“Publishing the lists is not enough—there needs to be accountability,” Brody said.
Unlike many other medical societies, the American College of Emergency Physicians has repeatedly voiced reservations about the campaign, deciding in 2012 not to participate.
In a May 2012 blog post, ACEP President Dr. David Seaberg said emergency medicine physicians have to “pick up the slack” for other medical professions and often have little choice about what tests to order. They also rarely have prior patient information with which to draw conclusions about medical appropriateness, he said.
Seaberg also criticized the ABIM Foundation for refusing “to allow any discussion of liability reform as a component of the Choosing Wisely campaign.”
“It is simply not possible for emergency physicians to talk about reducing 'unnecessary' testing without including messages about the need for medical liability reform,” he wrote.
The ACEP has since done an about-face, announcing on Feb. 20 that it plans to participate in Choosing Wisely. In a blog post about the shift, Seaberg said an ACEP task force had determined that there were eligible tests that “would not increase the physician's liability and would not negatively impact payments for emergency physicians.”
Worries persist for some emergency doctors, however.
Dr. William Sullivan, an emergency medicine physician and healthcare attorney based in Frankfort, Ill., contended that a decrease in tests—even those tests that are deemed to be often unnecessary—comes with an increased risk of missed diagnoses. He gave the example of the American College of Radiology's top-five list, which includes a recommendation not to image for suspected pulmonary embolism without moderate to high pre-test probability.
“Two percent of patients who are low-risk will still have a PE,” Sullivan said. “And radiologists aren't the ones who face repercussions if they are missed—we are. I'm a lawyer, and when things go wrong, no one thanks you for saving their money.”
In spite of the concerns of Sullivan and others, Dr. Christine Cassel, the ABIM Foundation's president and CEO, said she has seen minimal physician pushback.
“I really feel like there's been a collective sigh of relief on the professional side,” Cassel said, adding that participating societies are working to get the message out to their members through meetings, journal articles and continuing medical education.
She also said the foundation has been working with a number of consumer-facing groups, including AARP and Consumer Reports, to disseminate Choosing Wisely's lists among patients.
“Patients have to feel empowered to say, 'Do I really need this test?' ” Cassel said.
One challenge going forward, she added, will be to sustain momentum amid ever-changing evidence-based guidelines and seismic shifts in the healthcare delivery system. “We welcome that challenge,” she said.
Another early concern of many—that insurers would use the lists to deny payment—has not occurred, said Dr. Robert Wachter, professor and chief of the division of hospital medicine at the University of California at San Francisco, and a member of the ABIM Foundation's board of trustees. He acknowledged that payers are probably watching closely, but he gave them credit for staying on the sidelines.
Wachter listed a number of reasons why Choosing Wisely has likely been so well-received, including its sponsorship by the ABIM Foundation, good branding and a carefully chosen name.
“Think about the number of past efforts to try to get doctors and patients to think about tests and procedures,” Wachter said. “We've seen very little traction. Physicians were not engaged, patients were not engaged. But this effort has threaded the needle in an amazing way.”
TAKEAWAY: Provider and consumer groups are rallying around an effort to reduce overuse of healthcare, but some skeptics still question if the initiative is really changing clinical practices.