Impact of the Choosing Wisely® Campaign Recommendations for Hospitalized Children on Clinical Practice: Trends from 2008 to 2017
BACKGROUND: The Choosing Wisely® Campaign (CWC) was launched in 2012. Five recommendations to reduce the use of “low-value” services in hospitalized children were published in 2013.
OBJECTIVES: The aim of this study was to estimate the frequency and trends of utilization of these services in tertiary children’s hospitals five years before and after the publication of the recommendations.
METHODS: We conducted a retrospective, longitudinal analysis of hospitalizations to 36 children’s hospitals from 2008 to 2017. The “low-value” services included (1) chest radiograph (CXR) for asthma, (2) CXR for bronchiolitis, (3) relievers for bronchiolitis, (4) systemic steroids for lower respiratory tract infection (LRTI), and (5) acid suppressor therapy for uncomplicated gastroesophageal reflux (GER). We estimated the annual percentages of the use of these services after risk adjustment, followed by an interrupted time series (ITS) analysis to compare trends before and after the publication of the recommendations.
RESULTS: The absolute decreases in utilization were 36.6% in relievers and 31.5% in CXR for bronchiolitis, 24.1% in acid suppressors for GER, 20.8% in CXR for asthma, and 2.9% in steroids for LRTI. Trend analysis showed that one “low-value” service declined significantly immediately (use of CXR for asthma), and another decreased significantly over time (relievers for bronchiolitis) after the CWC.
CONCLUSIONS: There was some decrease in the utilization of “low-value” services from 2008 to 2017. Limited changes in trends occurred after the publication of the recommendations. These findings suggest a limited impact of the CWC on clinical practice in these areas. Additional interventions are required for a more effective dissemination of the CWC recommendations for hospitalized children.
© 2019 Society of Hospital Medicine
The Choosing Wisely® Campaign (CWC) was launched in 2012. This ongoing national initiative encourages conversations among patients and clinicians about the need —or the lack thereof—for frequent tests, treatments, and procedures in healthcare. More than 80 professional societies have developed short lists of evidence-based recommendations aimed at avoiding unnecessary, “low-value” care. More than 550 recommendations are currently available.1 The Society of Hospital Medicine (SHM) Pediatric Committee published a list of five recommendations for the CWC in 2013.2
After seven years, the campaign has posted several success stories highlighting the increase in clinicians’ awareness about the recommendations. Several local, regional, and national initiatives and quality improvement (QI) projects have been inspired by the CWC and its tenants.1,3 However, limited research has been performed on the true impact of these recommendations on avoiding “low-value” services. A more comprehensive approach is required to “measure wisely” the impact of the campaign on bedside clinical practice.4 Stakeholders in healthcare value have been challenged to collaborate in creating high-impact lists of “low-value” interventions and designing effective tools to measure their impact on clinical practice and costs.5
We initially developed a report card with five metrics derived from the CWC-SHM pediatric recommendations to help individual institutions and group practices to measure their performance and benchmark their results with peers.6 The report card is available for hospital members of the Children’s Hospital Association (CHA).7
The current study analyzes the frequency of utilization and trends of five metrics included in the CHA/Pediatric Health Information System® (PHIS) CWC report card in tertiary children’s hospitals in the United States. We analyzed data from five years before and five years after the CWC-PHM recommendations were published in 2013. We hypothesize that the publication and dissemination of the CWC-PHM recommendations—the intervention—will result in either an immediate decrease in the use of the “low-value” services studied and/or a change in the trend of utilization over time.
METHODS
Study Design
We conducted an observational, longitudinal retrospective study aimed at evaluating the impact of the CWC-PHM recommendations on clinical practice in tertiary children’s hospitals in the US.
Study Population
The population included inpatient and observation stays for children aged 0-18 years admitted to the 36 children’s hospitals consistently providing data from 2008 to 2017 to the PHIS administrative database (CHA, Lenexa, Kansas). This database contains inpatient, emergency department, ambulatory, and observation encounter–level data from more than 50 not-for-profit, tertiary care pediatric hospitals and accounts for ~20% of all pediatric hospitalizations in the US every year.
