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Publication Briefs

Study Shows How Payment Changes and Choosing Wisely Recommendations Affect Low-Value Lab Testing

Numerous studies have shown that low-value services – commonly defined as tests, treatments, or procedures that provide minimal benefit to the patient compared to cost or risk of harm – are prevalent and costly. Since 2012, the Choosing Wisely Initiative has partnered with medical professional societies to develop and promote recommendations about low-value services that should be discontinued. Choosing Wisely has since expanded to more than 20 countries, including Canada. This study examined the use of low-value lab testing, specifically, vitamin D screening and triiodothyronine (T3) level testing across three healthcare jurisdictions: Ontario, Canada; the VA healthcare system; and the U.S. employer-sponsored insurance market. Choosing Wisely Campaigns in the U.S. and Canada endorse recommendations against both population-based vitamin D screening (not associated with improved outcomes) and T3 level testing for monitoring patients with established hypothyroidism (in favor of thyroid-stimulating hormone level tests alone). In addition, a 2010 payment policy change in Ontario eliminated reimbursement for population-based vitamin D screening. Participants in this study (n = 54,223,448) had a primary care visit in one of these jurisdictions between January 1, 2010 and June 30, 2015 – or diagnosed hypothyroidism between January 1, 2012 and June 30, 2015.


  • In the three jurisdictions examined, Choosing Wisely recommendations were associated with only limited reductions in the use of low-value vitamin D screenings and were not associated with reduced use of low-value T3 testing. Specifically—
    • The December 2010 policy that eliminated reimbursement for low-value vitamin D screening in Ontario was associated with a 93% relative reduction in such screening. Corresponding Choosing Wisely recommendations were associated with smaller reductions: 5% in Ontario, 14% in VA, and 14% for U.S. employee-sponsored insurance.
    • In contrast, low-value use of T3 testing did not change significantly in Ontario (-1% to 2%), or VA (-5% to 6%), and increased for U.S. employee-sponsored insurance (2% to 4%).


  • Recommendations alone may not be enough to reduce the use of low-value services at a national or regional level – pairing recommendations with policy changes may be more effective.


  • The administrative data used in this study lack the clinical information necessary to label with complete confidence individual instances of low-value care; authors did not examine whether rates of necessary testing decreased.

Dr. Kerr and Ms. Klamerus are part of HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI

PubMed Logo Henderson J, Bouck Z, Holleman R, Chu C, Klamerus M, Santiago R, Bhatia S, and Kerr E. Comparison of Payment Changes and Choosing Wisely Recommendations for Use of Low-value Laboratory Tests in the United States and Canada. JAMA Internal Medicine. February 10, 2020; Epub ahead of print.

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