# High-Value Care and Choosing Wisely

## Introduction

**High-value care** delivers the best possible health outcomes relative to cost, avoiding unnecessary tests, treatments, and procedures that provide little or no benefit and may cause harm. The **Choosing Wisely** campaign, launched by the ABIM Foundation in 2012, encourages clinicians and patients to engage in conversations about avoiding wasteful medical practices.

## Defining Value in Healthcare

- **Value = Outcomes / Cost**: maximizing quality while minimizing waste
- **Low-value care**: services where potential harms exceed potential benefits, or where less costly alternatives exist
- An estimated **$760 billion to $935 billion** is spent annually on waste in US healthcare
- Categories of waste: overtreatment, failures of care delivery, failures of care coordination, administrative complexity, pricing failures, fraud

## The Choosing Wisely Campaign

- Over **80 medical specialty societies** have published lists of commonly overused tests and treatments
- Each society identifies **five things** physicians and patients should question
- Goal is to promote **shared decision-making** rather than mandate restrictions
- Does not replace clinical judgment but highlights areas where evidence shows frequent overuse

![Choosing Wisely campaign framework and specialty recommendations](images/choosing-wisely-framework.png)

## Common Low-Value Practices in Internal Medicine

### Diagnostic Testing

| Low-Value Practice | Why It Is Harmful | Better Approach |
|-------------------|-------------------|-----------------|
| Routine preop testing in low-risk surgery | No benefit; false positives delay surgery | Test only if indicated by history/exam |
| Daily routine labs in stable patients | Phlebotomy-related anemia, cost | Order only with a clinical question |
| CTPA without pretest probability assessment | Overdiagnosis of subsegmental PE | Apply Wells score + D-dimer first |
| Stress testing in asymptomatic low-risk patients | No mortality benefit; false positives | Test only if symptoms or high risk |
| Head CT for syncope without focal signs | Yield < 2% | Reserve for focal neuro deficits or trauma |

- **Routine preoperative testing** (CBC, BMP, coagulation studies, CXR, ECG) in low-risk patients undergoing low-risk surgery: no benefit
- **Daily routine labs** in stable hospitalized patients: increases cost, blood loss, and phlebotomy-related anemia
- **CT pulmonary angiography** without adequate pretest probability assessment (Wells score, D-dimer): leads to overdiagnosis of subsegmental PE of uncertain significance
- **Cardiac stress testing** in asymptomatic, low-risk patients: no mortality benefit
- **Head CT for syncope** without focal neurological findings or head trauma: yield < 2%

### Therapeutic Overuse

- **Antibiotics for upper respiratory infections**: viral etiology in > 90% of cases
- **Proton pump inhibitors (PPIs)** continued indefinitely without indication: increased C. difficile, fracture, and kidney disease risk
- **Benzodiazepines for insomnia** in older adults: falls, cognitive impairment, dependence
- **Foley catheter continuation** beyond indicated duration: CAUTI risk increases 3-7% per day
- **Telemetry monitoring** for low-risk chest pain or stable medical conditions: false alarms, delayed mobilization

### Screening Overuse

- **Cancer screening** in patients with limited life expectancy (< 10 years): unlikely to benefit
- **Annual screening ECGs** in asymptomatic adults: low yield, high false-positive rate
- **Cervical cancer screening** more frequently than guideline-recommended intervals
- **PSA screening** without shared decision-making discussion

## Strategies for Promoting High-Value Care

### Education and Culture Change

- Integrate **high-value care curricula** into medical education and residency training
- ABIM Foundation's **Teaching Value** and ACR's **Appropriateness Criteria** programs
- Morning report and case conferences should incorporate cost-consciousness discussions
- Model high-value behavior: attending physicians influence trainee ordering patterns

### Systems-Level Interventions

- **Clinical decision support**: embed best-practice alerts for commonly overused tests
- **Order set redesign**: remove routine daily labs from default admission orders
- **Price transparency**: displaying test costs at the point of ordering reduces unnecessary orders by 10-20%
- **Audit and feedback**: provide clinicians data on their ordering patterns compared to peers
- **Indication-based ordering**: require clinical indication for high-cost imaging and laboratory studies

![High-value care implementation strategies pyramid](images/high-value-care-strategies.png)

## Communicating with Patients About High-Value Care

- **Explain the reasoning**: "This test is unlikely to change your treatment and may lead to unnecessary procedures"
- **Acknowledge concerns**: patients may feel dismissed if testing is declined without explanation
- **Use shared decision-making**: present evidence, discuss potential harms and benefits, respect preferences
- **Reframe the conversation**: avoiding unnecessary tests is not about saving money but about preventing harm
- Resources: **Consumer Reports** Choosing Wisely patient materials

## Measuring Value

- Track **utilization metrics**: imaging rates, daily labs per patient, antibiotic prescribing rates
- **Total cost of care** analysis including downstream testing from false positives
- **Patient-reported outcomes** alongside utilization data
- Balance value initiatives against risks of **under-testing and missed diagnoses**

![Cost-conscious clinical decision-making framework](images/cost-conscious-framework.png)

## Key Clinical Pearls

- The most common form of low-value care is reflexive test ordering without a clear clinical question.
- Displaying test costs at the point of ordering is a simple, effective intervention to reduce waste.
- Choosing Wisely recommendations are conversation starters, not rigid rules; clinical context matters.
- High-value care is not about withholding care but about ensuring every test and treatment serves the patient.
- Teaching high-value care early in training shapes lifelong practice patterns.

## References

1. Cassel CK, Guest JA. Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care. *JAMA*. 2012;307(17):1801-1802.
2. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. *Best Care at Lower Cost: The Path to Continuously Learning Health Care in America*. Washington, DC: National Academies Press; 2013.
3. Moriates C, Arora V, Shah N. *Understanding Value-Based Healthcare*. New York: McGraw-Hill Education; 2015.
4. Feldman LS, Shihab HM, Thiemann D, et al. Impact of Providing Fee Data on Laboratory Test Ordering. *JAMA Internal Medicine*. 2013;173(10):903-908.