Table 1.

Measures developed to assess prevalence of services identified as low-value through Choosing Wisely

Choosing Wisely recommendation	Specialty societies	Health service	Affected population	Cohort exclusions
Low-value diagnostic services
Don’t do imaging for low back pain when no red flags are present	American Academy of Family Physicians, American College of Physicians, North American Spine Society	Beneficiaries who received a low back x-ray, CT, or MRI within six weeks of incident low back pain diagnosis	Beneficiaries with low back pain over age 65 without other imaging indication	Prior diagnosis of low back pain, trauma and neurological impairment, within previous 12 months and cancer at any point during the study period; “E” code (external causes of injury) or trauma diagnosis on imaging event claim
Don’t order upper-tract imaging for patients with benign prostatic hyperplasia (BPH)	American Urological Association	Beneficiaries who received an intravenous pyelogram or an abdominal CT, MRI, or ultrasound within 60 days of the index diagnosis	Male beneficiaries diagnosed with BPH over age 65 without other indications for imaging	Cancer diagnosis at any point during the study period (e.g., chronic renal failure, nephritis, calculus of kidney and ureter, kidney stones, abdominal pain) within 60 days of index diagnosis
Don’t order cardiac tests on low-risk, asymptomatic patients	American Academy of Family Physicians, American College of Cardiology, American College of Physicians, American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography	Beneficiaries who received a non-indicated cardiac test, including stress tests, echocardiograms, electrocardiograms, advanced cardiac imaging	Low-risk beneficiaries ages 66–80	Indications of cardiac disease or other conditions that could indicate cardiac testing (e.g., HIV/AIDS, diabetes, peripheral vascular disease, pulmonary disease, cancer) or use of a prescription drug associated with the above conditions in a calendar year; enrollment in hospice; appropriate clinical indication on testing event claim
Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer	American Academy of Family Physicians	Beneficiaries who received a Pap test	Female beneficiaries at low risk for cervical cancer over age 65	Gynecological cancers, HIV / AIDS, diethylstilbestrol use, HPV infection, or a previous abnormal Pap test during the study period
Don’t routinely repeat dual-energy x-ray absorptiometry (DXA) scans more often than once every two years	American College of Rheumatology	DXA scans performed on female beneficiaries at low risk for fracture within 23 months of a previous scan	DXA scans performed on female beneficiaries over age 66 at low risk for fracture	Fragility fracture or cancer diagnosis within 23 months of the index DXA scan
Don’t perform preoperative cardiac tests for cataract surgeries	American Academy of Ophthalmology, American College of Cardiology	Beneficiaries who received a non-indicated cardiac test, including stress tests, echocardiograms, electrocardiograms and advanced cardiac imaging in the 30 days before cataract surgery	Beneficiaries over age 65 undergoing cataract surgery	Appropriate clinical indication on testing event claim (e.g., palpitations) or admission in the 30 days before surgery
Don’t perform preoperative cardiac tests for low-risk, non-cardiac surgeries	American College of cardiology, American College of Physicians, American College of radiology, American College of surgeons, American Society of anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, Society of General Internal Medicine, Society of Thoracic Surgeons, Society for Vascular Medicine	Beneficiaries who received a non-indicated cardiac test, including stress tests, echocardiograms, electrocardiograms, CTs, MRIs or PETs within 30 days before low-risk surgery	Beneficiaries over age 65 undergoing low-risk, non-cardiac surgery (e.g. breast surgery, transurethral resection of the prostate, corneal transplant, inguinal hernia repair, lithotripsy, arthroscopy, laparoscopic cholecystectomy)	Appropriate clinical indication on testing event claim (e.g. palpitations) or admission in the 30 days before surgery
Don’t perform population based screening for 25-OH-Vitamin D deficiency	American Society for Clinical Pathology, Endocrine Society, American Association of Clinical Endocrinologists	Beneficiaries who received a test for vitamin D deficiency	Low-risk beneficiaries over age 65	Beneficiaries with osteoporosis, fragility fracture, kidney disease, renal dialysis during the same calendar year
Low-value treatments
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia	American Medical Directors Association, American geriatrics Society, American Psychiatric Association	Beneficiaries who received one or more prescriptions for an antipsychotic following two observed dementia diagnoses	Beneficiaries over age 65 with diagnosed dementia	Severe mental illness during the study period
Don’t recommend percutaneous feeding tubes in patients with advanced dementia	American Academy of Hospice and Palliative Medicine, American Geriatrics Society, American Medical Directors Association	Beneficiaries with two observed dementia diagnoses residing in an institution who received a feeding tube	Institutionalized beneficiaries over age 65 with diagnosed dementia	None
Don’t use opioid or butalbital treatment for migraine, except as a last resort	American Academy of Neurology	Beneficiaries who filled an opioid or butalbital prescription within 21 days of the office visit with migraine diagnosis	Beneficiaries over age 65 with a diagnosed migraine and no other indication for opioids	An “E” code, inpatient admission, back pain, abdominal pain, surgery, fracture, cancer or hospice enrollment within 60 days of index visit