Promoting Evidence-Based High-Value Health Care

Promoting evidence-based high-value health care remains one of the foremost challenges in medicine today. Increasing scrutiny of the real-world effectiveness, safety, and costs of medical care, including therapeutics, diagnostic tests, procedures, operations, and even decisions regarding whether to admit a patient to the hospital or schedule an outpatient follow-up, have broadened and deepened our understanding of high-quality and high-value care. In response, multiple specialty societies, prompted by the Choosing Wisely campaign,¹ have revised their clinical practice guidelines and recommendations to address not only what care should be provided but also what care should not. But avoiding overtreatment and overdiagnosis are often easier said than done, even at the most prestigious and well-resourced institutions in the world.

In this issue of JAMA Internal Medicine, Cai et al² reviewed all 550 esophagogastroduodenoscopies performed in adults at Massachusetts General Hospital in the last 4 months of 2013 to evaluate low-risk indications, finding substantial overuse of the procedure. More than one-third were discordant with the American College of Physicians’ evidence-based guidelines. Nevertheless, it is always easier to find mistakes and examples of health care that, in retrospect, need not have been provided. This article is a reminder of what we need to do to improve. Guidelines and recommendations are not enough. Practices need to change at the point of care. More steps need to be taken, including checklists before procedures, to review appropriate indications for use; substantive discussions with patients to obtain informed consent to comprehensively review expected benefits, risks, and costs as well as treatment alternatives; and better physician reimbursement policies are needed to provide sufficient financial support for these discussions between patients and their physicians. As patients and physicians grow increasingly aware of the need to promote evidence-based high-value health care, we need to develop the tools to make this care a reality in practice.

Conflict of Interest Disclosures: None reported.