Table 1. Choosing Wisely Recommendations; Study Sites; Inclusion, Exclusion, and Appropriate Decision Criteria; and Recommendation Adherence for a 6-Month Time Period Before and After the Intervention*
Recommendation (Specialty Society)Study SitesCriteriaBefore Intervention Percent AppropriateAfter Intervention Percent AppropriateP Value
InclusionExclusionAppropriate DecisionInappropriate Decision
Low-back pain (AAFP and ACP): Don't do imaging for low back pain within the first six weeks, unless red flags are present.Yale, Long Beach, Seattle§ICD-9 codes 724.4, 724.3, 724.02, 724.4, 724.5, 722.1, 722.2, 722.5, 722.51, 722.9, 846.0, 847.2Age <18 years, prior visit for acute back pain within the prior 3 months, preexisting chronic back pain, temperature >38°C, new-onset bowel or bladder symptoms, “saddle” anesthesia, prior cancer diagnosis, current IV drug use, unexplained weight lossNo imaging ordered for back painImaging ordered for back pain87.8 (108/123)87.8 (81/94).99
Sinusitis (AAFP): Don't routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms last for ≥7 days OR symptoms worsen after initial clinical improvement.Long Beach, SeattleICD-9 codes 461.0, 461.1, 461.3, 461.8, 461.9Age <12 years, prior visit for sinusitis within 3 months, temperature of 38°C, symptom duration >7 days, double sickening, severe pain or tenderness over sinuses, another diagnosis requiring antibioticsNo antibiotics prescribedAntibiotics prescribed45.4 (10/22)100 (21/21)<.00
Pap tests (AAFP): Don't perform Pap tests on women <21 years old or women who have had a hysterectomy for noncancer disease.Long Beach, SeattleAll pap smears performedPatient age >21 years, Pap performed on patient with hysterectomy for prior malignancyPatient age <21 years or Pap done on patient with hysterectomy for noncancer indication98.8 (237/240)99.3 (272/274).55
ECG (AAFP and ACP): Don't order annual ECGs or any other cardiac screening for low-risk patients without symptoms.Yale, Long Beach, SeattleAll ECGs performedECG ordered for cardiac or pulmonary symptoms, or for patients with hypertension, diabetes mellitus, or other clinical indicationECG ordered for screening purposes99.2 (119/120)99.2 (129/130).96
DEXA scanning (AAFP and ACP): Don't use DEXA screening for osteoporosis in women <65 years old or men <70 years with no risk factors.Yale, Long Beach, SeattleAll DEXAs orderedPatient age <18 yearsWomen >65 years old, men >70 years old, patients of any age with an underlying medical condition that increases osteoporosis riskWomen <65 years old without risk factors, men <70 years old without risk factors66.7 (8/12)90.0 (36/40).049
All decisions93.2 (482/517)96.5 (552/572).02
  • * The preintervention period included clinical decisions made between July 1 and December 31, 2011; the postinterventionperiods included clinical decisions made between April 26 and October 26, 2012.

  • Yale Primary Care Center, New Haven, CT, is the outpatient clinic for the Internal Medicine Residency.

  • Long Beach Memorial Family Medicine Residency, Long Beach, CA.

  • § Harborview Medical Center Family Medicine Clinic is a satellite clinic for University of Washington Family Medicine Residency, Seattle, Washington.

  • AAFP, American Academy of Family Physicians; ACP, American College of Physicians; DEXA, dual-energy X-ray absorptiometry; ECG, electrocardiogram; ICD-9, International Classification of Diseases, Ninth Revision; IV, intravenous.