How Should Top-Five Lists Be Developed?

Abstract

Readers might wonder why the editors of JAMA Internal Medicine decided to publish “A Top-Five List for Emergency Medicine.” Some of our readers might practice emergency medicine (EM), and many provide “urgent” care. However, we decided to publish this article for another reason. We believe that “A Top-Five List for Emergency Medicine” from Schuur et al1 at Partners Healthcare demonstrates a solid methodological approach to developing a list of low-value tests, procedures, and treatments in response to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.Althoughmanyprofessional societies havepublished “top-five” lists,most havenot detailed the methods by which the list was created. In some cases, it is clear that the lists were developed without much input fromfrontlinepractitioners, usingaprocess thatwasnot transparent andwithout clear criteria for inclusionon the list. We hope the article by Schuur et al1 will stimulate other professional societies to adopt clear, transparentmethods for developingand revising top-five listswith substantial input from practicing clinicians. We would like to see a consensus develop around criteria for choosing items on top-five lists. To start this conversation, we suggest that there should be clear evidence that the tests and treatments on a top-five list cause potential harm or provide little benefit to patients, are frequentlymisused in clinical practice, aremeasureable, and are under the control of providers. At least 50 specialty societies have now developed topfive lists for Choosing Wisely, and about 10 more are expected to publish lists in the next fewmonths. This activity is gratifying, butwebelieve it is also time to consider next steps. An important next step is to develop ways to evaluate the effect of the top-five lists onhealth caredelivery andhealth care value. To collect data, it will be important to focus on highimpact activities that can be tracked using electronic databases. Although partnering with specialty societies has been successful, we also believe that another crucial next step is to include other health care providers in the Choosing Wisely campaign so that nurses and pharmacists, among others, are on the same page. The involvement of the American College of Emergency Physicians (ACEP) in theChoosingWiselycampaignbeganwith discussion and a passionate floor debate at the 2012 national ACEP Council meeting. Those in favor of joining the Choosing Wisely campaign believed that identifying 5 good costsaving ideaswouldbe easy and that itwouldbe anembarrassment if EM ended up conspicuously absent from the movement.Thoseagainstnotedthat theACEPalreadyhadconvenedaCost-effectivenessCareTaskForce toaddress thesame issue. This group also believed that other barriers to joining ChoosingWisely are unique to EM, including that emergency department patients are sicker on average thanpatients cared forby someother specialists, thatmalpractice ismoreof a concern, that EMphysiciansmust follow the EmergencyMedical Treatment and Active Labor Act that requires they treat and stabilize anyone with an emergency medical condition, and that reimbursement is alreadyunderattackby third-partypayers who regularly down-code and discount emergency patient care. Furthermore,manyof theexistingChoosingWisely campaign recommendations fromother specialties seemed to be aimedat theEMscopeof practice. Theoutcomeof a closely divided council floor vote that followed was that the ACEP Council recommended against joining the Choosing Wisely campaign. At that time, Dr Schuur and colleagues at Partners Healthcare decided to independently develop a top-five list for EM. After further reflection, the board of directors of ACEP reversed their initial stance and decided to join the Choosing Wisely campaign. They asked Dr Schuur to help lead this effort. They built on his work described in this issue as well as the work of the Cost-effectiveness Care Task Force to create the ACEP’s top-five list. The Task Force had already developed a survey of all ACEP members for “cost-saving measures,” and more than 200 individual suggestions were received. The results of this surveywere grouped intodomains, and an expert panel used amodified Delphi technique to prioritize the recommendations following methods similar to those used by Dr Schuur and colleagues at Partners Healthcare.Multiple roundsofvoting followedto identifyhighly rated strategies that offered cost reductions and benefit to patients and were highly actionable by practicing EM physicians. The development process had a high level of specialty awareness (a floor debate at thenationalmeeting and specialty-wide survey data) and transparency. The final step included a literature review to establish a solid evidence base that specifically sought to include available cost data. Scientific support was assembled by a subcommittee of the Cost-effectiveness Care Task Force for each of the EM proposals for the Choosing Wisely campaign. The strategies that received majority support of the expert subgroup were then forwarded to the ACEP board of directors, who selected the top 5 for submission to the American Board of Internal Medicine Foundation (http://www.choosingwisely Related article page 509 Opinion