In the creation of lists by specialty societies of medical services deemed least beneficial (the "Choosing Wisely" initiative), inclusion was often justified by evidence suggesting no additional benefit with higher risk, higher cost, or both, compared with other options, according to a study in the April 9 issue of JAMA.
"Aiming to reduce wasteful medical care, the American Board of Internal Medicine Foundation's Choosing Wisely initiative asks leading physician specialty societies to create a 'Top 5' list of medical services that provide no overall benefit to patients in most situations. As of August 2013, 25 participating specialty societies had produced 1 or more Top 5 lists containing a total of 135 services," according to background information in the article.
Catherine Gliwa, B.A., and Steven D. Pearson, M.D., M.Sc., of the National Institutes of Health, Bethesda, Md., evaluated the role that evidence related to benefits, risks, and costs plays in selecting a service for the Top 5 lists. "As Choosing Wisely continues to grow, clarity on the evidentiary justifications for the lists will be crucial for the overall credibility of the campaign," they write. Using information provided by the specialty societies, the authors created categories based on the level of certainty of evidence regarding risks and benefits, how the risks and benefits of the service compare with other alternatives, and the comparative cost or cost-effectiveness of the service.
Of the 135 services identified, 36 percent were for diagnosis or monitoring; 34 percent for treatment; and 30 percent for population screening. Most services were included in the Top 5 lists based on evidence that demonstrates equivalent but not superior benefit with higher risk or higher costs, or both, compared with other options. The second most common rationale was that there was not enough evidence to evaluate benefit for use of the service beyond the established indications, frequency, intensity, or dosage.
The authors assessed the rationales for selecting all 135 services. Overall, 49 percent mentioned greater risks to patients, 24 percent mentioned higher costs, 16 percent mentioned both greater risk and higher cost, and 42 percent mentioned neither. Of the 25 specialty societies, 60 percent had at least 1 service whose inclusion was justified in part by higher costs.
"Our data show that the issue of cost was almost always raised in the context of a service being judged as good as other options but more expensive. We believe that specialty societies should seek greater opportunities to include within their Top 5 lists services that offer only small incremental benefits at much higher prices," the authors write.
"Specialty societies can enhance trust in the Choosing Wisely campaign by defining more clearly the types of potentially wasteful medical care they seek to eliminate, and by providing a clear evidentiary justification for the selection of each service."
- Catherine Gliwa, Steven D. Pearson. Evidentiary Rationales for the Choosing Wisely Top 5 Lists. JAMA, 2014; 311 (14): 1443 DOI: 10.1001/jama.2013.285362
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