Choosing Wisely® in Pediatrics

The provision of effective, safe, and accessible health-care is an overarching tenet across all fields of medicine. However, health-care spending in the United States is excessive, and health outcomes are often inferior to those achieved in other countries at lower cost. Although the problem is multifactorial, a factor modifiable by physicians is the provision of high-value care, defined as care that promotes optimal outcomes while reducing unnecessary cost. Provision of high-value care aligns with the principles of medical ethics: beneficence (choosing interventions with proven benefit), nonmaleficence (avoiding harm), autonomy (engaging patients in shared decision-making), and justice (ensuring equitable access to limited resources). Thus, choosing high-value care improves care overall while reducing the burden and cost of unnecessary interventions and avoiding wasteful utilization of resources. Studies suggest that provision of high-value care along with elimination of low-value care not only enhances patient satisfaction and improves overall health outcomes but also results in cost savings.Although physicians agree that controlling cost is important and that they should adhere to evidence-based guidelines, they acknowledge that they often instead prescribe low-value care—that which incurs cost while offering little benefit. It has been estimated that at least 20% of health-care interventions add no value, and most physicians report prescribing an unnecessary test or treatment at least once per week. Physicians report a variety of reasons for prescribing low-value care, including discomfort with uncertainty, patient request or perceived expectation, lack of time for lengthy discussion, malpractice concerns, financial incentives, lack of knowledge of cost or current evidence, and habits established during training or based on local norms.In 2012, the American Board of Internal Medicine Foundation, in partnership with Consumer Reports® (Consumer Reports Inc, Yonkers, NY) and 9 medical specialty societies, developed the Choosing Wisely® (CW) campaign. The campaign’s aim was to promote effective communication between providers and patients to avoid low-value interventions and encourage more frequent implementation of cost-effective, patient-centered, and evidence-based practices. At its inception, the founding societies each developed a Top 5 list of low-value practices that were commonly ordered by members of the specialty but lacked evidence of benefit. Consumer Reports provided education to the public intended to empower patients to initiate conversations and ask questions about the value of health-care recommendations. During the past decade, the campaign has been adopted by numerous specialty societies and has spread to more than 30 countries. At the heart of the CW campaign are the Top 5 lists, which medical groups generate and disseminate to their membership, highlighting low-value interventions to avoid. Although groups can develop their lists in any way they choose, each is required to disclose the methods used to generate the recommendations and to include supporting evidence.Specific to pediatric concepts, the American Academy of Pediatrics (AAP) participated in 2012 as 1 of the original 9 societies to develop a Top 5 list for members. The inaugural-year list had an outpatient focus and included guidance about avoiding antibiotics for viral respiratory infections, avoiding cold medicines in young children, and limiting imaging for simple febrile seizures and minor head injury. The following year, the Society of Hospital Medicine joined the campaign with lists for both adult and pediatric hospital care, with pediatric guidance to avoid tests and medications for asthma, bronchiolitis, and pneumonia where evidence of effectiveness or benefit was lacking. During the past decade, the CW campaign in pediatrics has expanded to include a variety of pediatric medical and surgical subspecialties. Recommendations encompass the breadth of health-care, including acute and preventive care, diagnostic laboratory and imaging studies, and therapeutic interventions, including medications, surgeries, and other procedures. Some recent examples include avoiding broad-spectrum antibiotics for uncomplicated community-acquired pneumonia, not obtaining abdominal radiographs for suspected constipation, avoiding referral for umbilical hernia repair before age 4 years, and not obtaining comprehensive respiratory viral testing for patients when results will not change management. At present, more than 75 unique recommendations can be found in the AAP CW campaign toolkit.Although engagement by medical societies in the CW campaign has increased and more Top 5 lists have been created and disseminated, awareness of the campaign across pediatric practice remains low. Studies conducted primarily in academic pediatric hospital systems suggest that simply raising awareness about low-value practices may be inadequate to change behavior and that sustained interventions over time may be necessary to effect even modest change. De-implementation science—the study of systematic processes to decrease utilization of unnecessary or low-value care—has demonstrated that techniques likely to be effective are similar to those used in quality improvement initiatives, such as engagement and education of team members, availability and monitoring of data, use of physician champions, and alteration of systems rather than a focus on individual behaviors alone. Studies in pediatric hospital systems suggest that successful interventions incorporate a combination of methods, including changes to electronic medical record (EMR) order sets, EMR prompts and alerts, clinician education sessions, prompt feedback about desired practices, and utilization review. A unique challenge to eliminating low-value care practices exists because tests and therapies are often initiated in emergency departments or acute care centers by providers who may lack knowledge of pediatric best practices. It may, therefore, be valuable for pediatricians to partner with practitioners in emergency and acute care settings in their community to offer support in implementing CW recommendations.It is also important to address the reasons clinicians are prone to choose low-value care practices, such as by ensuring that current, accurate information about health-care costs and evidence-based clinical guidelines are available in the clinical setting, that systems are structured to allow adequate time for conversations between clinicians and patients, and that financial systems reward high-value care rather than number of tests or treatments ordered. Clinicians can be reassured that studies have indicated that fostering effective patient communication, more than number of tests ordered or medicines prescribed, promotes patient satisfaction with care and is a protective factor against litigation.Efforts to educate patients and caregivers about the importance of high-value care while empowering them to engage in discussions and participate in medical decision-making remains at the heart of the CW campaign. Families can find resources to aid in health-care discussions from Consumer Reports as well as from the AAP’s CW campaign toolkit and the AAP parenting website, HealthyChildren.org. For clinicians, the CW campaign has developed communication skills training that promotes effective engagement in empathetic family-centered conversations about the value of potential tests and treatments; pediatric-specific training modules are available from the AAP. Recognizing the need to train future practitioners in the principles of high-value care, both the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have incorporated requirements for training about cost-conscious care into their guidelines for medical student and resident education, respectively. In response to these requirements, a growing number of published curricula and online modules targeted to student and resident physicians have been developed on topics such as health-care disparities, out-of-pocket costs, and high-value care.Patients, families, and pediatricians share a desire for the provision of high value, safe, effective, affordable, and accessible care for all children. Since its inception, the CW campaign has highlighted the importance of identifying and eliminating low-value care practices, both to promote patient well-being and as a steward for medical resources. As new health-care challenges arise, new tests and therapies become available, and the evidence base expands, pediatricians must be vigilant to continuously reevaluate practices that once were routine and eliminate those that lack value.Comments: Some estimates suggest that up to $101 billion is spent annually in what is considered low-value care on testing and performing procedures without an evidence base. Evidence that reform in our health-care system is needed is reinforced by the following statement: “The U.S. spends nearly 18 percent of GDP (higher than other high income countries) on health care, yet Americans die younger and are less healthy than residents of other high-income countries” (https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022).The CW campaign has been an initiative to improve health-care and decrease medical costs. Although beginning in the United States and Canada, CW campaigns have gained traction and have extended to more than 25 countries and 80 professional organizations, resulting in more than 700 recommendations when including all the disciplines in the medical field.In the pediatric focus of the AAP CW toolkit there are more than 75 recommendations. I worry that this large number of recommendations may make it difficult to focus on specific components to demonstrate national changes. What remains challenging is the development of effective interventions and methods of measurement to determine whether the interventions have been adopted and have been successful. In a study by Reyes et al mentioned in the recommended reading, 36 children’s hospitals participated and examined rates of low-value care 5 years before CW (2008–2012) and 5 years after (2013–2017). The authors found a variable range of decrease (36% in use of bronchodilators in bronchiolitis and 2.9% in use of corticosteroids for lower respiratory tract illness). Simultaneous to the development of CW concepts has been implementation of quality improvement projects in institutions and practices. Yet successful implementation of these concepts takes more than educating health-care professionals. Some components associated with success have included multidimensional interventions that incorporate “behavioral nudges,” having a clinician champion at a practice site, implementation of systems changes, use of EMR order sets, and providing feedback regarding implementation via a “report card” to name a few. Communication skills in how to discuss “what not to do” with patients is essential. More collaborative studies need to be performed to determine optimal implementation studies and also how to best partner with patients as 2 major issues are addressing patient expectations and malpractice concerns. Ongoing mechanisms of automatic measurement through EMR reporting could enhance evaluation and measurement of effectiveness to decrease health-care cost and enhance high-quality care.Janet Serwint, MDAssociate Editor, In Brief

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