Treatment guidance from medical specialty groups varies widely in terms of its potential financial impact on providers, acknowledges the head of the American Board of Internal Medicine Foundation, which backs the Choosing Wisely initiative to promote evidence-based care.
Most of the 60 physician societies and medical specialty groups participating in the American Board of Internal Medicine Foundation's Choosing Wisely campaign to curb unnecessary tests or treatments do not list high-revenue services, according to the New England Journal of Medicine.
The paper, entitled "Choosing Wisely–The Politics and Economics of Labeling Low-Value Services," is the first to criticize the lists generated by the campaign, an increasingly well-publicized effort to "promote conversations between physicians and patients" and reduce unnecessary or non-evidence-based care that may do more harm than good.
"We are not critical of the campaign. We applaud the campaign," says Nancy E. Morden, MD, lead author and associate with the Dartmouth Institute for Health Policy & Clinical Practice who worked with researchers at Harvard Medical School. "But there's no value in generating lists of things we [doctors] almost never do, and no value in generating lists of things that cost pennies. We need to get at more meaningful identification of services that really impact spending."
"We know that there are a lot of high-volume, high-cost services with low value that are still provided, so we hope this will evolve into bolder lists that really consider the bread and butter services of some of these specialties, services that may not represent true value in healthcare." It is, she says, no more than "giving lip service to stewardship."
For example, Morden says, The American Academy of Otolaryngology ?Head and Neck Surgery Foundation, lists three imaging tests and two uses of antibiotics that the academy suggests physicians and patients should avoid or think seriously about before undergoing.
But there's no mention of tonsillectomy and tympanostomy-tube placement, expensive procedures with wide national variation in frequency and ample documentation of overuse, Morden says.
'No Major Joint Procedures' Flagged
Likewise, the American College of Orthopedic Surgeons tells patients and doctors they shouldn't use over-the-counter glucosamine and chondroitin to treat symptomatic osteoarthritis of the knee, but they list no major joint procedures, "though documented wide variation in elective knee replacement and arthroscopy among Medicare beneficiaries suggests that some surgeries might have been appropriate for inclusion," Morden said.
Asked for a response, the American Academy of Orthopedic Surgeons' president, Joshua Jacobs, MD, replied:
"While the authors claim over-utilization of certain procedures based on geographic variations in Medicare expenditures, the reasons for such variations are complex and multifactorial and do not necessarily reflect over-utilization. In fact, there are some studies suggesting underutilization of total knee replacement in certain populations...
"The AAOS believes that utilization of preference-sensitive orthopaedic procedures are best addressed by appropriate use criteria (AUCs), based on a systematic review of the literature and clinical expertise. The AAOS is in the process of developing AUCs, using the rigorous RAND/UCLA methodology. To date, we have developed only three AUCs, with more in the pipeline."
Jacobs said that the AAOS "strongly supports" the Choosing Wisely campaign. He defended the inclusion of glucosamine and chondroitin in the AAOS' list because rigorous randomized trials show that although patients spend "more than $2 billion annually" on the supplements, they receive little value from them. "This is why our recommendation to question the use of commonly used, but ineffective supplements that have resulted in overuse and unnecessary cost incurred by patients is one we stand behind."
In another example, Morden said, "[It is] fascinating to me to see that the oncologists did not list changing their use of hospice and palliative services practices at all. But the emergency room doctors did. That was an omission on the part of the oncologists, but a fascinating choice on the part of the emergency physicians, who have nothing to lose or gain if they call in a palliative or hospice care team."
"The oncologists, on the other hand, if they were to embrace more palliative and hospice care, it would mean less chemotherapy and less of their services, and would really dip into their revenue generation," she said.
"Most of the lists fall short of truly embracing this stewardship challenge," she said. "They take on quality, which is very important, but not so much high cost or high volume services that have very low value."
Not all of the specialty societies lists contain minor items that don't affect the practitioners' revenue, she says. For example, the American Gastroenterological Association lists three endoscopic procedures that, if avoided, could meaningfully reduce low-value care and revenue that impacts the gastroenterologist's pocket.
For primary care, she praises the Society of General Internal Medicine, which suggests patients can avoid the routine annual checkup, a care practice that directly hits their revenue because they are paid only when the patient comes for a visit.
Richard Baron, MD, president and chief executive officer of the American Board of Internal Medicine Foundation, which launched the campaign in 2012 and has seen it mushroom, says Morden's article is "a pretty balanced presentation—there's a lot of variability when you look at the different recommendations, which vary widely in terms of their potential impact on care and spending.
"You Have to Start Somewhere"
"They call out some areas where specialty societies targeted things that may not be right in the wheelhouse of things they could have done, and other examples of societies that mentioned (procedures) that are actually right in the middle of what they do."
Baron says that when the lists started coming in, "I might have said 'why did they do this one rather than that one,' or 'why didn't they talk about X instead of Y.' But I think you have to start somewhere. And for some of the participants, they got pretty seriously into the mainstream of their discipline."
He adds that the NEJM article "will foster continuing conversations with societies to map this out, and be aware that people are looking at this and pay more attention. And as they think about the next steps they take, they may take more seriously some of the issues raised in this article."
The important thing to remember, he says, is that before the Choosing Wisely campaign launched, "these were unfamiliar conversations for doctors and patients and specialty societies to have."
He emphasizes that the success of the Choosing Wisely campaign is the selection of care practices and procedures that physicians themselves agree are of little value. It wouldn't work, he says, if the foundation tried to influence the items those professional groups might submit for inclusion.