Response: Re: Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely™

To the Editor: We thank Dr. Gladwell for his thoughtful comments regarding our article about the impact of the Choosing Wisely campaign on clinical decisions made in primary care clinics. As he notes, achieving value in health care is a critical component of improving our health care system. Thus it is necessary to know what kinds of interventions might be successful at increasing the rates of high-value care.

Space limitations precluded a full discussion of limitations in our study, so we welcome Dr. Gladwell's elaboration of the known limitations of the quasi-experimental design we used. Clinics were not randomly assigned, and all received the educational intervention and exposure to the launch of the Choosing Wisely campaign. We agree that it is not possible to quantify all potential aspects of this exposure. The launch of the Choosing Wisely campaign constituted a natural experiment that allowed us to compare the clinical decisions made before and after its national rollout. Our intervention was designed to achieve 3 goals: first, to make clinicians at each site aware of the Choosing Wisely campaign in general; second, to orient them to the 5 specific areas of low-value care; and third, to give them a tool to respond to patients who desired a care plan that did not adhere to the recommendations.

As Dr. Gladwell notes, the 5 areas of low-value care in the study were quite different. Two areas involved the correct use of screening tests (Papanicolaou test and dual-energy X-ray absorptiometry). One was a type of screening test that should be avoided altogether (electrocardiography). Two other areas—low back pain and sinusitis—responded to patient symptoms. In each of these areas clinicians needed to avoid doing something, either imaging or prescribing medication. Decision making around each of these types of clinical scenarios is different and may account for some of the variation we saw in our study.

High-value care in general and Choosing Wisely in particular are areas that require significant future research. One potential avenue is to investigate how clinicians are implementing the various Choosing Wisely recommendations (correct use of screening tests, avoidance of low-value screening tests, avoidance of diagnostic testing or certain treatment modalities for given conditions). Clinical decisions that fall into these larger categories could be studied across specialties to identify trends and potential areas for intervention. Perhaps it is easier for clinicians to improve their adherence to screening recommendations (eg, for dual-energy X-ray absorptiometry) than it is to not order a test that a patient desires (low back pain imaging).

To ensure all patients receive high-value care, a variety of interventions are needed. Some, such as ours, are educational, meant to generate awareness among clinicians and help them develop the skills needed to implement high-value care. System-based or point-of-care interventions could increase high-value care such as electronic health record flags that remind clinicians to order screening tests when indicated and remind them when they have requested a screening test that is not indicated for a specific patient. Patient-directed interventions, such as what is being done with Consumer Reports in conjunction with the Choosing Wisely campaign, will help patients become more savvy consumers of health care. Finally, policy-level interventions can also drive value, such as creating financial incentives for performing screening tests or vaccinations or, conversely, creating financial disincentives, such as not paying to catheter-associated urinary tract infections. High-value care for all patients is possible, although the path to get there will be long and complicated.