A. G. Antunez1, L. A. Dossett1 1University Of Michigan,Ann Arbor, MI, USA
Introduction:
Overutilization of unnecessary medical tests, treatments and procedures in the US is a major public health problem. Choosing Wisely is an initiative from the American Board of Internal Medicine that aims to reduce the use of low value practices across specialties using evidence-based recommendations. Multiple surgical organizations have participated and identified low value practices in their disciplines. However, these guidelines have not been systematically reviewed to understand the characteristics of de-implementation guidelines suggested by surgical societies or to evaluate their evidence base. This information is relevant to ongoing efforts to reduce the use of unnecessary or ineffective operative procedures and assess the strength of the recommendations.
Methods:
We systematically reviewed the Choosing Wisely guidelines proposed by surgical societies. We collected data on the number of guidelines proposed by each society and classified them as to whether they recommended de-implementation of a radiology, laboratory, surgical, or other practice. We further classified the low value surgical procedures by their indication, whether there was evidence they have been de-implemented, and whether the procedure that was recommended for de-implementation was typically performed concurrently with another indicated procedure. We then qualitatively analyzed the type of evidence provided to support the guidelines and the rationale provided by the society for including the surgical practice as low value.
Results:
Fifteen surgical societies participated in the Choosing Wisely campaign, submitting 100 low value practices related to their surgical specialty. Two of the guidelines were excluded from the analysis because they were recommendations to “avoid omitting”, therefore truly recommendations for implementing a high value procedure or process. Of these 98 eligible guidelines, only 23 (23%) targeted operative procedures, with the remaining targeted low-value medications, radiology, laboratory, or other peri-operative processes (i.e. the use of durable medical equipment). Of these, 5 (22%) concerned procedures that are typically performed concurrently. The evidence for surgical de-implementation recommendations primarily comes from published clinical guidelines (n=7), followed by comprehensive reviews (n=4) and randomized controlled trials (n=4), and finally meta-analyses (n=3) and systematic reviews (n=3).
Conclusion:
While surgical societies collectively submitted 100 guidelines, only a minority recommended de-implementing an operative procedure. The guidelines were primarily evidence-based and were finalized from consensus discussion among society leaders. Our findings demonstrate that while surgical organizations met the broader goals of Choosing Wisely by recommending evidence-based de-implementation practices, they tended to identify low value perioperative care instead of low value operations.