Response to New England Journal of Medicine Choosing Wisely® Article

I thought the authors of the recent New England Journal of Medicine article, “Choosing Wisely — The Politics and Economics of Labeling Low-Value Services” presented the campaign in a thoughtful and balanced manner. On one hand, I was pleased with how the campaign was depicted—particularly the authors’ praise for the way it carefully created a space for physicians and patients to have conversations. This has been our vision since the very beginning.

Along with the praise, however, the authors questioned the value of some specialty society recommendations and challenged us to think about the campaign’s future direction. As Nancy Morden, MD stated to HealthLeaders Media about her NEJM piece, “We are not critical of the campaign. We applaud the campaign. But there’s no value in generating lists of things we [doctors] almost never do, and no value in generating lists of things that cost pennies. We need to get at more meaningful identification of services that really impact spending.”

In response, I’d like to remind Dr. Morden that the goal of the campaign has never solely been about cost reduction. From the beginning, the campaign has attempted to:

• Raise awareness of the fact that there are tests and procedures performed that are wasteful. This goes beyond the 300 tests and procedures recommended.
• Create a national dialogue around the goal of the health care system to increase health and cultivate patient-centered experiences at affordable costs – the Triple Aim.
• Prevent harm, including an average of 30,000 deaths caused annually by these wasteful procedures.

The focus of the campaign is grounded in the role of the profession in addressing the issue of overuse and taking responsibility for being good stewards of resources (and knowing how to be good stewards). Having meaningful recommendations, such as those with high frequency, is important to the authenticity and credibility of the profession’s leadership role on the issue of overuse and waste.

Despite Dr. Morden’s opinion about the society lists, I am quite proud of the recommendations and applaud the efforts of the participating specialty societies. Although Dr. Morden dismisses items on the lists as “things we almost never do” and things that aren’t particularly challenging, I believe there are many recommendations to the contrary that take on bold and important patient-care issues, such as:

• Annual physical exams
• Issues related to hospice and palliative care
• Unnecessary imaging and perioperative tests
• Screening for cancer, including prostate
• Antibiotic use
• Elective deliveries before 39 weeks
• Tight hemoglobin control in adults age 65 and over
• The use of feeding tubes for patients with advanced dementia
• Use of proton beam therapy for prostate cancer

It should also be noted that several societies have released multiple lists and continue to refine or expand their recommendations.

As for the future of the campaign, I do concur with the authors’ assertion that more work is needed in order for Choosing Wisely to have a meaningful impact in eliminating waste and improving quality. And so the campaign continues. With new lists being released throughout 2014, ongoing work at the national, state and local levels by Robert Wood Johnson sub-grantees and additional specialty groups signing on to develop new lists, the conversation has only just begun.

Daniel B. Wolfson
EVP and COO, ABIM Foundation