Harvard Medical School, Boston, Massachusetts.
Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Intern Med. 2022 Feb 1;182(2):127-133. doi: 10.1001/jamainternmed.2021.6911.
The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed.
To analyze the characteristics and expected impact of Choosing Wisely recommendations.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021.
Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential).
Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services).
The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.
美国明智选择运动在动员减少低价值医疗服务方面取得了实质性进展，主要通过让医师专业学会参与管理。虽然一些早期的建议因避免创收服务而受到批评，但对于更多学会参与后建议的组成如何变化，几乎没有证据表明。
分析明智选择建议的特点和预期影响。
设计、地点和参与者：这是一项对截至 2021 年 3 月 1 日美国医师学会发布的所有 626 项明智选择建议进行的定性研究，包括内容和趋势分析。数据于 2021 年 3 月至 5 月间进行分析。
主要结果是根据特征（学会类型、服务类型、适应证、做或不做、临床背景）和预期影响（对学会成员收入、成本、风险人群数量、直接危害潜在性和级联潜在性的影响）来确定低价值服务的比例。
明智选择建议中确定的低价值服务主要包括慢性疾病背景下的影像学（168 [26.8%]）和实验室研究（156 [24.9%]）以及仅存在危险因素的健康患者（126 [20.1%]）的影像学和实验室研究。所确定的低价值服务中，大多数对推荐学会的收入没有影响（402 [64.2%]），且大多数成本较低（<$200；284 [45.4%]）；明智选择建议中确定的低价值服务中低成本服务的比例逐年增加（每年增加 1.2 个百分点；P = .001）。近一半（280 [44.7%]）的建议确定了具有高直接危害潜在性的服务，388 项（62.0%）确定了具有高级联（即触发下游服务）潜在性的服务。
这项定性研究的结果表明，明智选择建议确定了具有一系列预期影响的服务。利益相关者可以明确为未来的建议设定优先事项，而临床领导者和支付方可能会根据人群支出、直接危害和级联来针对最有影响潜力的建议来进行干预。
