Editorial
Good value care: when less is more
Ensuring patients receive appropriate care is a matter
of balance. Physicians must weigh up potential benefits
and harms when ordering a test or procedure for their
patients. Meanwhile, for health-care systems, ensuring
that limited resources are allocated appropriately,
to provide good value health care at the population
level, involves preventing the overuse of ineffective or
unnecessary medical tests and interventions.
The Choosing Wisely campaigninitiated in the USA
in 2012 by the American Board of Internal Medicine
marked its fifth anniversary in 2017. The campaign
works with specialty societies to create lists of tests and
procedures that experts agree tend to be overused and
are of low value within each specialty, and which doctors
and patients are encouraged to question. In October, the
American Academy of Pediatrics Section on Endocrinology
added a new list of five recommendations regarding tests
commonly ordered for children and adolescents that they
suggest are overused and often unnecessary, particularly
among otherwise healthy individuals.
The new list includes tests for luteinising hormone,
follicle-stimulating hormone, and testosterone or oestra
diol in children with pubic hair or body odour but no
other signs of precocious puberty, and screening tests
for healthy children growing at or above the third height
percentile. The authors note that even in those below the
third percentile, such tests detect an underlying disorder
in only about 1% of cases; for children with significantly
short stature (or who are much shorter than expected
based on their parents height), tiered or sequential
testing is suggested. Two entries on the list relate to the
thyroid, suggesting that clinicians should avoid testing
thyroid function in children with obesity but no other
reason to suspect thyroid dysfunction, and limit thyroid
ultrasounds to patients with asymmetric thyroid
enlargement, palpable nodules, or concerning cervical
lymphadenopathy, since routine ultrasounds in children
who have simple goitres or autoimmune thyroiditis can
lead to unnecessary treatment of non-harmful conditions.
The final recommendation is to avoid vitamin D testing
in healthy children, even those who are overweight or
obeseaccording to the authors, such testing should
be limited to patients with disorders related to bone
mass, such as recurrent fractures or rickets. Vitamin D
supplements can be recommended if patient history
www.thelancet.com/diabetes-endocrinology Vol 5 December 2017 925
suggests a low dietary intake, which the authors argue is
more cost-effective than testing.
Since the campaigns launch, Choosing Wisely has
grown in scope and participation, including publishing
several lists relevant to endocrinology. Recommendations
Burger/Phanie/Science Photo Library
from the Endocrine Society include avoidance of routine
multiple daily self-glucose monitoring in adults with
type 2 diabetes whose disease is stably controlled and who
are on drugs that do not tend to cause hypoglycaemia.
The society also warns against mistaken routine use of
1,25-dihydroxyvitamin D measurement and recommends For more on Choosing Wisely
see http://www.choosingwisely.
not to test total or free T3 levels when assessing org/
levothyroxine dose. Another recommendation is not to For the new paediatric
prescribe testosterone therapy except for men in whom endocrinology list see
http://www.choosingwisely.org/
there is biochemical evidence of deficiency. Worryingly, societies/american-academy-of-
recent evidence from the USA suggests that direct-to- pediatrics-section-on-
endocrinology/
consumer television advertising for testosterone therapy For the Endocrine Society list
is associated with increased initiation of use, including see http://www.choosingwisely.
org/societies/endocrine-society/
among men without recent serum tests.
For more on direct-to-
Despite some successes, the Choosing Wisely initiative consumer advertising of
faces important challenges. The results of a recent US testosterone therapy see JAMA
2017; 317: 115966.
survey suggest that awareness of the campaign has DOI:10.1001/jama.2016.21041
not increased substantially between 2014 and 2017,
For more on awareness of the
with only around a quarter of clinicians aware of the Choosing Wisely campaign see
campaign. Participants also identified barriers to the http://www.healthaffairs.org/
doi/10.1377/hlthaff.2017.0945
implementation of the recommendations, including For more on the future of the
worries about malpractice liability, patient demand, and Choosing Wisely campaign see
http://www.healthaffairs.org/
their own desire to reduce uncertainty. Suggestions to doi/10.1377/hlthaff.2017.0953
overcome these concerns include personalised education For more on the drivers of low-
and follow-upnotably, there is little empirical evidence value medical care see
http://www.thelancet.com/
to support concerns over malpractice and patient demand series/right-care
for inappropriate interventions. In a separate report
looking at how to improve the campaign in the future,
researchers suggest strengthening and codifying the way
recommendations are determined, as well as developing
interventions that target the drivers of low-value care.
Ultimately, cutting the use of low-value interventions
across all parts of the health-care system will require both
structural changesincluding the challenging of vested
interests that can drive overuseand cultural changes
among health-care providers and patients. For now,
initiatives such as Choosing Wisely can help clinicians to
ensure that their patients receive the most appropriate
care: sometimes, less really is more.
The Lancet Diabetes & Endocrinology