Trends in Use of Low-Benefit Health Care Services

Study Questions:

What are the trends in early Choosing Wisely low-benefit recommendations in a nationwide commercial health plan population?

Methods:

This was a retrospective analysis of claims data for members of Anthem-affiliated commercial health plans, assessed over a 2- to 3-year period ending in 2013. The seven Choosing Wisely recommendations included: 1) imaging tests for uncomplicated headache; 2) cardiac imaging without history of cardiac conditions; 3) low back pain imaging without red-flag conditions; 4) preoperative chest x-rays without unremarkable history and physical examination results; 5) human papillomavirus (HPV) testing for women younger than 30 years; 6) use of antibiotics for acute sinusitis; and 7) use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease. Trends were assessed across all quarters using Poisson regression.

Results:

Two Choosing Wisely services had declines over the study period: 1) use of imaging for uncomplicated headache declined from 14.9% to 13.4% (p < 0.001), and 2) use of cardiac imaging without a history of cardiac condition declined from 10.8% to 9.7% (p < 0.001). Two Choosing Wisely services had increases over the study period: 1) use of NSAIDs in select conditions increased from 14.4% to 16.2% (p < 0.001), and 2) HPV testing in young women increased from 4.8% to 6.0% (p < 0.001). The remaining Choosing Wisely services had no significant change during the study period.

Conclusions:

The authors concluded that two of the Choosing Wisely campaign recommendations had a modest decrease in population-level frequency, while two other services increased despite the Choosing Wisely campaign. The authors note that the statistically significant changes in four services may not have clinical or public health implications given the small effect size.

Perspective:

The Choosing Wisely campaign, designed to raise awareness of low-value health services that are thought to be frequently overused, has garnered significant medical and lay press coverage since its genesis in 2009. However, this study suggests that early population-level impact is limited. Further research is needed to explore implementation strategies to assist clinicians in applying the Choosing Wisely recommendations into their decision making in the clinic or at the bedside. Sample strategies may include electronic health record decision aids, adjustments to reimbursement strategies, and further patient empowerment to discuss these recommendations with their providers.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Acute Heart Failure, Interventions and Imaging, Hypertension

Keywords: Antibiotic Prophylaxis, Anti-Inflammatory Agents, Non-Steroidal, Diagnostic Imaging, Headache, Heart Failure, Human Papillomavirus DNA Tests, Hypertension, Low Back Pain, Mass Chest X-Ray, Paranasal Sinus Diseases, Primary Prevention


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