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Identifying Low-Value Care is One Thing; Eliminating it is Quite Another

The Practical Difficulties of Implementing 'Choosing Wisely' Recommendations

Last month, the American Board of Internal Medicine (ABIM) Foundation released the second wave of its groundbreaking campaign to identify and reduce low-value care, that is, common tests and procedures that are frequently overused or misused. This campaign, "Choosing Wisely," challenged medical professional societies to come up with the "Five Things Physicians and Patients Should Question." All told, 26 medical specialty societies have identified more than 130 tests and procedures; another 14 societies will release their lists later this year.
The participation of so many specialty groups is virtually unprecedented in its scope and unanimity. The ABIM Foundation has also partnered with
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ABIM Foundation CEO Christine Cassel, MD: 'It's about cutting waste; it's not about rationing.'
Consumer Reports to develop companion materials for patients and the public. The goal is to encourage "physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm."

No mention of costs
The campaign avoids much mention of cutting costs, for political and practical reasons. As Kevin Volpp, MD, PhD and colleagues recently noted in JAMA, "For too long, efforts to reduce the use of low-value services have been decried by critics as rationing or as schemes to enhance insurance company profits." Thus, the campaign has worked around this barrier by focusing on talk: with more conversation, patients and physicians will decide together that little Johnny doesn't need that antibiotic for his sinus infection, or that Mr. Smith won't benefit from an MRI for his uncomplicated, though unexplained, headache. And those decisions, writ large, will cut out a significant chunk of the estimated 20% to 30% of health care costs that are "wasted" on unnecessary care. As Christine Cassel, MD, President and CEO of the ABIM Foundation says, "It's about cutting waste; it's not about rationing." Freeing up more resources is "a collateral benefit," rather than the motivation behind this campaign.

But whether we acknowledge it or not, the impetus to identify and reduce low-value care is the unsustainable growth of health care costs. The precursor to the Choosing Wisely campaign was an ABIM-funded project by the National Physicians Alliance (NPA), which developed a Top 5 list for Family Medicine, Internal Medicine and Pediatrics. The NPA called its project "Promoting Good Stewardship in Clinical Practice." Good stewardship of what? Finite resources, of course.

British National Health Service
The U.S. already spends a higher share (18%) of its Gross Domestic Product on health care than other industrialized nations, but has poorer health outcomes to show for it. However, the U.S. is not unique in its need to contain health care costs, nor in its desire to start by reducing low-value care. The British National Health Service, through its National Institute for Health and Clinical Excellence (NICE),
NICE program
The British National Health Service's National Institute for Health and Clinical Excellence (NICE) has a 'Do Not Do' list of more than 800 procedures.
has developed a "Do Not Do" database of more than 800 practices and procedures that should be either be discontinued completely or used sparingly. One example is a lumbar spine Xray for non-specific low back pain, which is also a Top 5 Choosing Wisely pick by the American Academy of Family Physicians.

But the British are far more explicit in the need to connect this initiative to coverage decisions (or in their parlance, "commissioning.") The British Medical Association (BMA) recently testified that, "As NHS commissioners face increasing cost pressures, the decommissioning of existing services will become vital if they are to continue to fund new, expensive drugs and technologies in the future."

The NHS is way ahead of us in terms of identifying low-value care, but not so far ahead in reducing the level of that care. Because the NHS does not mandate the use or even consideration of the "do not do" guidance in "commissioning" decisions, the impact of database is limited. The BMA stated, "NICE's 'do not do' work is relatively unknown and a greater emphasis on helping NHS commissioners (and providers) to implement their recommendations could lead to improvements in relation to costs, quality and equity."

The beginning, not the end
To be fair, "Choosing Wisely" is likely the start of the process of reducing low-value care, rather than the end. Already, we see medical professional societies and researchers begin tackle the difficult task of implementing the Choosing Wisely guidelines. For example, the Robert Wood Johnson Foundation, a supporter of the Choosing Wisely Campaign, has issued a call for proposals for interventions that apply behavioral economic principles (such as financial incentives) to reduce low-value care.

So in that spirit, I offer my Top 5 observations about Low-Value Care:

1. We cannot expect most patients to question their health care professional's recommendations.

Amir Qaseem, MD, PhD, of the American College of Physicians (ACP) spoke recently about the need to reduce the estimated $210 billion "wasted" on low-value diagnostic tests, and the
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Amir Qaseem, MD, PhD, of the American College of Physicians: $210 billion annually 'wasted' on low-value care.
role physicians and patients should take in questioning such care. After his talk, "High Value Cost Conscious Care: Is it Rationing or Rational Care?", an elderly member of the public stood up, described an extensive workup that included an ultrasound, CT scan, MRI, laparoscopy, and Xray, and said, "No way could I intervene and say, 'I don't need this.'" Even physicians are not likely to question care recommended by subspecialists, as Craig Umscheid, MD describes in "Snapshots of Low-Value Medical Care" in JAMA Internal Medicine. He writes: "But despite my own medical and epidemiologic training, it was difficult to resist his advice. As my physician, his decision making was important to me. I trusted his instincts and experience."

And why would a well-meaning physician recommend a low-value test or procedure? Dr. Umscheid's doctor said, "to be sure," and "just in case." Gary Gottlieb, MD, MBA, President and CEO of Partners HealthCare, recently called for physicians to move away from "hypothesis testing that focuses on the pursuit of true negatives to one that focuses on the pursuit of true positives." In other words, physicians need to resist the impulse to rule out all possibilities, no matter how unlikely they may be. Part of the impulse to find the "true negative" may stem from a fear of malpractice claims, and part may be based in discomfort with uncertainty. Physician training may instill or install a mind-set that more care is better care. But whatever the cause, it seems unlikely that patients could change their physician's perspective within the clinical encounter.

2. Patients and physicians may not agree on what constitutes low-value care.

Whose values are we using in this definition of low-value care? Although it is tempting to equate value with effectiveness, doing so belies a bias toward certain
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Writing in NEJM Lisa Rosenbaum, MD, warns how 'inattentional blindness' can distort one's sense of low-value care.
direct, measurable health outcomes. It dismisses, or at least minimizes, the value patients (and even sometimes physicians) place on reassurance, reduction of anxiety, and the detection of catastrophic-though-highly improbable events. In a recent New England Journal of Medicine commentary, Lisa Rosenbaum, MD makes this point eloquently when she states, "Value in health care depends on who is looking, where they look, and what they expect to see." It is entirely plausible that discussions between patients and physicians will not significantly reduce the prevalence of some forms of "low-value care" that matter to patients. But as Dr. Jon Tiburt and Dr. Cassel note in a recent JAMA article, "The best for a given patient may not always be the same as what the patient wants; acquiescing to a patient's desires may help conclude the encounter but may not always be the right thing to do."

3. "Harmful" care will be easier to address than "wasteful" care.

Although defining low-value care as "waste" is strategically wise, it isn't likely to have as much traction with patients or physicians as low-value care that does more harm than good. In our system of decentralized private and public coverage, in the absence of global budgets, resources that are "wasted" on low-value care do not automatically go toward the provision of high-value care or toward improving access to care. The "waste" case is much stronger for the new clinical commissioning groups of the NHS, who must decide how to get the most health value out of a set budget.

Recommendations that point to some harm from low-value care will be easier to implement for physicians (first, do not harm) and for patients (ending up worse off, not better). Roughly one-third of the "Choosing Wisely" specialty society recommendations refer to the potential harm to patients from the test or treatment at issue. But the Consumer Reports companion materials hedge their bets; nearly all of them are structured with at least three sections: why the test or procedure usually won't help, that it can pose risks, and that it can be a waste of money.

4. "Choosing Wisely" deals with the "demand" side of the problem, but does not address the supply side.

Economists tell us that some proportion of low-value care represents supply-induced demand for services, especially in
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The state of Pennsylvania has more CT scanners than the entire country of Canada.
the case of advanced imaging technology. While the exact proportion attributable to excess supply is debatable, there is little doubt that proliferation of technology is associated with increased use of that technology, regardless of whether health outcomes are improved. About 40% of the Choosing Wisely recommendations involve imaging. This is a disproportionately American aspect of low-value care, made possible by the widespread dissemination and availability of new imaging technology. Dr. Qaseem of the ACP noted that Pennsylvania has more CT scanners than all of Canada. In general, the U.S. has about double the number of CT and MRI scanners per million people as most other OECD countries, and scans its population at about double the rate of the other countries. The supply side part of low-value care is a policy decision, rather than a clinical decision.

5. We need better explanations of how low-value services can, by chance, result in finding something serious, and how that may not be a good thing.

Everyone has heard a story of how a CT or MRI scan for a simple headache -- a Top 5 Choosing Wisely pick by the American College of Radiology -- found a brain tumor and resulted in life-saving surgery. We cannot ignore the power of these narratives to create strongly-held beliefs in the patient, his or her social network, and the masses through the Internet.

We need better language to explain key concepts of "incidentalomas," false positives, lead-time bias, and epidemiological truths that explain how diagnostic zeal does not, in and of itself, lower mortality. Lisa Schwartz, MD, and colleagues at Dartmouth describe the "paradox of the false alarm" in which false positive results are not experienced as a harm, but as a benefit. The anxiety, further testing, and painful procedures are perceived as a small price to pay for the opportunity to have one's life saved. "The more false alarms, the greater appreciation for life. The more unnecessary brushes with death, the greater the enthusiasm for testing."

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Janet Weiner, MPH, is Associate Director for Health Policy at the Leonard Davis Institute of Health Economics.

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