The frequency with which physicians provide tests and procedures deemed of little value to patients hasn't changed much in the three years since the start of a national campaign aimed at reducing them, according to a new study.
An analysis published online Monday in JAMA Internal Medicine looked at the rate of utilization of seven clinical services identified by the Choosing Wisely campaign as having minimal benefit. It found only two of those procedures considered to be low value to patients had significant clinical decreases since they were first recommended in 2012.
Researchers found the use of digital imaging for headaches that do not carry specific risk factors for structural disease, which the American College of Radiology recommended against as part of the Choosing Wisely campaign, had decreased to 13% from 15%.
The use of cardiac imaging for patients at low risk for a cardiac event had also declined since 2012, to 10% from 11%.
Some of the procedures targeted in the campaign are actually being performed more, not less. Testing for human papillomavirus, or HPV, for women under the age of 30 has increased to 6% from 5% since it was first recommended against in February 2013 by the American Academy of Family Physicians.
And the differences for other procedures was deemed clinically insignificant. For example, the frequency with which physicians prescribed antibiotics to treat a common runny or stuffed-up nose fell to 84% from 85% in October 2014, when the American College of Emergency Physicians first recommended against it.
The lead author on the study was Abiy Agiro, senior research analyst at HealthCore, a Wilmington, Del., subsidiary of Anthem. The researchers collected data from medical and pharmacy claims from 25 million Anthem-affiliated Blue Cross and Blue Shield health insurance plan members.
Agiro and co-authors conclude that making the campaign more effective requires steps such as providing data feedback, training physicians on how to communicate about the guidelines, clinician scorecards and financial incentives.
Choosing Wisely was the creation of the American Board of Internal Medicine Foundation, which launched the campaign in April 2012 with recommendations from nine medical organizations. It has since expanded to more than 70 specialty societies that each produce an evidence-based list of tests and procedures they consider to be overused and potentially harmful.
But soon after its inception, questions were raised about how effectively the campaign could persuade doctors to stop ordering services of questionable medical value. While many have lauded the program for raising awareness about the issue of overutilization, some have asked whether simply identifying unnecessary procedures was enough to lower the frequency of their use.
Many physician specialty organizations that present recommendations do not track how many of their own members follow the guidelines, making it difficult to assess their impact.
Another significant barrier to discouraging low-value care is a general dearth of comparative-effectiveness research and data. "Many of the interventions cited in the Choosing Wisely campaign were deemed low value precisely because they have not been tested in trials," write David Howard of Emory University and Dr. Cary Gross of the Yale University School of Medicine in a commentary piece accompanying the findings in JAMA Internal Medicine.
"Although it is not feasible to conduct a trial of every service mentioned in the Choosing Wisely recommendations, the lack of high-quality evidence will hamper efforts to reduce low-value care," they write.
