Early Trends Among Seven Recommendations From the Choosing Wisely Campaign
Early Trends Among Seven Recommendations From the Choosing Wisely Campaign
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DOI：
10.1001/jamainternmed.2015.5441
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发表时间：
2015-12-01
影响因子：
39
通讯作者：
DeVries, Andrea
中科院分区：
文献类型：
--
作者：
Rosenberg, Alan;Agiro, Abiy;DeVries, Andrea
“明智选择”活动包括70多个清单，这些清单是由专业学会编制的，列出了在大多数情况下对患者临床益处最小的医疗实践或程序，并提供了有关明智使用的建议。目的利用全国商业健康计划人口水平数据，量化一些最早的明智选择建议的频率和趋势。设计、设置和参与者：anthem附属商业健康计划成员索赔数据的回顾性分析。选择的低价值服务有：(1)单纯头痛的影像学检查；(2)无心脏病史的心脏显像；(3)腰痛影像学无红旗症状；(4)术前胸片无异常病史和体格检查结果；(5) 30岁以下妇女进行人乳头瘤病毒检测；(6)急性鼻窦炎抗生素的使用；(7)对患有高血压、心力衰竭或慢性肾病的会员使用处方非甾体抗炎药（NSAIDs）。主要结果和措施对所包括的低价值服务提出医疗和/或药房索赔的成员数量进行了季度评估，为期2至3年，直至2013年。使用以分母为偏移量的泊松回归对所有季度的建议趋势变化进行评估。结果两项服务均有下降：头痛影像学使用率从14.9%下降到13.4%（趋势估计，0.99 [95% CI, 0.98-0.99]; P < .001），心脏影像学使用率从10.8%下降到9.7%（趋势估计，0.99 [95% CI, 0.99-0.99]; P < .001）。两项服务有增加：非甾体抗炎药在特定条件下的使用从14.4%增加到16.2%（趋势估计，1.02 [95% CI, 1.01-1.02]; P < .001），年轻女性的人乳头瘤病毒检测从4.8%增加到6.0%（趋势估计，1.01 [95% CI, 1.00-1.01]; P < .001）。鼻窦炎的抗生素使用保持稳定（从84.5%下降到83.7%，下降0.8%；趋势估计为1.00 [95% CI, 1.00-1.00]; P = 0.16）。术前胸片使用率（下降0.2%，结束使用率91.5%，趋势估计1.00 [95% CI, 1.00-1.00], P = 0.70）和腰痛影像学使用率（整个研究期间使用率53.7%,P = 0.71）仍然很高，无统计学意义变化。结论和相关性在对7个低价值服务的人群水平分析中，变化不大，但对2个推荐（头痛影像学，低风险患者心脏影像学）的建议有理想的减少。然而，效应大小是边际的，尽管7个列表中有4个在统计上有显著的变化——考虑到大样本量，这并不奇怪——临床意义是不确定的。这些结果表明，为了更广泛地实施明智选择建议，需要额外的干预措施。
IMPORTANCE The Choosing Wisely campaign consists of more than 70 lists produced by specialty societies of medical practices or procedures of minimal clinical benefit to patients in most situations, with recommendations regarding judicious use.OBJECTIVE To quantify the frequency and trends of some of the earliest Choosing Wisely recommendations using nationwide commercial health plan population-level data.DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of claims data for members of Anthem-affiliated commercial health plans. The low-value services selected were (1) imaging tests for uncomplicated headache; (2) cardiac imaging without history of cardiac conditions; (3) low back pain imaging without red-flag conditions; (4) preoperative chest x-rays with unremarkable history and physical examination results; (5) human papillomavirus testing for women younger than 30 years; (6) use of antibiotics for acute sinusitis; and (7) use of prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease.MAIN OUTCOMES AND MEASURES The number of members with medical and/or pharmacy claims for the included low-value services was assessed quarterly over a 2- to 3-year span through 2013. Trend changes in recommendations were evaluated across all quarters using Poisson regression with denominators as offsets.RESULTS Two services had declines: Use of imaging for headache decreased from 14.9% to 13.4%(trend estimate, 0.99 [95% CI, 0.98-0.99]; P < .001), and cardiac imaging decreased from 10.8% to 9.7%(trend estimate, 0.99 [95% CI, 0.99-0.99]; P < .001). Two services had increases: Use of NSAIDs in select conditions increased from 14.4% to 16.2%(trend estimate, 1.02 [95% CI, 1.01-1.02]; P < .001), and human papillomavirus testing in younger women increased from 4.8% to 6.0% (trend estimate, 1.01 [95% CI, 1.00-1.01]; P < .001). Use of antibiotics for sinusitis remained stable (0.8% decrease from 84.5% to 83.7%; trend estimate, 1.00 [95% CI, 1.00-1.00]; P = .16). Use of preoperative chest x-rays (0.2% decrease, ending utilization 91.5%; trend estimate, 1.00 [95% CI, 1.00-1.00]; P = .70) and imaging for low back pain (53.7% utilization throughout study; P = .71) remained high with no statistically significant changes.CONCLUSIONS AND RELEVANCE For this population-level analysis of 7 low-value services analyzed, changes were modest but showed a desirable decrease for 2 recommendations (imaging for headache, cardiac imaging for low-risk patients). The effect sizes were marginal, however, and although 4 of the 7 lists had statistically significant changes-unsurprising given the large sample size-the clinical significance is uncertain. These results suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations.