If you don't know what Choosing Wisely is, start with our Healthcare Triage episode (points to Choosing Wisely-captioned video on the screen). If you do, go still watch it anyway - it's good.

I was a bit skeptical that Choosing Wisely would have a big impact, so  was I wrong? Is Choosing Wisely changing practice? Today, we go to the Research! This is Healthcare Triage News...

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Look, I'm all for Choosing Wisely. I think it's great. But it's also important to have a little perspective. None of the recommendations were news to those of us who practice medicine and follow the literature. Seriously, try and find me a physician who doesn't know that overuse of antibiotics for sinusitis is a problem. The real issue, as I've discussed before, isn't that doctors don't have access to evidence. Do you think that if Choosing Wisely said tomorrow we should not use arthroscopic surgery for knee pain, all of that would go away? Really? It hasn't worked yet - go watch that (Surgical Placebos) episode of Healthcare Triage! But maybe I was wrong. It's been years.

Lets look at the data. From JAMA Internal Medicine, "Early Trends Among Seven Recommendations From the Choosing Wisely Campaign". Such a great simple study! They looked at claims data to see how different Choosing Wisely recommendations affected practice in terms of usage before and after they were published in 2013.

The seven recommendations they specifically looked at were: 

1. Don't get imaging tests for uncomplicated headaches
2. Don't get cardiac imaging of people without a history of cardiac conditions.
3. Don't get imaging for low back pain unless there are serious conditions warranting it.
4. Don't get pre-op chest x-rays on otherwise healthy people.
5. Don't test for HPV in women less than 30 years old.
6. Don't treat acute sinusitis with antibiotics
7. Don't use NSAIDS in people who have hypertension, heart failure, or chronic kidney disease.

Since they were looking at numbers of claims, they used Poisson Regression. You don't really need to know that, but I like saying Poisson Regression. I used it in one of my first studies. Anyway, if you believe in the power of Choosing Wisely, you hope all of these things went down. Some did! Imaging for headache went from 14.9% of cases to 13.4%, and cardiac imaging went from 10.8% of cases to 9.7%. But some practices saw increases, too. Inappropriate NSAIDS use went from 14.4% to 16.2%, and HPV testing in women under 30 went from 4.8% to 6.0%. There were no significant changes in antibiotics for sinusitis (still used almost 84% of the time), pre-op chest x-rays (still used more than 90% of the time), and low back pain imaging (still more than half of the time).

So if you want to read this positively, you crow about the two things that went down. Of course, two went up, too, and the rest remained unaffected. But the bigger issue here is that almost none of these changes were likely clinically significant. Those that were common before, remained very common after. Publishing guidelines and holding press conferences isn't enough. The accompanying editorial offers some suggestions, most focusing on the use of better implementation strategies. Me, I haven't changed my mind since I originally wrote about this. When I think about it, I'm forced to admit my skepticism comes from a place of cynicism. I wish that wasn't the case, but it is. Some doctors fear lawsuits, and Choosing Wisely won't change that. Some doctors see a subset of patients that aren't representative of the general population and are conditioned to believe that more tests are necessary than really are. Choosing Wisely won't change that either. And yes, some doctors are influenced by financial incentives that subtly or overtly induce them to do more. Choosing Wisely certainly won't change that. Most of these efforts assume that we can change the behavior of physicians by willing them to do good. I wish that were true. We did a previous episode (points to HCT News slide) on that. We have to arm recommendations like these with teeth. Stop paying for stuff we know doesn't work! Or make people pay for it out of pocket. If we  know something doesn't work, there should be few people willing to defend [it], using both reimbursement limiting and consumer-directed means to reduce its use.

Healthcare Triage is supported in part by viewers like you through patreon.com, a service that allows you to support the show through a monthly donation. Your support help makes us bigger and better. We'd especially like to thank our Research Associate, Cameron Alexander, and our first-ever Surgeon Admiral, Sam. Thanks Cameron! Thanks Sam! More information can be found at patreon.com/heathcaretriage.

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