Tuesday, November 14, 2017 Choosing Wisely at 5: Is It Making a Difference (And What About the Next 5 Years)? Five years into the American Board of Internal Medicine (ABIM) Foundation's "Choosing Wisely" campaign, most health care providers and consumers who've heard about it agree that the initiative has something important to say about avoiding unnecessary tests and procedures, including some associated with physical therapy. But has that awareness increased significantly, and does it translate into changes in behavior? Some say no—or at least not yet. ABIM's recently released special report on the first 5 years of the Choosing Wisely program characterizes the initiative as a sorely needed effort that is gaining momentum. Since its beginnings in 2012, the collection of ineffective and overused treatments and tests has expanded to 525 recommendations from more than 80 specialty society partners, according to ABIM. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question." The initiative, which partnered with Consumer Reports, has received wide media attention during the past 5 years and has even expanded to 19 other countries around the world. "Clinicians and patients all across the United States—and now the world—are engaging in conversations about avoiding unnecessary care thanks to the efforts of medical specialty societies, health systems, clinical practices, consumer groups, and community collaborations to advance Choosing Wisely," the report states. But has the program gained traction? And more to the point, are the Choosing Wisely recommendations being followed on a wide scale? Answers to those questions may not be as positive, say researchers writing in Health Affairs. To find out the extent of Choosing Wisely's impact, researchers followed up on an ABIM survey of 600 practicing physicians conducted in 2014 with a survey of their own, conducted this year. Authors of the study wanted to find out if knowledge of the program has grown since 2014, and whether physicians were actually following Choosing Wisely recommendations. The results of the 2017 survey are based on an underwhelming response rate—just 5.5%—but the researchers pressed ahead, asserting that the low response rate may, if anything, skew results in favor of physicians who know and support Choosing Wisely and were thus more willing to participate. Authors of the study found that the percentage of physicians aware of the campaign in 2017 (42%) had not grown significantly since 2014 (39%), nor had the percentage of physicians who believe campaign is valuable, from 91% in 2014 to 93% in 2017. When asked for their opinions on what is driving the continued use of low-value care identified in Choosing Wisely, 87% of the 2017 respondents cited malpractice concerns (87%), followed by physicians' desire for more information (84%) and "just to be safe" (78%). As for changes to health care that would help to decrease use of low-value care, most physicians surveyed pointed to malpractice reform (92%), followed by spending more time with patients (88%) and financial rewards (72%). Authors were skeptical that malpractice concerns are truly a driver of use of low-value care, citing research that estimates "defensive medicine" adds roughly 3% to overall health care spending. Similarly, the argument that patient demand drives the use of low-value care is also not supported by research, according to the study's authors. The relatively slow decline in the use of unnecessary care since Choosing Wisely's debut points to a need to develop a "roadmap" for the next 5 years, 1 that will lead to a greater impact on care, say authors of a separate analysis and commentary that also appeared in Health Affairs. They stress the need for more robust efforts at almost all levels, from stronger recommendations from societies to the use of more rigorous study designs to evaluate barriers and outcomes. Authors cite 4 major areas that they believe need to be strengthened if the Choosing Wisely campaign wants to make a real difference in usage of low-value care: Strong methods for developing recommendations. Authors assert that early on, societies tended to select tests and treatments that were fairly safe bets among their members—low-value, to be sure, but also not necessarily widely practiced. Recommendations now need to move into areas that have wider prevalence and potential impact, they write. Innovative intervention methods. More thinking needs to go into why providers and patients are not opting out of low-value services, including looking into behavioral science frameworks that shed light on decision-making, and investigating ways to pursue cultural change among clinicians and patients. Meaningful evaluation techniques. Rigorous research should be applied to studying the barriers to and facilitators of success, authors write, including measurement of clinically meaningful outcomes. Collaborative dissemination. Authors believe that states, communities, patients, payers, health systems, and academic partners need to be brought together in a more coordinated way to "test and disseminate successful approaches." "Clearly, [Choosing Wisely] has been changing the conversation and is beginning to influence culture, thus setting the foundation for the next 10 years," authors write, citing "a convergence of activities" for realizing the campaign's potential already exists, including support from organizations, increased use of accountable care organizations and value-based payment models, and the pressure patients face through higher health insurance deductibles. "Choosing Wisely has created a principal pathway through which patients and their doctors can discuss when health care services may not be needed," authors write. "As we have outlined, several important steps still remain to fulfill the promise of Choosing Wisely. It is now time to take those steps." To get a better sense of how the Choosing Wisely campaign intersects with APTA's efforts to help PTs and PTAs understand their role in reducing fraud, abuse, and waste, visit the association's online Center for Integrity in Practice. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.