Appraising the Evidence Supporting Choosing Wisely® Recommendations
Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (IQR 33.3%-70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%-83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.
© 2018 Society of Hospital Medicine
CONCLUSIONS
Although a majority of Choosing Wisely® recommendations cite high-quality evidence, some reference low-quality evidence or low-quality CPGs as their highest form of support. To overcome clinical inertia and other barriers to the successful de-implementation of low-value services, a clear rationale for the impetus to eradicate entrenched practices is critical.2,22 Choosing Wisely® has provided visionary leadership and a powerful platform to question low-value care. To expand the campaign’s efforts, the medical field must be able to generate the high-quality evidence necessary to support these efforts; further, list development groups must consider the availability of strong evidence when targeting services for de-implementation.
ACKNOWLEDGMENT
This work was supported, in part, by a grant from the Agency for Healthcare Research and Quality (No. K08HS020672, Dr. Cooke).
Disclosures
The authors have nothing to disclose.
