How Choosing Wisely Decides a Test Is Low Value

Choosing Wisely does not use a single scoring formula to declare a test low value. Instead, each participating medical specialty society writes its own list of tests and treatments that clinicians and patients should question, applying three rules the ABIM Foundation set at the start: the item must fall within that specialty's own control, it must be used frequently or carry meaningful cost, and there must be evidence to support flagging it. Because the campaign delegates judgment to the societies, the evidence behind any given recommendation ranges from strong trial data to expert consensus, which is why each item is worth appraising rather than accepting on the strength of the brand.

Where the lists came from

The ABIM Foundation launched Choosing Wisely in April 2012 with nine national specialty societies representing roughly 375,000 clinicians, who together offered 45 initial examples of care that was common but poorly supported. The format borrowed from an earlier project by the National Physicians Alliance, funded through an ABIM Foundation grant, which asked physicians in internal medicine, family medicine, and pediatrics to name a short list of practices they could change to use resources more effectively. That "Five Things" structure, a compact list of specific, checkable recommendations, became the template every later society followed.

The campaign grew quickly. According to the ABIM Foundation, more than 80 specialty societies eventually contributed over 700 recommendations. The Commonwealth Fund has described Choosing Wisely as an international movement toward more appropriate care, reporting that by 2019 more than 20 countries had engaged with the idea and adapted the same list-building approach to their own systems. That reach is part of why the lists carry weight, and also why the underlying method deserves a close look.

The three criteria, and what they do and do not guarantee

The ABIM Foundation gave societies three parameters for selecting items. First, each recommendation had to sit within the specialty's own purview and control, so that the physicians writing it were the ones who order the test or perform the procedure. Second, the practice had to be used frequently or carry significant cost, which concentrates attention on care that matters at scale rather than rare edge cases. Third, there had to be evidence to support questioning the practice.

That third criterion is the one that varies most in practice. "Evidence to support the recommendation" can mean a body of randomized trials showing no benefit, or it can mean strong physiologic reasoning and professional consensus that a test rarely changes management. Both are legitimate reasons to question a practice, but they are not the same strength of claim. A recommendation against routine imaging for uncomplicated low back pain in the first weeks of symptoms rests on a large evidence base, including trial and guideline data showing early imaging does not improve outcomes and can trigger downstream harm. A recommendation against a rarely useful lab panel may rest mainly on the judgment of the society's committee. Neither is wrong, but a reader who treats every line on a list as equally proven is overreading the method.

Another structural feature shapes what the lists can say. Because each item must be within a specialty's own control, the campaign is built around self-regulation. That design has a real advantage, since the people who best understand when a test helps are the ones flagging when it does not. It also has a limit worth naming. Societies are more comfortable questioning practices at the edges of their work than the high-volume, high-revenue procedures at the center of it, and independent analyses have noted that lists tend to favor targets that are safe to name. This is a reason to read the lists as a floor for reducing overuse, not a complete map of it.

Does publishing a list actually change care?

The most important finding for anyone relying on these lists is that writing one is not the same as changing behavior. A systematic review by Cliff and colleagues in the Milbank Quarterly, published in 2021, examined 131 studies of Choosing Wisely interventions from 2012 through mid-2019. When the intervention was simply disseminating the recommendations, telling clinicians the list exists, about 13 percent of efforts produced the intended reduction in low-value care. Active interventions worked far more often, around 65 percent. Multicomponent programs, which paired the recommendation with tools like clinician education, decision support, or feedback, succeeded about 77 percent of the time, compared with roughly 47 percent for single-component efforts.

Two cautions about that review belong alongside its headline. Only about 17 percent of the studies included a control group, so much of the evidence comes from before-and-after designs that cannot fully separate the intervention from background trends. And the studies that get published may skew toward the ones that worked. The direction of the finding is nonetheless consistent and useful: the list identifies a target, but the machinery around it, not the list itself, is what moves practice.

How to appraise a recommendation yourself

For a clinician or an informed patient, the practical move is to treat a Choosing Wisely item as a well-sourced question rather than a verdict. Look at which society wrote it, since the recommendation reflects that specialty's vantage point. Trace the citations the society published with the item, because the campaign asks societies to document their evidence, and check whether they point to trials, to guidelines, or to consensus. Notice whether the recommendation is absolute or conditional, since most are framed as "avoid routinely" rather than "never," and the conditions carry the clinical meaning. A test that is low value for an average, low-risk patient can be exactly right for a higher-risk one.

Read this way, Choosing Wisely is a durable and honest contribution to reducing overuse, and its method, transparent criteria applied by the specialists closest to the care, is a reasonable way to build such lists. It is a starting point for a conversation grounded in evidence, and the quality of that conversation still depends on reading each recommendation for what it actually claims. This article is educational and is not medical advice.