Study Examines the Evidentiary Rationales of Choosing Wisely's Top 5 Lists

Choosing Wisely  is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices. As of August 2013, 25 participating specialty societies, including the ACC, External Link had produced one or more Top 5 lists containing a total of 135 services.

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A new research letter published in the Journal of the American Medical Association  evaluates the evidentiary rationales used by specialty societies to create the lists. With information provided by the specialty societies, the authors established categories based on the level of certainty of evidence regarding risks and benefits, how these risks and benefits compared with potential alternatives, and what the comparative cost or cost-effectiveness of the service would be.

Of the 135 identified services, 49 (36 percent) were for patient diagnosis, prognosis, or monitoring; 46 (34 percent) were for patient treatment, and 40 (30 percent) for population screening. The inclusion of 102 services (76 percent) was justified by claims that adequate evidence demonstrated no additional benefit with higher risk, higher cost, or both, compared with other options. The second most prevalent rationale for inclusion, given for 18 services (13 percent), was that there was insufficient evidence to evaluate comparative benefit for use of the service beyond the established indications, frequency, intensity, or dosage.

Overall, 66 (49 percent) of the attributed rationales mentioned greater risks to patients as a consideration in selecting the service, 33 (24 percent) mentioned higher costs, 21 (16 percent) mentioned greater risk and higher cost, and 57 (42 percent) mentioned neither.

"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," write Catherine Gliwa, BA, and Steven D. Pearson, MD, MSc, of the National Institutes of Health. The suggest 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. "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.

The ACC continues to work with Choosing Wisely to develop patient and provider tools that help facilitate discussions about appropriate tests and procedures. Already, physician/patient communication modules and patient fact sheets  have been developed. Learn more at  For more an ACC’s appropriate use tools and clinical documents go to

Keywords: Writing, Physician-Patient Relations, National Institutes of Health (U.S.), Risk Assessment

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