Cost considerations a major factor among Choosing Wisely lists

If a treatment or product has good cost-effectiveness data available, it is more likely to end up on a best practices list, according to an analysis published in JAMA.

The proliferation of lists tends to exclude information on new or experimental treatments, the study found. It may be time to expand to broader topics, researchers say, and to amend how the lists—done as part of the Choosing Wisely campaign of the ABIM Foundation—are created.

The campaign was launched in April 2012 by the foundation, which focuses on healthcare improvement. Various specialty societies collaborate with the campaign to create best practice lists that assist physicians and patients in reducing overuse of tests and procedures and that encourage efficient choices about healthcare services.

Researchers from the National Institutes of Health looked at 135 “top five lists” that had been generated by 25 specialty societies by August 2013. They sought to gauge the factors that played into the selection of a list-worthy treatment or procedure.

Roughly 76%, or 102 of the lists, were included because the societies had adequate evidence to demonstrate that a treatment or procedure had no additional benefits to justify higher risks or costs, compared with other options, they found. Of the 25 specialty societies, 60% had at least one service whose inclusion was justified by costs.

“It's a good place to start,” said Dr. Steven Pearson of the National Institutes of Health, a co-author of the research letter published Tuesday. As a supporter of the top-five lists, he said it makes sense that the emphasis in the first couple of years has been on topics where the evidence is strong. Still he said, “Over time they may want to broaden their reach and look at more emerging techniques.”

The process behind how top-five lists are being developed also could be more clear and consistent, Pearson said. Trust in the lists could be enhanced if clear definitions of potentially wasteful medical care and clearer justifications for the services chosen to be listed were provided, the analysis contends.

“I thought it was an interesting and valuable contribution, said Richard Baron, foundation president and CEO, regarding the results. For him, the research letter helped highlight common themes that have appeared since the lists were started two years ago. “When the issue of costs is raised, it is often in the context of marginal benefit. That's a valuable insight,” he said. “It's a roadmap to exploring where you have opportunity for future lists,” he said.

Authors of a previous editorial published in JAMA expressed concerns over the development of top-five lists, saying most did not provide detailed methods and that there appeared to be little input from frontline practitioners.

The specialty societies are asked to stick to services that are within their purview, used frequently or have significant costs, and have generally accepted evidence, Baron said. The groups have flexibility in identifying what those services are.

Nearly 50 groups, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Cardiology and the American College of Emergency Physicians, are listed on the ABIM website as having generated at least one list.

“This initiative is proving to be very important. Not only have many societies done their first top five list, but many are going back for more,” Pearson said.

Follow Sabriya Rice on Twitter: @MHSRice