Residency · Residency · Internal Medicine

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

Common Low-Value Practices in Internal Medicine

Diagnostic Testing

• 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

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

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.

Read this lecture as Markdown