Table 2

Integrative framework for measuring overuse (using low back pain as an example)

ExampleData sourceSpecific measure exampleAction itemsAdditional data needed for robust measurement
Change physician attitudes to clinical practice
 Assessment of provider awareness/attitudes of Choosing Wisely recommendation on low back pain imagingProvider surveyValidated physician survey on Choosing Wisely awareness and attitudesUnderstanding of provider awareness/understanding of Choosing Wisely recommendationData from a representative sample of physicians to avoid non-response bias
Tailor provider education on low back pain imaging
Provider attitudes data assist in intervention design and assess impactLinked responses from same physicians to track changes in attitudes over time
 Assessment of provider satisfaction with care provided for low back painProvider interviewsSemi-structured interviewsMonitor for unintended consequences (eg, clinician–patient trust, provider satisfaction)
Foster patient engagement and acceptance
 Determine patient perceptions regarding care for low back painPatient-reported experience measuresConsumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey (with expanded questions for low-value care)Provide patient input in developing interventions to reduce low-value careMeasures from patients in areas not exposed to Choosing Wisely to assess campaign impact and monitor for unintended consequences
Monitor for unintended consequences (eg, patient dissatisfaction, clinician–patient trust)
Assist providers in designing care plans for individual patients
 Assessment of patient-reported outcomes such as pain, function, work lossPatient-reported outcome measuresOswestry Low Back Pain Disability Questionnaire (OSW)Data to assist in developing decision aids/care pathways to reduce low-value careLinked experience and outcome measures to assess the relationship between patient care experience and outcomes
Monitor for unintended consequences
Change key clinical practices
 Determine practice-specific rates of imaging for uncomplicated low back painClinical dataRate of CT/MRI excluding red flags (ie, history of cancer)Feedback to providers on ordering behaviour—identification of outliersData from other practices to provide context of rate and similar practices not exposed to Choosing Wisely to assess impact of local interventions
Validation of administrative data on true degree of overuse
Data to administrators to implement local interventions to reduce low-value care
Assessment of impact on local Choosing Wisely effortsClinical data from all points of access to healthcare system (eg, walk-in clinics, ER visits)
 Determine practice-specific rates of high-value imaging for low back painClinical dataRate of indicated CT/MRI (red flags)Monitor for unintended consequences (eg, underuse of high-value services)
Promote alignment with the healthcare system
 Determine regional rates of imaging for uncomplicated low back pain imaging (CT/MRI scans)Administrative dataRate of CT/MRI utilisation per 1000 populationData to policy makers to inform policy development (i.e, payment reforms)Utilisation rates from areas not exposed to Choosing Wisely to assess campaign effects
Feedback to regions/institutions on regional variation
Assessment of impact of regional Choosing Wisely initiativesDetailed clinical information (eg, symptoms, risk factors, disease severity, physician intent to treat) for exclusions
International comparisons
 Determine regional rates of alternate imaging for uncomplicated low back pain imagingAdministrative dataRate of X-ray utilisation per 1000 populationMonitor for unintended consequences (eg, increased use of alternate procedures)