Choosing Wisely: Physician Groups Make Recommendations to Improve Health Care and Reduce Costs

Nyedra W. Booker, PharmD, MPH, and Mariah Baker, National Center for Health Research

In 2012, the American Board of Internal Medicine Foundation and Consumer Reports initiated the Choosing Wisely campaign, aimed at decreasing healthcare costs by reducing unnecessary medical tests and procedures.1 Their goal is to improve medical care in the U.S. and save healthcare dollars at the same time. The Choosing Wisely campaign comprises 70 national physician groups representing all types of medical records.1 They have proposed lists of medical tests and treatments that physicians and patients should question, and at the launch of the program in 2012, each medical specialty group was asked to develop a list of five recommendations based on evidence from research findings within their specific fields. 

This national campaign is a bold move by medical groups that collectively represent hundreds of thousands of physicians. Currently, doctors are paid more for ordering additional tests and diagnostic procedures. The Choosing Wisely recommendations do not financially benefit physicians but have the potential for reducing the cost of medical care for patients, health insurance companies, and government health programs such as Medicare, Medicaid, and Veterans’ healthcare.

How Will This Help?

An increase in the number of people living with chronic illnesses, rising prescription drug prices, and the high administrative costs all contribute to increased healthcare costs.2 For example, healthcare spending reached $3.8 trillion in 2019, a 4.6% increase from 2018.3 These figures are expected to rise an additional 5.4% each year and reach $6.2 trillion by 2028.3 While many continue to debate the exact reasons why spending is out of control, most agree that something needs to be done immediately. The Choosing Wisely campaign is one method to combat this issue. 

Many doctors and health experts understand that more medical care, and more expensive medical care, is not necessarily better medical care.  However, studies show that many Americans mistakenly assume that running more tests and relying on newer, more costly technologies translates into better health (see Is Newer and More Expensive Care Better?). Doctors often err on the side of caution by ordering more tests, and there is sometimes a financial incentive for doctors to do so as well. That’s why the Choosing Wisely campaign is so important: it relies on experts to urge doctors and patients to avoid tests and treatments that are likely to do more harm than good.

Recommendations

Choosing Wisely names over 450 tests and treatments that patients and physicians should question. Their website includes a search function (linked here) where specific recommendations can be found. Here are a few of their recommendations:

Allergy Testing – Allergy testing, specifically “at home” testing kits, are not recommended for patients with chronic hives. These tests are usually inaccurate and report false positives. Allergy testing at a doctor’s office is only recommended after a consultation of the patient’s medical history and a physical exam.4

Pap Tests – Routine Pap tests (also called Pap smears) to screen for cervical cancer are not recommended for women under the age of 21 or over the age of 65.5 (Also see Cervical Cancer Screening Options: What Is Best For You?)

Imaging for Lower-Back Pain – Imaging with Magnetic Resonance Imaging (MRIs), where strong magnetic fields are used to generate internal images of the body, and X-Rays are not recommended for patients with lower back pain, as most patients, regardless of the tests performed, find relief within a month.6,7

Imaging Tests for Headaches – Imaging of the brain, including MRIs and Cranial CTs (cranial computed tomography), a test that creates images of the skull, brain, or sinus cavities, are not recommended for patients with a headache unless their doctor cannot diagnose their headache based on a neurological exam or a patient’s medical history.8,9

Imaging for Early-Stage Breast Cancer Patients – Imaging such as Positron Emission Tomography scans (PET) or Computerized Tomography scans (CT), imaging methods that test if cancer has spread to other parts of the body is not recommended for patients with early-stage breast cancer. These tests expose patients to greater amounts of radiation and are not usually necessary in early-stage breast cancer patients.10,11

Cancer Screening in Dialysis Patients – Routine cancer screenings (including colonoscopy, mammography, and Pap tests) are not recommended for patients on dialysis who have a short life expectancy unless specific signs and symptoms are present.12

Cardiac Imaging for Chest Pains – Routine cardiac imaging including, a stress echocardiogram (which uses ultrasound to show how well the heart is pumping blood), is not recommended for patients with chest pain who are at low risk for a heart attack or cardiac-related death, are able to exercise, and have a normal electrocardiogram (EKG).13

The Bottom Line

While medical tests and procedures can save or prolong lives, some can have greater risks than benefits. Unnecessary tests and procedures also increase healthcare spending in the US, where spending is already disproportionately high. Choosing Wisely is a tool that patients and providers can use to determine if imaging or procedures are necessary for their individual health concerns. These recommendations are meant to arm patients with more knowledge and help them find the right questions and concerns to discuss with their providers. Although the recommendations listed in this article were made between 2012 and 2019, as of January 2021 they are still up-to-date.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References

  1. Foundation ABIM. History. Choosing Wisely. https://www.choosingwisely.org/our-mission/history/. Published January 23, 2018.
  2. Grande R. 5 Reasons Why Healthcare Costs are Rising. Definitive Healthcare Blog. https://blog.definitivehc.com/5-reasons-why-healthcare-costs-are-rising. Published June 26, 2019.
  3. Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2019-2028 Forecast Summary. Baltimore, MD: Center for Medicare & Medicaid Services; 2019. https://www.cms.gov/files/document/nhe-projections-2019-2028-forecast-summary.pdf 
  4. Foundation ABIM. Allergy Tests: When you need them and when you don’t: Choosing Wisely. https://www.choosingwisely.org/patient-resources/allergy-tests/. Published July, 2016.
  5. Foundation ABIM. Pap Tests. Choosing Wisely. https://www.choosingwisely.org/patient-resources/pap-tests/. Published October 17, 2016.
  6. Foundation ABIM. Imaging tests for lower-back pain. Choosing Wisely. https://www.choosingwisely.org/patient-resources/imaging-tests-for-lower-back-pain/. Published 2017.
  7. Foundation ABIM. NASS – Imaging for low back pain. Choosing Wisely. https://www.choosingwisely.org/clinician-lists/north-american-spine-society-advanced-imaging-of-spine-within-first-six-weeks-of-non-specific-acute-low-back-pain/. Published April 8, 2019. 
  8. Foundation ABIM. Imaging Tests for Headaches. Choosing Wisely. https://www.choosingwisely.org/patient-resources/imaging-tests-for-headaches/. Published April 4, 2012. 
  9. Quinlan C. Patient-Friendly Summary of the ACR Appropriateness Criteria Headache. Journal of the American College of Radiology. https://www.jacr.org/article/S1546-1440(17)31652-6/fulltext. Published January 15, 2018. 
  10. Foundation ABIM. Imaging and Blood Tests in Early Breast Cancer. Choosing Wisely. https://www.choosingwisely.org/patient-resources/imaging-and-blood-tests-in-early-breast-cancer/. Published October 31, 2018.
  11. Pesapane F, Downey K, Rotili A, Cassano E, Koh DM. Imaging diagnosis of metastatic breast cancer. Insights Imaging. 2020;11(1):79. Published June 16, 2020. 
  12. Foundation ABIM. Chronic Kidney Disease. Choosing Wisely. https://www.choosingwisely.org/patient-resources/chronic-kidney-disease/. Published September 2012.
  13.  Foundation ABIM. Stress Tests for Chest Pain. Choosing Wisely. https://www.choosingwisely.org/patient-resources/stress-tests-for-chest-pain/. Published October 25, 2018.