BMJ

Confidential: For Review Only Advancing Choosing Wisely Campaigns: There is More To Do

Journal: BMJ

Manuscript ID BMJ-2019-051921

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the 30-Jul-2019 Author:

Complete List of Authors: Born, Karen; University of Faculty of Medicine, Institute of Health Policy, Management & Evaluation Levinson, Wendy; St Michaels Hospital, Inner City Health Research Unit

overdiagnosis, overuse, Choosing Wisely, implementation science, de- Keywords: implementation

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1 2 3 1 4 5 2 6 3 Title: 7 8 4 Advancing Choosing Wisely Campaigns: There is More To Do 9 5 10 11 6 12 7 Confidential: For Review Only 13 8 Karen Born 1 14 1,2 15 9 Wendy Levinson 16 10 17 11 18 12 1 Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, 19 13 Faculty of Medicine, . Toronto, . Canada. 20 2 21 14 Department of Medicine, University of Toronto. Toronto, Ontario. Canada. 22 15 23 16 Correspondence to: 24 17 Karen Born, PhD 25 18 Institute of Health Policy, Management and Evaluation 26 27 19 University of Toronto 28 20 Health Sciences Building 29 21 155 College Street, Suite 425 30 22 Toronto, ON M5T 3M6 31 32 23 Email: [email protected] 33 24 Phone: 416 254 7505 34 25 35 26 Word count: 2272 36 27 References: 22 37 38 28 39 29 40 30 Standfirst 41 31 Choosing Wisely campaigns worldwide have galvanized physician leadership on overuse by 42 32 issuing recommendations and raising public awareness. However, Karen Born and Wendy 43 44 33 Levinson argue the campaigns alone cannot change practice, rather health system reforms, 45 34 broad public engagement, innovative de-implementation approaches, and robust evaluation 46 35 are needed to reduce overuse in practice. 47 36 48 37 KEY MESSAGES 49 50 38 51 39 ● Choosing Wisely is a global movement to reduce overuse in health care. 52 40 ● Although campaigns have a simple and powerful goal to raise physician and public 53 41 awareness about overuse through lists of recommendations of ‘things physicians and 54 42 patients should question’, there are complex barriers to putting recommendations into 55 43 practice. 56 44 ● There are innovative efforts aligned with Choosing Wisely taking place at the health 57 45 system, physician, and patient level to implement Choosing Wisely. Research and 58 46 evaluation is needed to assess impact. 59 47 60

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1 2 3 48 Overdiagnosis and overuse are well-recognized quality problems in medicine. There is a 4 49 growing body of literature demonstrating the prevalence and threats of overuse to patients, 5 1 6 50 providers and health systems. The harms of overuse take many shapes – from the global 7 51 threat of antibiotic resistant bacteria driven by overprescribing to individual consequences of 8 52 side effects from unnecessary tests or treatments. Yet, solutions to this complex problem are 9 53 elusive.2 10 54 11 12 55 ChoosingConfidential: Wisely was initially launched Forin 2012 inReview the United States Only to galvanize physician 13 56 leadership by establishing specialty-specific recommendations on overused tests, treatments 14 57 and procedures. Choosing Wisely campaigns has spread to more than 20 countries globally 15 58 (Table 1). As campaigns mature, questions are arising about the value of list development and 16 17 59 dissemination efforts, and whether these efforts are sufficient to make progress in addressing 18 60 the complex problem of overuse. 19 61 20 62 In many countries the initial goal of Choosing Wisely has been to raise physician and public 21 63 awareness about overuse—and the rationale for trying to address it. While awareness is an 22 23 64 important step, influencing the habits and behaviours of physicians requires much more than 24 65 a voluntary effort of specialty societies. Overuse is a wicked, multifactorial problem situated at 25 66 the intersection of physician habits, behaviours and training, alongside public and patient 26 67 expectations and demands. 27 68 28 29 69 The presence of Choosing Wisely campaigns around the world offers a natural experiment to 30 70 bolster collective knowledge about strategies and approaches to addressing overuse. 31 71 32 72 Physicians have Taken Leadership on Reducing Overuse, but they cannot do it Alone 33 34 73 35 74 A key hallmark of Choosing Wisely has been physician specialty society leadership in 36 75 developing lists of recommendations to disseminate amongst their peers.3 Societies have 37 76 autonomy to develop the lists independently, resulting in significant heterogeneity in scope. 38 77 Some critics have criticized lists as lacking ambition, and omitting tests or procedures that are 39 4 40 78 significant income drivers. Choosing Wisely campaigns around the world have generated 41 79 thousands of recommendations, and there is the risk that lists of recommendations are added 42 80 to the dizzying volume of guidelines, new research and information bombarding todays’ 43 81 practicing physician. 44 82 45 46 83 Studies have demonstrated that practice changes do not result from publishing a research 47 84 article or releasing a list of recommendations.5 Rather, strategies sensitive to contextual 48 85 barriers and enablers are needed to change practice. Further, expectations of physicians need 49 86 to be attuned to todays’ practice environment and growing demands for electronic data entry 50 87 and documentation, which is increasingly seen as a major driver of steep rates of 51 6 7 52 88 dissatisfaction and physician burnout. Asking for physicians’ time and energy to implement 53 89 recommendations on their own volition in these challenging circumstances is wholly unrealistic. 54 90 Choosing Wisely campaigns have helped set the stage by generating increased awareness 55 91 about the campaign, but physicians alone cannot put recommendations into practice. 56 57 92 58 93 Indeed, physicians are not the only clinicians who contribute to overuse. While Choosing 59 94 Wisely campaigns began with physicians, most countries have partnered with non-physician 60 95 clinicians to develop lists of recommendations. Interventions to address overuse require

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1 2 3 96 participation of multiple health professionals to be effective. For example, a medical directive 4 97 to empower nurses to remove unnecessary urinary catheters on an inpatient medical unit 5 8 6 98 resulted in sustained decreased catheter days. 7 99 8 100 No Simple Solutions to Complex Problem of Overuse & Practice Change 9 101 10 102 Health system factors often embed overuse, and these are often beyond the locus of control 11 12 103 of physicians.Confidential: For example, it is common For to have Reviewdaily standing orders Only or bundled laboratory 13 104 panels that can drive overuse for hospitalized inpatients. Simply asking physicians to order 14 105 tests more parsimoniously will have limited impact if there are administrative barriers to 15 106 change.9 Indeed, implementation research demonstrates that multiple, interacting 16 17 107 components (which may include top down changes alongside grassroots efforts) targeting a 18 108 number of different groups and organizational levels are need to make change, with medical 19 109 practice culture playing a vital role.10 11 20 110 21 111 Globally, there is a groundswell of innovative and ambitious implementation efforts across 22 23 112 heterogeneous settings, levels and systems of care related to Choosing Wisely. To date, the 24 113 majority of literature describing robust interventions to reduce overuse have been in the 25 114 hospital setting. Studies from Canada and have demonstrated sustained success 26 115 in reducing overuse of laboratory testing through multiple, complementary interventions 27 116 including physician education, order set revisions and administrative changes.12 13 Both 28 29 117 studies highlighted the importance of timely and relevant audit and feedback data of individual 30 118 physician performance. Data is a powerful tool to motivate physicians and indeed health care 31 119 organizations and systems to change, but access to timely and meaningful measures of 32 120 individual, organizational and system performance remains a stubborn challenge.14 33 34 121 35 122 Implementing Choosing Wisely in the community setting can be particularly challenging since 36 123 primary care physicians tend to lack the technical and data support present in hospital settings. 37 124 Yet, creative approaches are underway in Canada and which distribute tools for 38 125 physicians to offer patients alternatives antibiotic prescriptions for viral illnesses using a ‘viral 39 40 126 prescription pad’. Rather than offering an actual prescription, this tool advises patients on fever 41 127 and symptom management strategies alongside information explaining the harms of 42 128 unnecessary antibiotics.15 More research is needed to measure impact of these tools, and 43 129 understanding what are enablers or barriers to their use in practice. 44 130 45 46 131 Nation-wide Choosing Wisely efforts are also emerging. For example, has launched a 47 132 Choosing Wisely effort to reduce overuse in oncology through the countries’ National Cancer 48 133 Grid. The National Cancer Grid treats 600,000 patients annually and will facilitate 49 134 dissemination, reporting and quality improvement based on a Choosing Wisely list of 50 135 recommendations developed by India’s four oncology specialist societies.16 This large-scale 51 52 136 mobilization of Choosing Wisely is unprecedented and will offer unique insights in terms of 53 137 scale and scope of de-implementation efforts. 54 138 55 139 How Can the Public Be Meaningfully Educated and Engaged on Overuse? 56 57 140 58 141 Central to addressing overuse is understanding and incorporating patient and public views of 59 142 this complex problem. A core principle of Choosing Wisely is encouraging conversations with 60 143 patients about whether a test or treatment is necessary. Campaigns in many countries attempt

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1 2 3 144 to deliver a key publicly-facing message that “more is not always better” in order to influence 4 145 public attitudes and knowledge with the goal that this have an effect on the physician-patient 5 6 146 encounter. 7 147 8 148 There is a perception amongst physicians that patients’ demands for unnecessary tests or 9 149 treatments drive overuse.17 These perceptions are valid and reinforced through a broad lack 10 150 of health literacy amongst the public and widespread health misinformation. Choosing Wisely 11 12 151 has situatedConfidential: itself as an evidence-informed For conversation Review between Onlyphysicians and patients. 13 152 Yet, there are threats to this discourse when physicians believe that patients are not receptive 14 153 to evidence.18 In a complex clinical environment with pressures of time and efficiency, 15 154 conversations about overuse with patients are perceived by physicians as time consuming, 16 17 155 challenging and confrontational. 18 156 19 157 Effective communication strategies are needed to convey the nuanced message of Choosing 20 158 Wisely. Key concepts in overuse such as risk-benefit analysis, number needed to treat or 21 159 number needed to harm are challenging to understand. Campaigns use novel communication 22 23 160 strategies to simply convey these concepts in efforts to influence public attitudes and 24 161 awareness of overuse. This has included film festivals in Australia, media outreach and 25 162 editorials in Canada and the United States, and poster campaigns in Switzerland, Norway, 26 163 and Canada. The impact of these efforts on public knowledge is limited, however what 27 164 is known is that patients and the public want more resources and tools to support decision 28 29 165 making. A Canadian survey of the public found that over 90% of respondents believe they 30 166 ‘need more support and/or tools to make decisions about .’19 31 167 32 168 A number of campaigns around the world have developed a generic set of questions for 33 34 169 patients or caregivers to ask physicians about overuse. This tool, intended to foster shared 35 170 decision making, has demonstrated some limited impact, but has not been evaluated to be 36 171 generalizable across multiple settings.20 Comparing and contrasting the experience of these 37 172 questions across countries has not been studied, but would generate valuable cross-national 38 173 insights on tools to advance shared decision-making. (Box 1) 39 40 174 41 175 More Research, Science Needed on De-Implementation and Choosing Wisely 42 176 43 177 The spread of Choosing Wisely campaigns globally across diverse health system and country 44 178 contexts offers a unique natural experiment. As campaigns continue to advance, it is clear that 45 21 46 179 issuing recommendations is not sufficient to change overuse and that there is much to learn. 47 180 The stubborn challenges of implementing evidence into practice are well known, with a wealth 48 181 of strategies to hasten the knowledge to action gap.22 Yet, most of these strategies have been 49 182 designed for implementation, rather than de-implementation.23 What is different about efforts 50 183 engaging a diverse set of actors to de-implement rather than implement? While there is a 51 52 184 dearth of large-scale studies on the impact of Choosing Wisely to patient outcomes, there is 53 185 a growing body of single or multi-site interventions of robust de-implementation efforts with 54 186 evidence of impact. These key lessons and clinical implications of promising studies and 55 187 strategies implementing Choosing Wisely into practice will be the focus of a series of ‘Change’ 56 57 188 articles in the Education section of BMJ. 58 189 59 190 Choosing Wisely campaigns to date have had broad physician engagement in generating 60 191 recommendations and grassroots awareness strategies. The next challenge facing campaigns

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1 2 3 192 is to demonstrate how this awareness and engagement has impacted meaningful clinical 4 193 outcomes, as well as patients and public behaviours and expectations. Bridging the gap 5 6 194 between awareness and action is a challenge due to the complex drivers of overuse. Yet, this 7 195 has the potential to advance de-implementation science. Studying campaign efforts across 8 196 multiple countries can explore the common elements of successful interventions and 9 197 components that need to be modified to specific country contexts. 10 198 11 12 199 This seriesConfidential: will share evidence-based resources For usedReview by physicians, Only patients and health care 13 200 system leaders to put the campaign into practice. Further, each article will describe barriers 14 201 and challenges to de-implementation specific to Choosing Wisely recommendations from 15 202 around the world. Each article in the series will be co-authored by patients, physicians and 16 17 203 researchers with expertise in the practice area, highlighting the nuances of advancing 18 204 Choosing Wisely in practice from the perspectives on both sides of the clinical encounter. 19 205 20 206 21 207 22 23 Table 1. Launched Choosing Wisely Campaigns Around the World 24 Country Campaign name Year Lead Organization 25 name launched 26 Australia Choosing Wisely Australia 2014 NPS Medicine Wise 27 Gemeinsam gut entscheiden 2017 Gemeinsam gut entscheiden - 28 Deciding Well Together 29 Brazil Choosing Wisely Brasil 2017 Proqualis, National Quality Health 30 Agency 31 32 Canada Choosing Wisely Canada 2014 Canadian Medical Association/ 33 University of Toronto 34 Vælg Klogt 2019 Danish Medical Association/ 35 Danish Patients Association 36 Choosing Wisely UK 2016 Academy of Medical Royal 37 Colleges 38 Choisir avec soin 2017 Fédération Hospitalière de France 39 (FHF) 40 Gemeinsam klug entscheiden 2015 Arbeitsgemeinschaft der 41 ("Choose Wisely Together"). Wissenschaftlichen Medizinischen 42 Fachgesellschaften (AWMF) 43 Association of the Scientific 44 Medical Societies in Germany 45 India Choosing Wisely India 2019 4 National Oncology Societies, 46 47 National Cancer Grid ( Medical Association (IMA 2017 מנהיגים איכות Israel 48 49 Slow Medicine Italy 2014 The National Federation of Medical 50 Doctors’ and Dentists’ Colleges 51 (FNOMCeO) 52 および 2016 Japan Primary Care Association 53 Choosing Wisely Netherlands 2015 Dutch Federation of Medical 54 Specialists 55 New Choosing Wisely 2016 Council of Medical Colleges 56 57 Zealand 58 Norway Choosing Wisely Norway 2018 Norwegian Medical Association 59 60

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1 2 3 Portugal Escolhas Criteriosas em Saúde 2018 Centre for Evidence Based 4 Medicine Portugal/Cochrane 5 Portugal 6 South Choosing Wisely Korea 2017 Institute for Evidence Based 7 8 Korea Medicine, Korea University 9 Switzerland Smarter Medicine: Choosing 2014 Swiss Society of General Internal 10 Wisely Switzerland Medicine 11 USA Choosing Wisely 2012 American Board of Internal 12 Confidential: For ReviewMedicine Only Foundation 13 Gwneud Dewisiadau Gyda 'N 2016 Academy of Medical Royal 14 Gilydd/ Making Choices Together Colleges - Wales 15 Choosing Wisely Wales 16 Partnership 17 208 18 209 19 20 Box 1: Choosing Wisely Questions 21 22 Choosing Wisely campaigns have adapted a set of questions for patients to ask their doctor 23 24 about unnecessary tests and treatments, based on an initial set of question from the United 25 States. 26 27 USA 28 5 Questions to Ask Your Doctor Before You Get a Test, Treatment and Procedure 29 30 1.Do I really need this test or procedure? 31 2.What are the risks? 32 3.Are there simpler, safer options? 33 4.What happens if I don’t do anything? 34 5.How much does it cost? 35 36 37 38 210 39 211 40 212 Acknowledgements 41 213 The authors would like to thank Todd Sikorski and Amy Ma, who serve as the Choosing 42 214 Wisely Canada Patient and Public Advisors, for their comments and suggestions on this 43 215 manuscript. 44 216 45 217 Patient involvement 46 218 Todd Sikorski and Amy Ma, who serve as the Choosing Wisely Canada Patient and Public 47 219 Advisors provided input into a drafted version of this article. Specifically, both suggested 48 220 adding further data to describe the harms of overuse and contextualize aspects of the article 49 221 content. 50 222 51 52 223 Conflicts of Interest 53 224 We have read and understood BMJ policy on declaration of interests and have the following 54 225 interests to declare: None. 55 226 56 227 Licence 57 228 The Corresponding Author has the right to grant on behalf of all authors and does grant on 58 229 behalf of all authors, an exclusive licence (or non exclusive for government employees) on a 59 230 worldwide basis to the BMJ Publishing Group Ltd ("BMJ"), and its Licensees to permit this 60

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1 2 3 231 article (if accepted) to be published in The BMJ's editions and any other BMJ products and 4 232 to exploit all subsidiary rights, as set out in The BMJ's licence. 5 233 6 234 7 235 8 9 236 10 237 11 238 12 Confidential: For Review Only 13 239 14 15 1 Moynihan Ray, Doust Jenny, Henry David. Preventing overdiagnosis: how to stop harming the 16 healthy BMJ 2012; 344 :e3502 17 2 Morgan Daniel J, Brownlee Shannon, Leppin Aaron L, Kressin Nancy, Dhruva Sanket S, Levin Les 18 et al. Setting a research agenda for medical overuse BMJ 2015; 351 :h4534 3 19 Levinson W, Born K, Wolfson D. Choosing Wisely Campaigns: A Work in Progress. JAMA. 20 2018;319(19):1975–1976. doi:10.1001/jama.2018.2202 4 21 Lenzer Jeanne. Choosing Wisely: setbacks and progress BMJ 2015; 351 :h6760 5 22 Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. Published 2008 Sep 29. 23 doi:10.1136/bmj.a1655 24 6 Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in 25 Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. [Epub ahead of print 26 6 September 2016]165:753–760. doi: 10.7326/M16-0961 27 7 Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US 28 Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377–1385. 29 doi:10.1001/archinternmed.2012.3199 30 8 Leis JA, Corpus C, Rahmani A, et al. Medical Directive for Urinary Catheter Removal by Nurses on 31 General Medical Wards. JAMA Intern Med. 2016;176(1):113–115. 32 doi:10.1001/jamainternmed.2015.6319 33 9 34 Wertheim BM, Aguirre AJ, Bhattacharyya RP, et al. An Educational and Administrative Intervention 35 to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service. Am J Med. 2017;130(1):47–53. doi:10.1016/j.amjmed.2016.08.021 36 10 Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new 37 Medical Research Council guidance. BMJ. 2008;337:a1655. Published 2008 Sep 29. 38 doi:10.1136/bmj.a1655 39 11 Mafi JN, Parchman M Low-value care: an intractable global problem with no quick fix BMJ Quality & 40 Safety 2018;27:333-336. 41 12 Strauss R, Cressman A, Cheung M, et al Major reductions in unnecessary aspartate 42 aminotransferase and blood urea nitrogen tests with a quality improvement initiative BMJ Quality & 43 Safety Published Online First: 09 May 2019. doi: 10.1136/bmjqs-2018-008991 44 13 Erard, Y, Del Giorno, R, Zasa, A, et al. A multi‐level strategy for a long lasting reduction in 45 unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network. Int 46 J Clin Pract. 2019; 73:e13286. https://doi.org/10.1111/ijcp.13286 47 14 Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen 48 M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare 49 outcomes. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD000259. DOI: 50 10.1002/14651858.CD000259.pub3 51 15 NPS MedicineWise : Respiratory Tract Infections Manage Your Symptoms. Retrieved from 52 https://cdn0.scrvt.com/08ab3606b0b7a8ea53fd0b40b1c44f86/fc2723c4a3fcdec8/31e4936adc6c/NPS- 53 MedicineWise-RTI-Action-Plan--1-.pdf on June 21, 2019. 54 16 Pramesh, CS, Chaturyedi, H, Reddy, A et al. Choosing Wisely India: ten low-value or harmful 55 practices that should be avoided in cancer care. Lancet Oncology. 2019: 20 (4): e218-e223 17 56 Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, Kerr EA. Perceived 57 Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of 58 Primary Care Providers. J Gen Intern Med. 2017;32(2):210–217. doi:10.1007/s11606-016-3853-5 18 59 Poland GA, Tilburt JC, Marcuse EK. Preserving Civility in Vaccine Policy Discourse: A Way 60 Forward. JAMA. Published online June 21, 2019. doi:10.1001/jama.2019.7445

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