Importance Evidence comparing the consequences of Choosing Wisely recommendations across health systems or with the consequences of recommendations plus policy change is lacking. Objectives To compare changes in the use of 2 low-value laboratory tests after the release of Choosing Wisely recommendations across 3 health care jurisdictions and changes associated with a related policy change. Design, Setting, and Participants This cross-sectional study was a population-based interrupted time series of adult patients (aged 18-64 years) who had primary care visits between January 1, 2010, and June 30, 2015, or established hypothyroidism between January 1, 2012, and June 30, 2015, across 3 health care delivery jurisdictions: Ontario, Canada; the US Veterans Health Administration; and the US employer-sponsored insurance market. Data analysis was performed from March 21, 2018, to October 31, 2019. Exposures A December 2010 payment policy change that eliminated reimbursement of vitamin D screening in Ontario, Canada, and the subsequent release of Choosing Wisely recommendations against low-value use of vitamin D tests in February 2013 and triiodothyronine tests in October 2013 in the United States and both tests in October 2014 in Canada. Main Outcomes and Measures Relative marginal effects (RMEs) comparing low-value testing rates after the release of Choosing Wisely recommendations with rates expected based on prerelease trends and the associated change in low-value vitamin D testing after the 2010 payment policy change in Ontario, Canada. Results Of 54 223 448 total persons, 28 504 576 (52.6%) were female, with 17 895 458 persons (33.0%) aged 18 to 34 years, 11 101 985 (20.5%) aged 35 to 44 years, and 25 226 005 (46.5%) aged 45 to 64 years. The December 2010 policy eliminating reimbursement for low-value vitamin D screening in Ontario, Canada, was associated with a 92.7% (95% CI, 92.4%-93.0%) relative reduction in such screening. Corresponding Choosing Wisely recommendations were associated with smaller reductions: 4.5% (95% CI, 2.6%-6.3%) in Ontario, 13.8% (95% CI, 11.8%-15.9%) for US Veterans Health Administration, and 14.0% (95% CI, 12.8%-15.2%) for US employer-sponsored insurance. In contrast, low-value use of triiodothyronine testing did not change significantly in Ontario, Canada (RME, 0.3%; 95% CI, -1.4% to 2.0%) or the US Veterans Health Administration (RME, 0.7%; 95% CI, -4.7% to 6.4%) and increased (RME, 3.0%; 95% CI, 1.6%-4.4%) for US employer-sponsored insurance. Conclusions and Relevance In this study, marginal reductions in the use of 2 low-value laboratory tests were associated with the release of related Choosing Wisely recommendations but a greater reduction in low-value vitamin D screening was associated with a previous payment policy change implemented in Ontario, Canada. These findings suggest that recommendations alone may be insufficient to significantly reduce use of low-value services and that pairing recommendations with policy changes may be more effective.

中文翻译：

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美国和加拿大低价值实验室检测的付款变化比较和明智选择建议

缺乏重要证据来比较卫生系统中明智选择建议的后果或与建议加政策变化的后果进行比较。目标 比较 3 个医疗保健辖区发布“明智选择”建议后 2 种低价值实验室检测的使用变化以及与相关政策变化相关的变化。设计、背景和参与者 这项横断面研究是一项基于人群的中断时间序列的成年患者（年龄 18-64 岁），这些患者在 2010 年 1 月 1 日至 2015 年 6 月 30 日期间接受过初级保健，或在2012 年 1 月 1 日和 2015 年 6 月 30 日，跨越 3 个医疗保健提供管辖区：加拿大安大略省；美国退伍军人健康管理局；以及美国雇主赞助的保险市场。数据分析于2018年3月21日至2019年10月31日期间进行。 暴露 2010年12月的支付政策变更取消了加拿大安大略省维生素 D 筛查的报销，以及随后发布的针对低价值使用维生素的“明智选择”建议D 测试于 2013 年 2 月在美国进行，三碘甲状腺原氨酸测试于 2013 年 10 月在美国进行，两项测试均于 2014 年 10 月在加拿大进行。主要成果和措施 相对边际效应 (RME) 将“明智选择”建议发布后的低值检测率与基于预发布趋势的预期率以及 2010 年安大略省支付政策变化后低值维生素 D 检测的相关变化进行比较，加拿大。结果 54 223 448 人中，女性 28 504 576 人（52.6%），其中 17 895 458 人（33.0%）年龄在 18 至 34 岁，11 101 985 人（20.5%）年龄在 35 至 44 岁，25 226 005 人(46.5%) 年龄在 45 至 64 岁之间。2010 年 12 月加拿大安大略省取消低价值维生素 D 筛查报销的政策与此类筛查相对减少 92.7%（95% CI，92.4%-93.0%）相关。相应的“明智选择”建议与较小的减少相关：安大略省为 4.5%（95% CI，2.6%-6.3%），美国退伍军人健康管理局为 13.8%（95% CI，11.8%-15.9%），美国退伍军人健康管理局为 14.0%（95美国雇主赞助保险的% CI，12.8%-15.2%）。相比之下，加拿大安大略省（RME，0.3％；95％CI，-1.4％至2.0％）或美国退伍军人健康管理局（RME，0.7％；95％CI）三碘甲状腺原氨酸检测的低价值使用没有显着变化，-4.7% 至 6.4%），并且美国雇主赞助保险有所增加（RME，3.0%；95% CI，1.6%-4.4%）。结论和相关性 在本研究中，2 种低价值实验室检测的使用量的边际减少与相关“明智选择”建议的发布有关，但低价值维生素 D 筛查的大幅减少与之前实施的支付政策变化有关。加拿大安大略省。