Download Identification of Choosing Wisely® Recommendations Using

Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Identification of Choosing Wisely® Recommendations Using Administrative
Claims Data
Geoffrey B. Crawford, MD, MS, 1 Jeffrey Clyman, MD, MPH, 2 David S. Chiou,3 BA, Kevin L.
Bowman, MD, MBA, MPH, 4 Alan B. Rosenberg, MD 5
------------------------------------------------------------------------------------------------------------------------------Abstract:
Importance: As part of the Choosing Wisely® initiative, partner specialty societies have developed
recommendations (lists of Things Physicians and Providers Should Question) to promote conversations
to improve care and eliminate unnecessary tests and procedures. Measurement of these
recommendations may help healthcare stakeholders estimate the magnitude and potential for
improved care, as well, facilitate program development.
Objective: To identify individuals who might benefit from discussion regarding unnecessary care
according to Choosing Wisely® recommendations, Anthem developed measures based on administrative
claims data. A subset was developed to identify clinical scenarios presented by the recommendations.
Findings: Of 305 Choosing Wisely® recommendations released as of May, 2014, 202 (66%) were
developed into measures to identify individuals who might benefit from discussion; 145 (48%) measures
were developed to identify cases suggestive of unnecessary care. Complete, detailed technical
specifications are presented with this paper.
Conclusions and Relevance: The Choosing Wisely® campaign marks an enormous opportunity for
providers, patients and other health care stakeholders to identify situations where unnecessary care can
be reduced. Many clinical scenarios can be represented using administrative data, although data
constraints and questions of clinical appropriateness remain a paramount challenge. Additional dialogue
and subsequent measure enhancement of recommendations should follow.
------------------------------------------------------------------------------------------------------------------------------Introduction:
Launched in April 2012, the Choosing Wisely® initiative “aims to promote conversations between
providers and patients by helping patients choose care that is: supported by evidence; not duplicative of
other tests or procedures already received; free from harm; and truly necessary.” (1) The Choosing
Wisely® campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation, has
created lists from more than 70 national organizations to date, representing medical specialists to
“improve care and eliminate unnecessary tests and procedures”. (1) These lists (Things Providers and
1
Corresponding Author: Medical Director, Clinical Pharmacy and Medical Policy, Anthem Inc.
[email protected]
2
Director, RHI Clinical Analytics, Anthem Inc.
3
RHI Clinical Solutions Analyst, Anthem Inc.
4
Director, Enterprise Clinical Quality, Anthem Inc.
5
Vice President, Clinical Pharmacy and Medical Policy, Anthem Inc.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Patients Should Question) include evidence-based recommendations “providers and patients should
discuss together in order to make wise decisions about the most appropriate care based on their
individual situation.” (1)
Objective measurement of recommendations listed in the Choosing Wisely® campaign might provide
valuable information to healthcare stakeholders, including both organizations and providers. Plausible
applications are numerous, including, but not limited to: establishing a baseline magnitude of
unnecessary care at a system, clinic or provider level; tracking care patterns and behaviors based on the
recommendations; and/or formulating opportunities for improved patient-provider discussion.
To determine the technical feasibility and clinical appropriateness of developing a set of objective
measurements based on Choosing Wisely® recommendations, Anthem initiated a project following
announcement of the campaign in 2012. Using administrative claims data, Anthem aimed to construct
two sets of measures; the first: a set of measures to identify individuals who might benefit from
conversations regarding unnecessary care (i.e. individuals at risk, but not yet identified as having
received inappropriate care); the second: a set of measures to identify cases suggestive of scenarios
outlined in Choosing Wisely® recommendations (i.e. inappropriate care).
Methods:
The first set of measures aims to identify individuals who might benefit from conversations regarding
unnecessary care. By utilizing clinical scenarios involving medical tests and procedure presented in the
Choosing Wisely® campaign, the goal is to highlight opportunities for patient engagement as part of a
shared decision making initiative. For example, these individuals might qualify as candidates for shareddecision making outreach: a set of messages based on Choosing Wisely® recommendations that are
personally tailored to their age, gender and past medical history. As an example, a 62 year old male
with no risk factors for osteoporosis (and no history of bone-density testing) might receive information
regarding the lack of evidence regarding dual-energy x-ray absorpiometry (DEXA) screening before the
test is conducted. The second set of measures aims to identify cases suggestive of scenarios outlined in
Choosing Wisely® recommendations. Using the example above, the same 62 year old male would be
identified if administrative billing claims suggested the presence of osteoporosis screening (DEXA).
From March 2012 to May, 2014, a master file of Choosing Wisely® recommendations was compiled from
the campaign website (http://www.choosingwisely.org/) according to specialty society, and updated as
new recommendations were published online. The recommendations were systematically reviewed with
the following questions in mind: (a) could the population in the recommendation be identified using
administrative claims data in a clinically appropriate manner; (b) could the population be identified prior
to the procedure/test/imaging/event, assuming real-life constraints such as claims processing lag-time;
(c) would the population likely benefit from a shared-decision making type of program or intervention;
and lastly (d) would the population not find the topic of interest overtly emotionally-charged or
sensitive? If the above criteria were met, a team of physicians, coding specialists, pharmacists and
analysts proceeded to construct a measure to identify individuals pertinent to the Choosing Wisely®
recommendation. The measures were constructed using proprietary software and validated using deidentified data. Claims of individuals identified by each measure were manually reviewed by a physician
(GC) and deemed clinically appropriate. Reiterative modification of each measure proceeded until the
resulting data reached team consensus and passed general clinical approval.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Measures used to identify cases suggestive of “unnecessary” care (as defined by Choosing Wisely®
recommendations) were developed using the population defined above as a denominator. Additional
logic was included to ascertain “unnecessary” care (e.g. laboratory test, procedure, imaging test) as
noted by each recommendation (using available administrative data). Custom adjustments were made
to the denominator logic depending on the clinical scenario posed by the recommendation. This subset
was developed for Choosing Wisely® recommendations only where deemed clinically appropriate and
technically feasible.
Results:
Of the 305 Choosing Wisely® recommendations released as of May, 2014, 202 recommendations (66%)
were developed into measures to identify individuals appropriate for a shared-decision making
intervention; and 145 measures (48%) were developed to identify individuals representing the clinical
scenario presented in the Choosing Wisely® recommendation. All Choosing Wisely® recommendations
corresponding to an Anthem measure(s) can be found in Table 1, ordered alphabetically by specialty
society. Fifty three specialty societies are represented. Simplified examples of measure technical
specifications are provided in Figures 1 and 2. Complete, detailed technical specifications (including
code-set values) are available with permission as supplemental material at:
http://www.anthem.com/wps/portal/ahpculdesac?content_path=medicalpolicies/noapplication/f1/s0/t
0/pw_034471.htm&na=onlinepolicies&rootLevel=0&label=Overview (header “Choosing Wisely®”,
bottom of the webpage) (eTable 1, eTable 2, eFigure 1).
Discussion:
Based on 305 Choosing Wisely® recommendations (as of May, 2014), 202 were developed by Anthem
into claims-based measures to identify individuals who might benefit from discussion. Of these
recommendations, 145 were developed to identify cases suggestive of unnecessary care according to
specific Choosing Wisely® recommendations. Complete, detailed technical specifications are presented
with this manuscript.
Objective measurement, as detailed in the methods of this manuscript, represents an important first
step in the process of evaluation and potential application of Choosing Wisely® recommendations.
Information gleaned from these measures might prove valuable to providers, particularly those
responsible for sharing costs in accountable care organizations, risk contracts, bundles, and sharedsavings models (2); also providers who wish to track their own behavior with the intent of improving
efficiency of care. Further elaboration of these measures might prove tenable for quality-measurement,
and adopted (where appropriate) by quality-endorsement organizations such as the National Quality
Forum (NQF) or National Committee on Quality Assurance (NCQA). As noted by Clement and Charlton
(3), no measurable data has been published to suggest that implementation of the Choosing Wisely®
campaign has reduced low-value medical practices.
The first set of measures (identifying individuals who might benefit from discussion) represents the
underlying framework of the Choosing Wisely campaign, namely “supporting conversations between
physicians and patients about what care is truly necessary”. (4) As noted by Morden et al. (5) and
Hoverman (2), many of the recommendations pose significant challenges to the process of objective
translation. Some are unworkable or impractical to operationalization using claims-data (discrete data
elements are difficult to retrieve), others involve acute decision-making that precludes identification of
populations (i.e. acute appendicitis) or inpatient management (e.g. daily routine laboratory testing),
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
while many are dictated by esoteric or obscure medical procedures. Also difficult are many
recommendations that pertain to emotionally loaded clinical scenarios such as cancer diagnosis or end
of life care.
Given technical feasibility (from a claims-data perspective) and clinical appropriateness limitations, only
145 of the recommendations were developed to identify cases where “unnecessary care” appears to
have already occurred. The ability of these measures to identify to inappropriate care varies given
restrictions inherent to administrative claims data; as well, multi-factorial nuances found in each
recommendation (e.g. symptom severity and/or duration; risk factors or time intervals not captured by
administrative claims-data, etc.).
A number of limitations to our methodology should be noted: firstly, administrative claims data cannot
reliably reflect the intent of the caring clinician, nor does it capture much of the granularity implicit to
Choosing Wisely® recommendations (e.g. symptom severity, duration, non-billable counseling, over-thecounter medications etc.); likewise, using administrative claims data to identify individuals will result in
both false-positive and false negative identification and incorrectly recognize individuals based on the
coding error and coding generalities; our methodology was adapted based on the input of small number
of experienced professionals and does not reflect ABIM intent, medical specialty society intent, or
Anthem medical or clinical pharmacy policy. In this sense, our measures have been shared to generate
additional dialogue and enhance the development of subsequent measure refinement and/or
construction. It is important to note (ABIM verbatim) that “Choosing Wisely® recommendations should
not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation
about what is appropriate and necessary treatment. As each patient situation is unique, providers and
patients should use the recommendations as guidelines to determine an appropriate treatment plan
together.” (1)
Conclusion:
The Choosing Wisely® campaign marks an enormous opportunity for improvement in both health care
quality and value. Anthem has demonstrated that many clinical scenarios can be represented using
administrative data to identify individuals who might benefit from discussion regarding unnecessary
care; another subset of measures can be developed to identify cases suggestive of unnecessary care
according to specific Choosing Wisely® recommendations. Although clinical appropriateness and
technical feasibility limit the scope and breadth of this collection, additional dialogue and subsequent
measure enhancement of recommendations should follow.
Acknowledgements:
David Wetzel, PharmD (pharmacy code set development)
Geraldine Nojadera, BS, CCS (medical, laboratory and procedure code set development)
Jevon Mitsuoka PharmD, PA (pharmacy code set development, pharmacy measure support)
Weihong Huang, MD, MS (measure logic integrity and quality review)
All authors (including individuals listed in the acknowledgment) are employees of Anthem Inc. All sources of
financial and material support and assistance necessary for work presented in this manuscript are the result of
Anthem Inc. employment. No other potential conflicts of interest, including relevant financial interests, activities,
relationships, and affiliations have been disclosed.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
References:
1. Choosing Wisely: an initiative of the ABIM Foundation. Available at:
http://www.choosingwisely.org). Last accessed July, 20, 2015.
2. Hoverman J.R. Getting from choosing wisely to spending wisely. J Oncol Pract. 2014 May;10(3):2235.
3. Clement, F. & Charlton, B. Challenges in Choosing Wisely's International Future: Support, Evidence,
and Burnout. JAMA Intern Med. 2015 Feb 23.
4. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment
overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014 Jul;89(7):9905.
5. Morden, N.E, Colla, C.H., Sequist, T.D, and Rosenthal, M.D. Choosing Wisely — The Politics and
Economics of Labeling Low-Value Services. NEJM January 2014.
Figure 1. Example technical specifications for Choosing Wisely® recommendation: American
Society for Clinical Pathology: "Don’t perform population based screening for 25-OH-Vitamin D deficiency.”
Note: Italics represent collections of administrative billing codes.
Measure to identify individuals who might benefit from discussion regarding unnecessary care:
Description: This measure identifies adults who MIGHT receive inappropriate vitamin D deficiency screening
(excluding higher risk individuals: those with a history of osteoporosis, chronic kidney disease, obesity, metastatic
cancer, pathologic fracture, any bone fracture during the last year, or malabsorption (including inflammatory
bowel disease/or gastric restrictive surgery, etc.).
Technical Specifications:
Denominator:
Age ≥ 18 to < 75 years-old; AND
Current member eligibility; AND
Exclude members with claims for Vitamin D Deficiency (with concurrent Evaluation or Management codes)
anytime in the past; AND
- Exclude members with claims indicating any of the following conditions – indicating or acting as a surrogate
for “higher risk” (using existing operationalized measures): osteoporosis, chronic kidney disease, obesity,
inflammatory bowel disease, metastatic cancer (including multiple myeloma with bone involvement and
metastatic kidney cancer), pathologic fracture, current pregnancy, irreversible liver disease, intestinal
malabsorption, history of a gastric restrictive procedure, hyperparathyroidism, aromatase inhibitor use, recent
bone fracture in men > 50 years-old, chronic steroid use, prostate cancer taking androgen deprivation therapy,
women with diabetes and a risk or history of bone fracture who are taking thiazolidinediones, human
immunodeficiency virus (HIV) and greater than 50 years-old or estrogen-deficient (post-menopausal or
without ovaries), or chronic proton pump inhibitor use.
Numerator = Denominator
Measure identifying clinical scenario represented by the recommendation:
Technical Specifications:
Denominator = same as above
Numerator:
Procedure claims or laboratory data over the last year for vitamin D testing/screening.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Figure 2. Example technical specifications for Choosing Wisely® recommendation: American
College of Cardiology: "Don’t perform echocardiography as routine follow-up for mild, asymptomatic native
valve disease in adult patients with no change in signs or symptoms.” Note: Italics represent collections of
administrative billing codes.
Measure to identify individuals who might benefit from discussion regarding unnecessary care:
Description: This measure identifies adults with asymptomatic native cardiac valve disease who MIGHT be
inappropriately imaged (echocardiography) as routine follow-up.
Technical Specifications:
Denominator:
Age ≥ 18-years-old; AND
Current eligibility; AND
Member eligibility over the last 6 months; AND
Multiple claims for Native Cardiac Valve Disease (with concurrent Evaluation or Management codes) anytime
in the past; AND
Claims for Echocardiogram at least over a year ago; AND
Exclude members with:
o Multiple claims for Serious Native Cardiac Valve Disease (with concurrent Evaluation or Management
codes) anytime in the past); OR
o Claims for Valve Surgery anytime during the past; OR
o Claims indicating any of the following conditions (using existing operationalized measures):
congestive heart failure, atrial fibrillation, cardiac arrhythmias, coronary heart disease, cerebral
vascular accident, bacterial endocarditis, left ventricular hypertrophy; OR
o Claims for Cardiac Valve Disease Symptoms (with concurrent Evaluation or Management codes)
during the last 3 months.
Numerator = Denominator
Measure identifying clinical scenario represented by the recommendation:
Technical Specifications:
Denominator = same as above
Numerator:
Claims for Echocardiogram during the last year, mark as onset date (OD); AND
Exclude members with claims for Cardiac Valve Disease Symptoms (with concurrent Evaluation or
Management codes) 30 days prior to or on OD.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Table 1. List of Choosing Wisely® recommendations corresponding to an Anthem measure:
Choosing Wisely® recommendations (by specialty society, as of May, 2014) listed where corresponding Anthem
measures have been constructed to identify individuals who might benefit from discussion regarding unnecessary care
(n = 202), and (if applicable), measures identifying clinical scenarios represented by the recommendation (n = 145).
Note: total count of Choosing Wisely® recommendations = 305 (only recommendations that are operationalized are
presented in Table 1).
Specialty Society
Recommendation (n = 202)
AMDA - Dedicated to Long Term
Care Medicine
Don’t insert percutaneous feeding tubes in individuals with advanced
dementia. Instead, offer oral assisted feedings.
Don’t use sliding scale insulin (SSI) for long-term diabetes management for
individuals residing in the nursing home.
Don't obtain a urine culture unless there are clear signs and symptoms that
localize to the urinary tract.
Don’t prescribe antipsychotic medications for behavioral and psychological
symptoms of dementia (BPSD) in individuals with dementia without an
assessment for an underlying cause of the behavior.
Don't routinely prescribe lipid-lowering medications in individuals with a
limited life expectancy.
Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG)
testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the
evaluation of allergy.
Don’t order sinus computed tomography (CT) or indiscriminately prescribe
antibiotics for uncomplicated acute rhinosinusitis.
Don’t routinely do diagnostic testing in patients with chronic urticaria.
Don’t diagnose or manage asthma without spirometry.
Don’t perform food IgE testing without a history consistent with potential IgEmediated food allergy.
Don’t routinely order low- or iso-osmolar radiocontrast media or pretreat with
corticosteroids and antihistamines for patients with a history of seafood
allergy, who require radiocontrast media.
Don’t routinely avoid influenza vaccination in egg-allergic patients.
Don’t overuse non-beta lactam antibiotics in patients with a history of
penicillin allergy, without an appropriate evaluation.
Don’t prescribe oral antifungal therapy for suspected nail fungus without
confirmation of fungal infection.
Don’t perform sentinel lymph node biopsy or other diagnostic tests for the
evaluation of early, thin melanoma because they do not improve survival.
Don’t treat uncomplicated, non-melanoma skin cancer less than one
centimeter in size on the trunk and extremities with Mohs micrographic
surgery.
Don’t use oral antibiotics for treatment of atopic dermatitis unless there is
clinical evidence of infection.
Don’t routinely use topical antibiotics on a surgical wound.
Don’t do imaging for low back pain within the first six weeks, unless red flags
are present.
Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis
unless symptoms last for seven or more days, or symptoms worsen after initial
clinical improvement.
Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis
in women younger than 65 or men younger than 70 with no risk factors.
Don’t order annual electrocardiograms (EKGs) or any other cardiac screening
for low-risk patients without symptoms.
Don’t perform Pap smears on women younger than 21 or who have had a
hysterectomy for non-cancer disease.
Don’t schedule elective, non-medically indicated inductions of labor or
Cesarean deliveries before 39 weeks, 0 days gestational age.
Avoid elective, non-medically indicated inductions of labor between 39 weeks,
0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients.
American Academy of Allergy,
Asthma & Immunology
American Academy of
Dermatology
American Academy of Family
Physicians
Copyright 2015 by Anthem Inc.
Measure identifying clinical
scenario represented by
recommendation (yes = 145)
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
7
Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
American Academy of Hospice
and Palliative Medicine
American Academy of
Neurology
American Academy of
Ophthalmology
American Academy of
Orthopaedic Surgeons
American Academy of
Otolaryngology — Head and
Neck Surgery Foundation
American Academy of Pediatrics
American Association for
Pediatric Ophthalmology and
Strabismus
Don’t screen women older than 65 years of age for cervical cancer who have
had adequate prior screening and are not otherwise at high risk for cervical
cancer.
Don’t screen women younger than 30 years of age for cervical cancer with HPV
testing, alone or in combination with cytology.
Don’t prescribe antibiotics for otitis media in children aged 2–12 years with
non-severe symptoms where the observation option is reasonable.
Don’t routinely screen for prostate cancer using a prostate-specific antigen
(PSA) test or digital rectal exam.
Don’t screen adolescents for scoliosis.
Don’t require a pelvic exam or other physical exam to prescribe oral
contraceptive medications.
Don’t recommend percutaneous feeding tubes in patients with advanced
dementia; instead, offer oral assisted feeding.
Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is
inconsistent with the patient/family goals of care.
Don’t recommend more than a single fraction of palliative radiation for an
uncomplicated painful bone metastasis.
Don’t perform electroencephalography (EEG) for headaches.
Don’t use opioid or butalbital treatment for migraine except as a last resort.
Don’t prescribe interferon-beta or glatiramer acetate to patients with disability
from progressive, non-relapsing forms of multiple sclerosis.
Don’t recommend CEA for asymptomatic carotid stenosis unless the
complication rate is low (<3%).
Don’t perform preoperative medical tests for eye surgery unless there are
specific medical indications.
Don’t place punctal plugs for mild dry eye before trying other medical
treatments.
Avoid performing routine post-operative deep vein thrombosis
ultrasonography screening in patients who undergo elective hip or knee
arthroplasty.
Don’t use needle lavage to treat patients with symptomatic osteoarthritis of
the knee for long-term relief.
Don’t use glucosamine and chondroitin to treat patients with symptomatic
osteoarthritis of the knee.
Don’t use post-operative splinting of the wrist after carpal tunnel release for
long-term relief.
Don’t prescribe oral antibiotics for uncomplicated acute tympanostomy tube
otorrhea.
Don’t prescribe oral antibiotics for uncomplicated acute external otitis.
Don’t routinely obtain radiographic imaging for patients who meet diagnostic
criteria for uncomplicated acute rhinosinusitis.
Don’t obtain computed tomography (CT) or magnetic resonance imaging (MRI)
in patients with a primary complaint of hoarseness prior to examining the
larynx.
Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis,
pharyngitis, bronchitis).
Cough and cold medicines should not be prescribed or recommended for
respiratory illnesses in children under four years of age.
Don’t perform screening panels for food allergies without previous
consideration of medical history.
Avoid using acid blockers and motility agents such as metoclopramide
(generic) for physiologic gastroesophageal reflux (GER) that is effortless,
painless and not affecting growth. Do not use medication in the so-called
“happy-spitter.”
Avoid the use of surveillance cultures for the screening and treatment of
asymptomatic bacteruria.
Infant home apnea monitors should not be routinely used to prevent sudden
infant death syndrome (SIDS).
Don’t put asymptomatic children in weak reading glasses.
Annual comprehensive eye exams are unnecessary for children who pass
routine vision screening assessments.
Don’t recommend vision therapy for patients with dyslexia.
Don’t routinely order imaging for all patients with double vision.
Copyright 2015 by Anthem Inc.
Yes
Yes
Yes
Yes
No
No
Yes
No
No
Yes
No
No
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
Yes
8
Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
American Association for the
Study of Liver Diseases
American College of Cardiology
American College of Chest
Physicians and American
Thoracic Society
American College of Medical
Toxicology and The American
Academy of Clinical Toxicology
The American College of
Obstetricians and Gynecologists
American College of
Occupational and
Environmental Medicine
American College of Physicians
American College of Radiology
American College of
Rheumatology
American College of
Rheumatology – Pediatric
Rheumatology
Don’t order retinal imaging tests for children without symptoms or signs of eye
disease.
Don’t perform surveillance esophagogastroduodenoscopy (EGD) in patients
with compensated cirrhosis and small varices without red signs treated with
non-selective beta blockers for preventing a first variceal bleed.
Don’t continue treatment for hepatic encephalopathy indefinitely after an
initial episode with an identifiable precipitant.
Don’t repeat hepatitis C viral load testing outside of antiviral therapy.
Don’t perform stress cardiac imaging or advanced non-invasive imaging in the
initial evaluation of patients without cardiac symptoms unless high-risk
markers are present.
Don’t perform annual stress cardiac imaging or advanced non-invasive imaging
as part of routine follow-up in asymptomatic patients.
Don’t perform stress cardiac imaging or advanced non-invasive imaging as a
pre-operative assessment in patients scheduled to undergo low-risk noncardiac surgery.
Don’t perform echocardiography as routine follow-up for mild, asymptomatic
native valve disease in adult patients with no change in signs or symptoms.
Don’t perform computed tomography (CT) surveillance for evaluation of
indeterminate pulmonary nodules at more frequent intervals or for a longer
period of time than recommended by established guidelines.
Don’t routinely offer pharmacologic treatment with advanced vasoactive
agents approved only for the management of pulmonary arterial hypertension
to patients with pulmonary hypertension resulting from left heart disease or
hypoxemic lung diseases (Groups II or III pulmonary hypertension).
For patients recently discharged on supplemental home oxygen following
hospitalization for an acute illness, don’t renew the prescription without
assessing the patient for ongoing hypoxemia.
Don’t perform CT screening for lung cancer among patients at low risk for lung
cancer.
Don’t remove mercury-containing dental amalgams.
Yes
Don’t schedule elective, non-medically indicated inductions of labor or
Cesarean deliveries before 39 weeks 0 days gestational age.
Don’t schedule elective, non-medically indicated inductions of labor between
39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Don’t perform routine annual cervical cytology screening (Pap tests) in women
30–65 years of age.
Don’t treat patients who have mild dysplasia of less than two years in
duration.
Don’t screen for ovarian cancer in asymptomatic women at average risk.
Don’t initially obtain X-rays for injured workers with acute non-specific low
back pain.
Don’t routinely order X-ray for diagnosis of plantar fasciitis/heel pain in
employees who stand or walk at work.
Don’t obtain screening exercise electrocardiogram testing in individuals who
are asymptomatic and at low risk for coronary heart disease.
Don’t obtain imaging studies in patients with non-specific low back pain.
Don’t obtain preoperative chest radiography in the absence of a clinical
suspicion for intrathoracic pathology.
Don’t do imaging for uncomplicated headache.
Avoid admission or preoperative chest x-rays for ambulatory patients with
unremarkable history and physical exam.
Don’t recommend follow-up imaging for clinically inconsequential adnexal
cysts.
Don’t perform MRI of the peripheral joints to routinely monitor inflammatory
arthritis.
Don’t prescribe biologics for rheumatoid arthritis before a trial of
methotrexate (or other conventional non-biologic DMARDs).
Don’t routinely repeat DXA scans more often than once every two years.
Don’t routinely perform surveillance joint radiographs to monitor juvenile
idiopathic arthritis (JIA) disease activity.
Don’t perform methotrexate toxicity labs more often than every 12 weeks on
No
Copyright 2015 by Anthem Inc.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
9
Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
American College of Surgeons
American Gastroenterological
Association
American Geriatrics Society
American Headache Society
American Medical Society for
Sports Medicine
American Psychiatric
Association
American Society for Clinical
Pathology
stable doses.
Don’t repeat a confirmed positive ANA in patients with established JIA or
systemic lupus erythematosus (SLE).
Don't perform axillary lymph node dissection for clinical stages I and II breast
cancer with clinically negative lymph nodes without attempting sentinel node
biopsy.
Avoid colorectal cancer screening tests on asymptomatic patients with a life
expectancy of less than 10 years and no family or personal history of colorectal
neoplasia.
Avoid admission or preoperative chest X-rays for ambulatory patients with
unremarkable history and physical exam.
For pharmacological treatment of patients with gastroesophageal reflux
disease (GERD), long-term acid suppression therapy (proton pump inhibitors
or histamine2 receptor antagonists) should be titrated to the lowest effective
dose needed to achieve therapeutic goals.
Do not repeat colorectal cancer screening (by any method) for 10 years after a
high-quality colonoscopy is negative in average-risk individuals.
Don’t recommend percutaneous feeding tubes in patients with advanced
dementia; instead offer oral assisted feeding.
Don’t use antipsychotics as first choice to treat behavioral and psychological
symptoms of dementia.
Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age
65 and older; moderate control is generally better.
Don’t use benzodiazepines or other sedative-hypnotics in older adults as first
choice for insomnia, agitation or delirium.
Don’t use antimicrobials to treat bacteriuria in older adults unless specific
urinary tract symptoms are present.
Don’t prescribe cholinesterase inhibitors for dementia without periodic
assessment for perceived cognitive benefits and adverse gastrointestinal
effects.
Don’t recommend screening for breast or colorectal cancer, nor prostate
cancer (with the PSA test) without considering life expectancy and the risks of
testing, overdiagnosis and overtreatment.
Avoid using prescription appetite stimulants or high-calorie supplements for
treatment of anorexia or cachexia in older adults; instead, optimize social
supports, provide feeding assistance and clarify patient goals and
expectations.
Don’t prescribe a medication without conducting a drug regimen review.
Don’t perform neuroimaging studies in patients with stable headaches that
meet criteria for migraine.
Don’t recommend surgical deactivation of migraine trigger points outside of a
clinical trial.
Don’t prescribe opioid or butalbital-containing medications as first-line
treatment for recurrent headache disorders.
Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain
medications for headache.
Avoid ordering an abdominal ultrasound examination routinely in athletes
with infectious mononucleosis.
Avoid ordering a knee MRI for a patient with anterior knee pain without
mechanical symptoms or effusion unless the patient has not improved
following completion of an appropriate functional rehabilitation program.
Avoid recommending knee arthroscopy as initial management for patients
with degenerative meniscal tears and no mechanical symptoms.
Don’t prescribe antipsychotic medications to patients for any indication
without appropriate initial evaluation and appropriate ongoing monitoring.
Don’t routinely prescribe two or more antipsychotic medications concurrently.
Don’t use antipsychotics as first choice to treat behavioral and psychological
symptoms of dementia.
Don’t routinely prescribe antipsychotic medications as a first-line intervention
for insomnia in adults.
Don’t routinely prescribe antipsychotic medications as a first-line intervention
for children and adolescents for any diagnosis other than psychotic disorders.
Don’t perform population based screening for 25-OH-Vitamin D deficiency.
Don’t perform low risk HPV testing.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
American Society of Plastic
Surgeons
American Society for Radiation
Oncology
American Society for
Reproductive Medicine
American Society of
Anesthesiologists
American Society of
Anesthesiologists – Pain
Medicine
American Society of Clinical
Oncology
American Society of
Echocardiography
American Society of
Hematology
American Society of Nephrology
Avoid performing routine and follow-up mammograms of reconstructed
breasts after mastectomies.
Don’t initiate management of low-risk prostate cancer without discussing
active surveillance.
Don’t perform routine diagnostic laparoscopy for the evaluation of
unexplained infertility.
Don’t perform advanced sperm function testing, such as sperm penetration or
hemizona assays, in the initial evaluation of the infertile couple.
Don’t perform a postcoital test (PCT) for the evaluation of infertility.
Don’t routinely order thrombophilia testing on patients undergoing a routine
infertility evaluation.
Don’t perform immunological testing as part of the routine infertility
evaluation.
Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal
echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable
patients with known cardiac disease (e.g., CAD, valvular disease) undergoing
low or moderate risk non-cardiac surgery.
Don’t prescribe opioid analgesics as first-line therapy to treat chronic noncancer pain.
Don’t prescribe opioid analgesics as long-term therapy to treat chronic noncancer pain until the risks are considered and discussed with the patient.
Avoid imaging studies (MRI, CT or X-rays) for acute low back pain without
specific indications.
Avoid irreversible interventions for non-cancer pain that carry significant costs
and/or risks.
Don’t perform PET, CT, and radionuclide bone scans in the staging of early
prostate cancer at low risk for metastasis.
Don’t perform PET, CT, and radionuclide bone scans in the staging of early
breast cancer at low risk for metastasis.
Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and
radionuclide bone scans) for asymptomatic individuals who have been treated
for breast cancer with curative intent.
Don’t give patients starting on a chemotherapy regimen that has a low or
moderate risk of causing nausea and vomiting antiemetic drugs intended for
use with a regimen that has a high risk of causing nausea and vomiting.
Don’t use combination chemotherapy (multiple drugs) instead of
chemotherapy with one drug when treating an individual for metastatic breast
cancer unless the patient needs a rapid response to relieve tumor-related
symptoms.
Avoid using PET or PET-CT scanning as part of routine follow-up care to
monitor for a cancer recurrence in asymptomatic patients who have finished
initial treatment to eliminate the cancer unless there is high-level evidence
that such imaging will change the outcome.
Don’t perform PSA testing for prostate cancer screening in men with no
symptoms of the disease when they are expected to live less than 10 years.
Don’t order follow up or serial echocardiograms for surveillance after a finding
of trace valvular regurgitation on an initial echocardiogram.
Don’t repeat echocardiograms in stable, asymptomatic patients with a
murmur/click, where a previous exam revealed no significant pathology.
Avoid echocardiograms for preoperative/perioperative assessment of patients
with no history or symptoms of heart disease.
Avoid using stress echocardiograms on asymptomatic patients who meet “low
risk” scoring criteria for coronary disease.
Limit surveillance computed tomography (CT) scans in asymptomatic patients
following curative-intent treatment for aggressive lymphoma.
Don’t perform routine cancer screening for dialysis patients with limited life
expectancies without signs or symptoms.
Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney
disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL
without symptoms of anemia.
Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with
hypertension or heart failure or CKD of all causes, including diabetes.
Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD
patients without consulting nephrology.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
American Society of Nuclear
Cardiology
American Urological Association
Commission on Cancer
The Endocrine Society
Heart Rhythm Society
North American Spine Society
Society for Cardiovascular
Angiography and Interventions
Society for Cardiovascular
Magnetic Resonance
Don’t initiate chronic dialysis without ensuring a shared decision-making
process between patients, their families, and their physicians.
Don’t perform stress cardiac imaging or coronary angiography in patients
without cardiac symptoms unless high-risk markers
are present.
Don’t perform radionuclide imaging as part of routine follow-up in
asymptomatic patients.
Don’t perform cardiac imaging as a pre-operative assessment in patients
scheduled to undergo low- or intermediate-risk non-cardiac surgery.
A routine bone scan is unnecessary in men with low-risk prostate cancer.
Don’t prescribe testosterone to men with erectile dysfunction who have
normal testosterone levels.
Don’t order creatinine or upper-tract imaging for patients with benign
prostatic hyperplasia (BPH).
Don’t perform ultrasound on boys with cryptorchidism.
Don't perform surgery to remove a breast lump for suspicious findings unless
needle biopsy cannot be done.
Don't initiate surveillance testing after cancer treatment without providing the
patient a survivorship care plan.
Don’t use surgery as the initial treatment without considering pre-surgical
(neoadjuvant) systemic and/or radiation for cancer types and stage where it is
effective at improving local cancer control, quality or life or survival.
Don't initiate cancer treatment without defining the extent of the cancer
(through clinical staging) and discussing with the patient the intent of
treatment
Avoid routine multiple daily self-glucose monitoring in adults with stable type
2 diabetes on agents that do not cause hypoglycemia.
Don’t routinely measure 1,25-dihydroxyvitamin D unless the patient has
hypercalcemia or decreased kidney function.
Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in
hypothyroid patients.
Don’t prescribe testosterone therapy unless there is biochemical evidence of
testosterone deficiency.
Don’t implant pacemakers for asymptomatic sinus bradycardia in the absence
of other indications for pacing.
Don’t implant an ICD for the primary prevention of sudden cardiac death in
patients unlikely to survive at least one year due to non-cardiac comorbidity.
Don’t use Vaughan-Williams Class Ic antiarrhythmic drugs as a first-line agent
for the maintenance of sinus rhythm in patients with ischemic heart disease
who have experienced prior myocardial infarction.
Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six
weeks in patients with non-specific acute low back pain in the absence of red
flags.
Don’t perform elective spinal injections without imaging guidance, unless
contraindicated.
Don’t use electromyography (EMG) and nerve conduction studies (NCS) to
determine the cause of axial lumbar, thoracic or cervical spine pain.
Don’t recommend bed rest for more than 48 hours when treating low back
pain.
Avoid performing routine stress testing after percutaneous coronary
intervention (PCI) without specific clinical indications.
Avoid coronary angiography in post-coronary artery bypass graft (CABG) and
post-PCI patients who are asymptomatic, or who have normal or mildly
abnormal stress tests and stable symptoms not limiting quality of life.
Avoid coronary angiography for risk assessment in patients with stable
ischemic heart disease (SIHD) who are unwilling to undergo revascularization
or who are not candidates for revascularization based on comorbidities or
individual preferences.
Avoid coronary angiography to assess risk in asymptomatic patients with no
evidence of ischemia or other abnormalities on adequate non-invasive testing.
Don’t perform stress CMR as a pre-operative assessment in patients scheduled
to undergo low-risk, non-cardiac surgery.
Don’t perform coronary CMR in symptomatic patients with a history of
coronary stents.
Copyright 2015 by Anthem Inc.
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Identification of Choosing Wisely® Recommendations Using Administrative Claims Data
Society for Maternal-Fetal
Medicine
Society for Vascular Medicine
Society of Cardiovascular
Computed Tomography
Society of General Internal
Medicine
Society of Gynecologic Oncology
Society of Hospital Medicine –
Pediatric Hospital Medicine
Society of Nuclear Medicine and
Molecular Imaging
The Society of Thoracic
Surgeons
Don’t perform coronary CMR in the initial evaluation of asymptomatic
patients.
Don’t use progestogens for preterm birth prevention in uncomplicated
multifetal gestations.
Don’t reimage DVT in the absence of a clinical change.
Avoid cardiovascular testing for patients undergoing low-risk surgery.
Refrain from percutaneous or surgical revascularization of peripheral artery
stenosis in patients without claudication or critical limb ischemia.
Don’t screen for renal artery stenosis in patients without resistant
hypertension and with normal renal function, even if known atherosclerosis is
present.
Don’t use coronary artery calcium scoring for patients with known coronary
artery disease (including stents and bypass grafts).
Don’t order coronary artery calcium scoring for preoperative evaluation for
any surgery, irrespective of patient risk.
Don’t routinely order coronary computed tomography angiography for
screening asymptomatic individuals
Don’t recommend daily home finger glucose testing in patients with Type 2
diabetes mellitus not using insulin.
Don’t perform routine general health checks for asymptomatic adults.
Don’t perform routine pre-operative testing before low-risk surgical
procedures.
Don’t recommend cancer screening in adults with life expectancy of less than
10 years.
Don’t screen low risk women with CA-125 or ultrasound for ovarian cancer.
Don’t perform Pap tests for surveillance of women with a history of
endometrial cancer.
Don’t perform colposcopy in patients treated for cervical cancer with Pap tests
of low-grade squamous intraepithelial lesion (LGSIL) or less.
Avoid routine imaging for cancer surveillance in women with gynecologic
cancer, specifically ovarian, endometrial, cervical, vulvar and vaginal cancer.
Don’t delay basic level palliative care for women with advanced or relapsed
gynecologic cancer, and when appropriate, refer to specialty level palliative
medicine.
Don’t order chest radiographs in children with uncomplicated asthma or
bronchiolitis.
Don’t routinely use bronchodilators in children with bronchiolitis.
Don’t use systemic corticosteroids in children under 2 years of age with an
uncomplicated lower respiratory tract infection.
Don’t treat gastroesophageal reflux in infants routinely with acid suppression
therapy.
Don’t use PET/CT for cancer screening in healthy individuals.
Don’t perform routine annual stress testing after coronary artery
revascularization.
Don’t use PET imaging in the evaluation of patients with dementia unless the
patient has been assessed by a specialist in this field.
Patients who have no cardiac history and good functional status do not require
preoperative stress testing prior to non-cardiac thoracic surgery.
Copyright 2015 by Anthem Inc.
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