Are you “Choosing Wisely” with Cardiac Imaging?

Results are in from the Choosing Wisely initiative - a campaign designed to reduce the use of frequent tests deemed "low value" - like cardiac imaging.

A recently published study from JAMA Internal Medicine examining the frequency and trends of services from 2012 Choosing Wisely recommendations across 25 million Anthem health plan members found statistically significant reductions in cardiac imaging and other "low value" services.

Some context: many uses of cardiac imaging were deemed "low value" by the ACC in 2012.

The American College of Cardiology contributed to some of the earliest Choosing Wisely recommendations from 2012 - the recommendations that this study tracked. One of these recommendations has since been withdrawn due to new science, but the four that remain relate to cardiac imaging.

They are:


  1. Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

  2. Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

  3. Don't perform stress cardiac imaging or non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non cardiac surgery.

  4. Don't perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.


As a result, the authors argue, use of cardiac imaging decreased from 10.8 percent of the population to 9.7 percent.

On the horizon: wider implementation?

While this result demonstrated statistical significance, the clinical significance remains uncertain, and the authors argue that "the relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice."

Similar to initiatives attempting to reduce radiation exposure in the cath lab, the authors argue that wider commitment to the recommendations will require some cultural change in clinician behavior - especially when "less is more."

Has your organization committed to "Choosing Wisely?"

Has your organization decreased the use of cardiac imaging in these situations?

Would committing to these recommendations significantly impact volume or staffing?

Are these changes inevitable?

Leave a comment below!

Update (10/22): What constitutes high risk?

Especially when following recommendation number one - it's important to stay on top of the latest in cardiovascular risk factors. A new factor as predictive as cholesterol levels could be a new high-risk marker justifying cardiac imaging.

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