Low-value care persists five years into Choosing Wisely campaign

The Choosing Wisely campaign, which launched five years ago, hasn't curbed the widespread use of low-value services even as physicians and health systems make big investments in the effort, a new report found.

The analysis, released Tuesday in Health Affairs, said a decrease in unnecessary healthcare services "appear to be slow in moving" since the campaign was formed in 2012. The report found that recent research shows only small decreases in care for certain low-value services and even increases for some low-value services.

The Choosing Wisely campaign was created by ABIM Foundation and Consumer Reports to raise awareness in the healthcare community about unnecessary care and encourage providers to change practices.

Approximately $200 billion is spent every year on healthcare services in the U.S. that provide little value to patients. A Health Affairs study published in April found only a 4% decrease in low-value back imagining 2.5 years after the Choosing Wisely campaign launched. Another study published in JAMA Internal Medicine of seven Choosing Wisely recommendations found only two recommendations had "modest" decreases in usage.

The extensive use of low-value services persists even as the healthcare industry has rallied in support of the Choosing Wisely campaign. Nearly 80 medical societies are now part of the campaign and 500 recommendations on ways to curb overuse of healthcare services have been issued. Many health systems have also implemented Choosing Wisely principles at their organizations.

Despite efforts by stakeholders, progress to curb low-value care is bogged down by flawed approaches and stubborn cultural norms that encourage waste, according to the report.

"What we've learned is that it's just really hard to change practice," said Dr. Eve Kerr, one of the study's authors and a professor in the department of internal medicine at the University of Michigan. "Medical professionals have been practicing one way for a long time and patients expect that kind of practice to change the paradigm," Kerr said. "That doesn't happen in five years."

Physicians feel pressure to do unnecessary testing and other services because they don't want to be hit with a malpractice suit. Other physicians feel they should abide by patient requests for more services to preserve the physician-patient relationship.

"Culture is one of the hardest things to change and it takes the longest," Kerr said.

The report recommends that more research be conducted to explore how cultural and behavioral norms of physicians and patients exacerbate the use of low-value services.

Kerr added that healthcare organizations should empower physicians to be confident in their clinical decisions and educate them on ways to talk with patients about unnecessary services.

The campaign is also stifled by weak recommendations. Researchers criticized some medical societies because they didn't include services frequently performed in their specialty or they neglected to evaluate how the low-value service affects costs.

Medical societies should more rigorously assess the recommendations they have created by involving clinicians and patients in the decision-making process. "You wind up with recommendations they (clinicians) are aware of, instead of a top-down approach," Kerr said.

Medical societies that overlap on similar services should also work together to create recommendations, the report recommended. For example, multiple societies have issued varying recommendations about how to treat lower-back pain. The report suggests these societies get together and agree on recommendations so physicians across the spectrum use the same approaches.

Collaboration across health systems, medical societies and payers to address low-value care can increase progress as well, Kerr said.

"To make (the campaign) more powerful, we really need to help each of our health systems across the state work together," she said. "It is important that we espouse the same philosophy and we share data."

University of Chicago Medicine is in the midst of partnerships with medical socialites and health systems across the nation to adopt Choosing Wisely principles together. For example, U of C is part of the High Value Practice Alliance organized by Johns Hopkins Medicine in Baltimore. The goal is to engage medical students and residents on ways to reduce unnecessary testing and other services.

"That is the wave of the future that does take time," said Dr. Vineet Arora, a hospitalist and director of the GME Clinical Learning Environment Innovation at the U of C.

An edited version of this story can also be found in Modern Healthcare's Oct. 30 print edition.