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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. 1 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. 2 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. 3 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. 4 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. 5 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. 6 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. Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No No No Yes No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes 10 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. Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11 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. No Yes Yes Yes No Yes No Yes No No No No Yes Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes No Yes Yes Yes 12 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. Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes 13