Gliwa C, Pearson SD. Evidentiary Rationales for the Choosing Wisely Top 5 Lists. JAMA. 2014;311(14):1443-1444. doi:10.1001/jama.2013.285362
Aiming to reduce wasteful medical care, the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely initiative asks leading physician specialty societies to create a “Top 5” list of medical services that provide no overall benefit to patients in most situations.1,2 As of August 2013, 25 participating specialty societies had produced 1 or more Top 5 lists containing a total of 135 services.
The goal of this study was to evaluate the role that evidence on benefits, risks, and costs plays in selecting a service for the Top 5 lists. As Choosing Wisely continues to grow, clarity on the evidentiary justifications for the lists will be crucial for the overall credibility of the campaign.
We analyzed the evidentiary rationales provided by specialty societies using a framework of different types of marginal medicine (Table 1).1,3 These categories are based on the level of certainty in the evidence regarding risks and benefits, how the risks and benefits of the service compare with other alternatives, and the comparative cost or cost-effectiveness of the service.
Categorization was performed independently by both authors, and disagreements were resolved through discussion. We relied solely on the information given explicitly in the published rationales for each Top 5 list.
Of the 135 services, 49 (36%) were for patient diagnosis, prognosis, or monitoring; 46 (34%) for patient treatment; and 40 (30%) for population screening. Initial evidence categorization was identical for 128 (95%) of 135 services.
Inclusion of 102 services (76%) was justified by claims that adequate evidence demonstrated no additional benefit with higher risk, higher cost, or both, compared with other options (Table 2). The second most common rationale, given for 18 services (13%), was that there was insufficient evidence to evaluate comparative benefit for use of the service beyond the evidentiary boundaries of established indications, frequency, intensity, or dosage. Other evidentiary rationales shown in Table 2 were used infrequently.
Overall, 66 (49%) of all 135 rationales mentioned greater risks to patients as a consideration in selecting the service, 33 (24%) mentioned higher costs, 21 (16%) mentioned both greater risk and higher cost, and 57 (42%) mentioned neither. Of the 25 specialty societies, 15 (60%) had at least 1 service whose inclusion was justified in part by higher costs.
Most services were included in the Top 5 lists on the basis of evidence considered to be adequate to demonstrate equivalent but not superior benefit with higher risk or higher costs, or both, compared with other options. The specialty societies did not emphasize emerging or experimental interventions.
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. We believe 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.
Less than half (49%) of the rationales mentioned specific patient risks. However, we only noted explicit mentions of risk, so it is likely that some risks (such as those from radiation exposure) were an implicit concern.
Our analysis has additional limitations. We did not evaluate the procedures through which each specialty society created its Top 5 list or analyze the evidence cited in their rationales. However, we believe the rationales given by the specialty societies need to stand on their own in justifying the selection of services. Specialty societies can enhance trust in the Choosing Wisely campaign by defining more clearly the types of potentially wasteful medical care they seek to eliminate, and by providing a clear evidentiary justification for the selection of each service.
Corresponding Author: Steven D. Pearson, MD, MSc, National Institutes of Health, 10 Center Dr, Bldg 10, Room 1C118, Bethesda, MD 20892 (firstname.lastname@example.org).
Author Contributions: Ms Gliwa and Dr Pearson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Both authors.
Administrative, technical, or material support: Gilwa.
Study supervision: Pearson.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: This research was supported by the Intramural Research Program of the National Institutes of Health.
Role of the Sponsor: The Intramural Research Program of the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The opinions expressed are those of the authors and do not reflect the position or policy of the National Institutes of Health, the Public Health Service, or the Department of Health and Human Services.
Additional Contributions: We thank our colleagues in the Department of Bioethics at the National Institutes of Health for their thoughtful comments and advice during the early stages of this project.