Neurology Choosing Wisely recommendations

Abstract

To increase neurologist awareness and inform future efficiency efforts, we identified all neurology-related Choosing Wisely items. Items were categorized by neurologic specialty, disease/symptom, and test/treatment. Of 370 items provided by 65 medical societies, 74 (20%) items were relevant to neurologists. Twelve were duplicated by multiple societies. Items pertaining to 10 neurologic subspecialties were identified, but none for movement disorders and neuromuscular disease. While many recommendations question the use of imaging, few address other high-cost neurologic tests such as EMG/nerve conduction studies and EEG. A rapidly growing number of neurology-related Choosing Wisely recommendations exist including areas of consensus and areas with few recommendations despite high costs. Consensus items should be prioritized for near-term interventions, while areas with few recommendations represent opportunities for future research.

Since 2012, the Choosing Wisely initiative has tasked medical specialty societies to identify tests and treatments that are commonly used by their physicians and whose necessity should be questioned (http://www.choosingwisely.org). Over 60 societies have created top 5 lists of these medical services, with the goal of enhancing patient and physician communication to limit these potentially unnecessary tests and treatments. The American Academy of Neurology (AAN) developed a top 5 list in 2013, and is in the process of creating a second top 5 list.¹ While the AAN is the only neurology specialty society to publish a list to date, many other societies have made recommendations that address clinical care provided by neurologists. Specialty societies are developing these lists at a rapid pace, with 9 societies contributing 45 items between September 2014 and February 2015.

The aim of this study was to identify all Choosing Wisely items pertinent to neurologists, make them easily accessible, and categorize them by neurologic subspecialty, disease/symptom, and test/treatment. Furthermore, we sought to highlight areas where recommendations are lacking and where consensus already exists to inform future development of top 5 lists.

METHODS

Two board-certified neurologists (BCC, LES) independently identified all Choosing Wisely items relevant to neurologists using the master list provided on the Choosing Wisely Web site (downloaded on February 19, 2015, from http://www.choosingwisely.org/doctor-patient-lists/). Disagreements were resolved via adjudication with a third neurologist (L.B.D.L.). Three neurologists (BCC, LES, LBD) then categorized the neurology-related items by neurologic specialty, disease/symptom, and test/treatment using group consensus. Items that were duplicated by multiple societies were also identified.

RESULTS

The Choosing Wisely master list contained a total of 370 items from 65 specialty societies. Of these 370 items, 74 recommendations (20%) from 30 different specialty societies were determined to address clinical activities performed by neurologists (table).²

Table.

Choosing Wisely initiatives relevant for neurologists²

Of the 74 neurology-related items, 5 were proposed by the AAN. Five other specialty societies also issued 5 neurology-related items including the American Academy of Sleep Medicine, American Academy of Physical Medicine and Rehabilitation, American Academy of Neurological Surgeons, American Geriatrics Society, and American Headache Society.

The neurologic subspecialties with the most items were general neurology (n = 33), followed by cognitive (n = 10), stroke (n = 10), and headache (n = 8) disciplines (figure 1). Of note, no items were identified in the fields of movement disorders or neuromuscular disease, and only one item each pertaining to epilepsy and multiple sclerosis (MS). The neurologic diseases/symptoms with the most items were low back pain (n = 15), dementia/delirium (n = 10), headache (n = 8), concussion/traumatic brain injury (n = 6), and stroke (n = 5) (figure 2A). The tests/treatments with the most items were imaging (n = 28), opioids (n = 6), antipsychotics (n = 4), and polysomnogram (PSG) (n = 4) (figure 2B). Only one item was found for EEG, antiepileptic drugs (AEDs), and MS medications. The only EEG item was for patients with headache, and the only AED recommendation was to question prophylactic use in ischemic stroke patients. Only 2 items addressed electrodiagnostic tests (EMG/nerve conduction studies [NCS]) and both addressed their use in patients with spine pain.

Figure 1. Choosing Wisely items by neurologic specialty.

The number of Choosing Wisely items categorized by neurologic specialty. N-Oph = neuro-ophthalmology; N-Oto = neuro-otology.

Figure 2. Choosing Wisely items by neurologic disease/symptom and test/treatment.

The number of Choosing Wisely items categorized by neurologic disease/symptom (A) and test/treatment (B). AED = antiepileptic drugs; CEA = carotid endarterectomy; MS = multiple sclerosis; OSA = obstructive sleep apnea; PSG = polysomnogram; RLS = restless leg syndrome; TBI = traumatic brain injury.

Topics that were duplicated by multiple societies included recommendations to question imaging in patients with low back pain (n = 8), CT scans for mild head injury (n = 4), medications for insomnia (n = 4), placement of feeding tubes in patients with dementia (n = 3), antipsychotics for behavioral control in patients with dementia (n = 3), imaging in patients with uncomplicated or migraine headache (n = 2), opioids for chronic noncancer pain (n = 2), carotid imaging for asymptomatic patients (n = 2), EMG/NCS for spine pain (n = 2), PSG for insomnia (n = 2), CT scans for syncope (n = 2), bed rest for low back pain (n = 2), and autoantibody panels without a positive antinuclear antibody (n = 2) (table).

DISCUSSION

While the AAN established one top 5 Choosing Wisely list, 69 additional neurology-relevant recommendations have been proposed by other medical specialty societies. Of all the Choosing Wisely items, 1 in 5 addressed clinical activities performed by neurologists, but only 7% were issued by a neurology society. Knowledge of these recommendations is important in delivering efficient neurologic care and should be used to jumpstart patient and physician communication regarding the need for these tests and treatments.

Interestingly, 12 Choosing Wisely neurology-relevant recommendations have been duplicated by multiple specialty societies. These likely represent a consensus among the medical community that they are commonly ordered medical services of low value. For these consensus recommendations, such as not imaging patients with low back pain, now is the time to concentrate our efforts on interventions designed to reduce these unnecessary tests. Furthermore, future Choosing Wisely recommendations, like the second top 5 list from the AAN, will have to balance the importance of establishing new consensus recommendations with exploring new medical tests and treatments to target.

We also found multiple areas that have not received attention. No current Choosing Wisely items pertain to the neurologic subspecialties of movement disorders and neuromuscular diseases and only one item each pertains to epilepsy and MS. An opportunity exists to identify commonly performed tests and treatments of questionable benefit in these subspecialties. Furthermore, prior research shows that the tests with the highest aggregate costs in outpatient neurology are MRI, EMG/NCS, and EEG.³ While many Choosing Wisely recommendations call into question MRI use in several common clinical scenarios, such as low back pain and headache, only one item pertaining to EEG and only one unique item involving EMG/NCS were identified. Given that these tests have large costs associated with them, EEG and EMG/NCS should be the focus of future efforts to identify neurology efficiency targets. In the United States, we currently spend more money on neurologist-ordered MRIs than on reimbursement for neurology visits.³ Moreover, neurologist-ordered EMG/NCS and EEGs combined account for more than half of the money spent on neurology visit reimbursement. By continuing to rely on expensive tests, our specialty runs the risk of devaluing our most important value to patients and the medical community, namely seeing patients in clinic and managing their care. Providing efficient neurologic care is likely to be particularly relevant to neurologist compensation as health care reimbursement changes from volume to value-based systems such as accountable care organizations and medical homes.

It is unlikely that the Choosing Wisely lists will meaningfully affect care without additional dissemination and implementation interventions. Interventions could focus on patients, providers, payers, or a combination; however, specific interventions known to reduce overutilization are limited and should be a focus of future research efforts. Prioritizing which Choosing Wisely items to intervene upon requires consideration of cost.⁴ Few data exist to give precise cost estimates for these services in the clinical contexts where their value is questioned. Recently, we estimated that approximately $1 billion per year is spent on neuroimaging for outpatients for headache in the United States.^5,6 A separate group found similar neuroimaging utilization in headaches.⁷ Likewise, high and rising neuroimaging utilization has been reported for patients with low back pain with high resulting costs.^8,9 Neuroimaging for headache and low back pain are ideal intervention candidates as multiple societies and guidelines have recommended against their use and the costs of guideline discordant care are known to be high.^10,11 Future studies are needed to probe the costs of the other 64 items, and cost estimates should be provided with all future Choosing Wisely items.

With an ever-growing number of specialty societies developing Top 5 lists, finding neurology-relevant items is becoming increasingly challenging. We plan to add these 74 items categorized by neurologic subspecialty, disease/symptom, and test/treatment to the AAN Web site (https://www.aan.com/practice/choosing-wisely/), and update it annually. Neurologists from all subspecialties will be able to quickly review the items most pertinent to their patients and practice. While 74 neurology-related Choosing Wisely items is a great start, future efforts should focus on identifying new targets and designing interventions to reduce utilization of currently identified tests and treatments.

AUTHOR CONTRIBUTIONS

Dr. Callaghan was involved in the study design, data acquisition, planning and interpretation of the data, and wrote the manuscript. Dr. Kerber contributed to the study design, interpretation of the data, and critical revisions of the manuscript. Dr. Burke contributed to interpretation of the data and critical revisions of the manuscript. Drs. De Lott and Skolarus contributed to data acquisition, interpretation of the statistical analysis, and critical review of the manuscript.

STUDY FUNDING

Dr. Callaghan is supported by the Katherine Rayner Program, the Taubman Medical Institute, and NIH K23 NS079417. Dr. De Lott is supported by NIH/National Institute of Neurological Disorders and Stroke T32NS7222. Dr. Kerber is supported by NIH/NCRR K23 RR024009, AHRQ R18 HS017690, and 1R01DC012760. Dr. Burke is supported by National Institute of Neurological Disorders and Stroke K08 NS082597. Dr. Skolarus is supported by NIH/National Institute of Neurological Disorders and Stroke K23NS073685.

DISCLOSURES

B.C. Callaghan serves as consultant and scientific advisory board member for a Patient-Centered Outcomes Research Institute grant; has received honoraria from the British Medical Journal; has received funding for travel from the American Academy of Neurology and World Federation of Neurology; certifies ALS centers for the ALS Association and performs medical consultations for Advance Medical; and receives research support from Impeto Medical Inc. and NIH. L.B. De Lott receives research support from NIH and has served as a consultant in medico-legal cases. K.A. Kerber has received author honoraria from Elsevier Inc., and funding for travel from the AAN; receives publishing royalties for Clinical Neurophysiology of the Vestibular System, 4th edition (Oxford University Press, 2011); serves as a consultant for AAN, University of California San Francisco (including work on a project funded by AstraZeneca), and Best Doctors, Inc.; has received a loan repayment award from NIH and speaker honoraria from AAN and University of Southern California; receives research support from NIH/NIDCD and AHRQ; and has reviewed records in medico-legal cases. J.F. Burke has received honoraria from the AAN for contributing to the Continuum series; has received compensation from AstraZeneca for his role as an adjudicator in the SOCRATES trial; has received research support from NIH; and has reviewed case materials in a medical malpractice defense case. L.E. Skolarus has received hotel accommodations from American Neurological Association and the AAN and funding for travel from the Association of University Professors of Neurology and receives research support from NIH/National Institute of Neurological Disorders and Stroke, Blue Cross Blue Shield of Michigan Foundation, and institutional support from the University of Michigan for stroke-related research. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.