Choosing Wisely.

Authors of the commentary agreed. They called for the following:

• Professional societies must create incentives to consolidate recommendations, codify them, and make them specific to populations, common conditions, and indications.
• Funders of the next wave of initiatives must require designs and benchmarks that account for patient perspectives, since getting patients to appreciate overuse of testing is key. Those with high-deductible plans must see the connection between unnecessary tests and what they pay out of pocket.
• State and local health alliances must be engaged to produce a culture of change.

It’s not all bad news, however. “Choosing Wisely has created a principal pathway through which patients and their doctors can discuss when healthcare services may not be needed,” the commentary writers state. “Several important steps still remain to fulfill the promise of Choosing Wisely. It is now time to take those steps.”