Downloaded from http://qualitysafety.bmj.com/ on November 11, 2015 - Published by group.bmj.com BMJ Quality & Safety Online First, published on 31 December 2014 as 10.1136/bmjqs-2014-003821 NARRATIVE REVIEW ‘Choosing Wisely’: a growing international campaign

Wendy Levinson,1 Marjon Kallewaard,2 R Sacha Bhatia,1 Daniel Wolfson,3 Sam Shortt,4 Eve A Kerr,5 On behalf of the Choosing Wisely International Working Group

▸ Additional material is ABSTRACT even clinically indicated, the fundamental published online only. To view Much attention has been paid to the quality improvement target becomes please visit the journal online (http://dx.doi.org/10.1136/bmjqs- inappropriate underuse of tests and treatments unnecessary care itself. 2014-003821). but until recently little attention has focused on Eliminating unnecessary medical care and the overuse that does not add value for patients optimising value has received increasing 1Department of Medicine, University of Toronto, Toronto, and may even cause harm. Choosing Wisely is a attention from health systems in the past Ontario, Canada campaign to engage physicians and patients in decade. Critical evidence shows that in 2 Dutch Association of Medical conversations about unnecessary tests, some countries, particularly the USA, an Specialists, Utrecht, treatments and procedures. The campaign began estimated 30% of all medical spending is The Netherlands 3ABIM Foundation, Philadelphia, in the United States in 2012, in Canada in 2014 unnecessary and does not add value in 56 USA and now many countries around the world are care. Some countries have appointed task 4 Canadian Medical Association, adapting the campaign and implementing it. forces to identify ways to eliminate waste in Ottawa, Canada 5 This article describes the present status of healthcare, seeking to deliver quality care at VA Center for Clinical Management Research, VA Ann Choosing Wisely programs in 12 countries. It lower cost, optimising the value derived Arbor Healthcare System, and articulates key elements, a set of five principles, from investments in healthcare. Department of Internal Medicine and describes the challenges countries face in Choosing Wisely, a campaign that and Institute for Healthcare Policy and Innovation, University the early phases of Choosing Wisely. These started in the USA, has garnered attention of Michigan, Ann Arbor, USA countries plan to continue collaboration worldwide as a potentially promising including developing metrics to measure overuse. approach to the vexing problem of Correspondence to unnecessary care by focusing on value of Dr Wendy Levinson, Professor of Medicine, University of Toronto, care and potential risks to patients rather 7 30 Bond Street, Toronto, During the last decade, considerable than using cost as the motivating factor. Ontario, Canada M5B 1X1; attention has focused on addressing the Choosing Wisely was launched in April [email protected] underuse of evidence-based processes of 2012 by the American Board of Internal Received 26 November 2014 care, improving patient safety and achiev- Medicine (ABIM) Foundation to encour- Revised 2 December 2014 ing more patient-centred care. Much less age physicians and patients to talk about Accepted 5 December 2014 attention, however, has focused on the medical tests and procedures that may be problems related to the overuse of unnecessary, and in some instances, can – medical tests and treatments—care that cause harm.8 11 One of the key elements can lead to harm and consumes resources of Choosing Wisely in the USA is that it without adding value for patients.12 is a physician-led campaign, with medical Clinicians know that most care can specialty societies creating lists of tests, unintentionally harm their patients— treatments and procedures in their discip- adverse drug reactions, cumulative radi- line for which there is strong scientific ation exposure from diagnostic imaging, evidence of overuse and significant complications or errors during procedures potential harm or cost. Based on the —are all unfortunate potential outcomes early success of Choosing Wisely, many of medical care. The patient safety move- countries sought to learn more about the ment has taken on the challenge of redu- creation and implementation of the cam- To cite: Levinson W, cing such adverse outcomes of care paign, and some have begun to develop Kallewaard M, Bhatia RS, through checklists, bundles, teamwork their own versions of Choosing Wisely. et al BMJ Qual Saf . Published Leaders from 12 countries met in June Online First: [please include training, improved communication, well- Day Month Year] designed informatics systems and a variety 2014 to learn from one another about doi:10.1136/bmjqs-2014- of other strategies.34But when the inter- each country’s campaigns and to consider 003821 ventions leading to patient injuries are not potential collaborative efforts.

Levinson W, et al. BMJ Qual Saf 2014;0:1–9. doi:10.1136/bmjqs-2014-003821 1 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence. Downloaded from http://qualitysafety.bmj.com/ on November 11, 2015 - Published by group.bmj.com Narrative Review

The goals of this article are to share the present only be achieved by a fundamental shift in the atti- experiences from these countries in planning or imple- tudes, knowledge and behaviours of physicians related menting Choosing Wisely and to articulate common to diagnosis and treatment. A change from ‘more is principles for reducing unnecessary care. better’ to ‘more is NOT always better’ in physician attitudes and behaviours seems critical. There was WHAT ARE DIFFERENT COUNTRIES DOING? agreement that the key mechanism for change lies in Leaders from Australia, Canada, Denmark, England, the communication between physicians and patients Germany, Italy, Japan, the Netherlands, New Zealand, during routine clinical encounters. Switzerland, Wales and the USA shared their early But physicians cannot do it alone. Fundamentally experiences with Choosing Wisely programmes. Ta b l e 1 patients, and the public, also hold the view that ‘more summarises the present status in these countries and is better’ in medical care and a Choosing Wisely cam- describes the specific goals, lead organisation, role of paign can only be effective with significant patient physicians and other healthcare providers, role of and public engagement. There was consensus that patients, funding source and additional special issue. educational efforts targeted to patients and public are Choosing Wisely has been most fully developed in required to engage them in a real dialogue about the the USA where over 60 medical societies have created use of unnecessary tests and treatments and ultimately lists of five common tests, treatments or procedures to change their attitudes. Emphasising the centrality where there is strong scientific evidence that they do of the physician–patient relationship to help patients not benefit patients or may even cause harm.12 13 make the right decisions for their situation is import- Typically list items are worded in this fashion—’Don’t ant to a campaign’s success. Terms like ‘right care’, order imaging tests for patients with low back pain, ‘avoiding harm’ and ‘wise choices’ seem to resonate unless red flags are present’ (see online supplementary with patients in multiple countries. Other terms like appendix A for a sample list). Modelled on the US ini- ‘value’, ‘waste’, ‘sustainability’ and ‘use of finite tiative, Choosing Wisely Canada was launched in resources’ were considered problematic in some coun- April 2014 and 21 societies have released lists to tries as they may appear to focus on the needs of the date.14 Italy adopted the principles of Choosing population rather than what might be best for the Wisely, incorporating them into a campaign called individual person. Most countries found that bringing ’Doing more does not mean doing better’, launched cost into the discussion diminishes both physician and by ‘Slow Medicine’ (an independent organisation patient engagement. However, the financing of health- linked to the Slow Food movement), and the care in different countries may influence how the mes- Netherlands recently launched the ‘Choosing Wisely saging is received; for example, in some countries, the Netherlands Campaign’. In both Italy and the concept of value or waste reduction may be acceptable Netherlands, the Choosing Wisely programme is part or desirable to the public. of a larger campaign directed at reducing low-value While ultimately each country does seek to manage care. Other countries have well-established organisa- their healthcare expenditures, we felt that both phys- tions that assess the quality of evidence and make ician and public support will more likely be garnered recommendations to physicians, like the National with an articulated goal of quality of care. In reality, Institute for Clinical Evidence in England. These simply saving money is not the goal of Choosing countries are considering how to incorporate Wisely—rather the goal is to provide high-quality care, Choosing Wisely into their existing quality improve- prevent harm and decrease the use of unnecessary care. ment efforts. In some cases, cost savings may result from those Choosing Wisely depends on changing physician choices and, in other cases, care may be more appropri- attitudes and practices and patients’/public knowledge ate, more timely or less inconvenient for patients. and attitudes. There was a broad agreement that the central goal of a Choosing Wisely campaign is to KEY ELEMENTS OF CHANGE change the culture of medical care that has historically In an effort to create clarity on the ways a Choosing supported overuse of unnecessary tests, treatments Wisely campaign could influence physician attitudes – and procedures.15 17 Despite the differences between and behaviours and patient/public attitudes, the parti- the countries, all recognised that common factors cipants created a model (table 2). In this model, the have contributed to the physician practice of ordering highest level goal is to reduce unnecessary care, avoid unnecessary services, including patient expectations, harm and decrease waste. The actual objectives are to fears of missing a possible diagnosis or malpractice influence the system at multiple levels: change phys- concerns, reimbursement incentives, the way physi- ician attitudes, increase patient acceptance that more cians are taught and avoiding the challenging conver- is not always better, change actual clinical practice and sation of telling patients they do not need specific align the broader healthcare system with these goals. tests or treatment.2 While the relative weight of these Each of these leverage points will require specific factors differs in each country, they are remarkably types of activities, leading to outputs and anticipated similar overall. Hence, we agreed that our goals could outcomes. Each suggests a type of measurement to

2 Levinson W, et al. BMJ Qual Saf 2014;0:1–9. doi:10.1136/bmjqs-2014-003821 eisnW, Levinson Table 1 Choosing Wisely programme summaries Role of physician/ tal et healthcare provider Country Name and goal Current status Organising group Role of patient Funder Special issues . M ulSaf Qual BMJ Australia Choosing Wisely Australia Planning and implementation NPS MedicineWise (http://www. Plan to have physicians Government grant to NPS Federated government structure Downloaded from facilitate dialogue between health stages: First wave of lists currently nps.org.au) and patients lead with MedicineWise to support means hospital funding is via the professionals and patients about in development in anticipation of NPS MedicineWise playing quality use of diagnostics states and primary care funding

2014; improving quality of care through 2015 launch Stakeholder facilitator role (akin to via the federal government reduction in unnecessary tests, engagement ongoing Advisory American Board of Internal Emphasis on evaluating impacts

0 treatments and procedures group to inform on longer term Medicine (ABIM) of the programme to measure :1–

.doi:10.1136/bmjqs-2014-003821 9. strategy for implementation and Foundation) effectiveness of the campaign

evaluation Strong emphasis on http://qualitysafety.bmj.com/ demonstrating evidence to support recommendations Canada Choosing Wisely Canada Launched nine national specialty Choosing Wisely Canada (based General practitioners (GPs)/ Mixed funding (Government Healthcare is delivered help physicians and patients societies in April 2014 at University of Toronto) is family physicians and of Ontario, Canadian provincially; choosing Wisely engage in conversations about Additional 25 plus societies in partnering with the Canadian specialty societies creating Medical Association, Canada is national unnecessary tests, treatments and progress with release of second Medical Association and disseminating lists University of Toronto) procedures, and to help wave recommendations in October Engaging large patient physicians and patients make 2014 groups (ie, Patients smart and effective choices to Canada) to endorse and ensure high-quality care disseminate onNovember11,2015-Publishedby Advertising to public Denmark N/A Not planned presently. N/A N/A N/A Danish Health and Medicines recent survey of specialties showed Authority, Danish Medical quite limited interest in Choosing Societies and five Danish regions Wisely process are continuously developing national guidelines and measuring on clinical indicators England Probably Choosing Wisely Planning stage with launch early The Academy of Medical Royal Medical Royal Colleges AoMRC The National Institute for Clinical 2015 Colleges (AoMRC) and Specialist Societies will Potentially NHS England Effectiveness has extensive history A Steering Group is to be develop lists with an of guideline products including established involving key expectation of patient 1000 recommendations on a ’do stakeholders to guide the involvement at all stages not do’ database programme National Voices, the AoMRC has published a report

This will comprise colleges, coordinating body for about waste in clinical care group.bmj.com clinicians, patient groups, BMJ, patient groups, will be a The intention would be for all lists commissioners, providers co-partner to collate together into a single

NHS England wish to database or document Review Narrative engage in the process but Despite large databases and would not lead it high-quality evidence recommendation, practice does not align Germany Facilitate dialogue about Planning stages AWMF Guideline developing At the beginning self-funding Building on existing efforts of value-based healthcare, inform Working group on Choosing Wisely (http://www.awmf.org) Scientific Medical Societies of the AWMF and its multidisciplinary guideline groups the public and facilitate transfer established based on the Initiative AWMF has a 20-year history of to take leadership key member societies on a small (including representatives of

3 Continued 4 Table 1 Continued Review Narrative Role of physician/ healthcare provider Country Name and goal Current status Organising group Role of patient Funder Special issues of priority recommendations of of the German Network for coordinating and supporting the Plan to engage scale— later to be patients and other health

high-quality guidelines into Evidence Based Medicine guideline activities of its 168 multidisciplinary guideline determined, additional professions) to give shape to a Downloaded from practice Annual guideline conference of the member societies and runs a development groups funding will need to be German Choosing Wisely initiative Association of the Scientific quality managed guideline including representatives of sought for Topic-related approach, based on Medical Societies (AWMF) to register healthcare providers as existing evidence-based, discuss potential benefits, risks AWMF-Institute for Medical well as patient multidisciplinary guidelines and implementability of a Knowledge Management representatives Plan to address ’don’tdo’ as well campaign as a complementary tool (AWMF-IMWi) takes on as ’do’ recommendations based to transfer guidelines into practice responsibility for these tasks on on a systematic process of http://qualitysafety.bmj.com/ in November 2014 the operational level criteria-driven priority setting The development of a manual /generic method report is in progress Italy ‘Doing more does not mean Campaign launched December Board of Italy’s Slow Medicine, Medical and nurse Italy’s Slow Medicine, an Part of the broader goal of Italy’s doing better’ launched by Italy’s 2012 with the collaboration of: societies creating and independent organisation, is Slow Medicine has three Slow Medicine 25 specialty physician and nurse National Federation of Medical disseminating lists funded partly by medical components including measured Primary goal is culture change societies engaged Doctors and Dentists; National Altroconsumo and other societies (doing more does not mean doing —‘doing more does not mean 10 Italian lists done Federation of Nurses’ Colleges; patients and public Seeking funding better), respectful (patient values) doing better’ Now in implementation stage Society for Quality in Healthcare; organisations developing and equitable care (appropriate onNovember11,2015-Publishedby Improve quality and Altroconsumo and other patients patient materials and and good quality of care for all) appropriateness of care and and public organisations disseminating lists and Early implementation with Italian ensure patient safety through culture Society of General Practitioners in eisnW, Levinson reduction of tests and treatments; Piedmont region decrease harm; promote partnership tal et Japan Choosing Wisely—Japan Planning stages Establishment of a subcommittee Medical specialty plus Volunteering Conflict of interest of university

. Top have Japanese medical Using recommendations from in Japan Primary Care Association primary care group leading clinical researchers with M ulSaf Qual BMJ professionals and public be Choosing Wisely and BMJ ‘Too ( JPCA) Patient engagement in pharmaceutical industry has aware of current overuse of Much Medicine Series’ Collaboration of JPCA and planning stages recently been publicised by media expensive diagnostic and Dissemination through publication Japanese Chapter of American therapeutic measures and to and conferences College of Physicians, and 2014; encourage change A booklet in Japanese language eventually with Japanese Society

entitled, ‘Choosing Wisely in Japan of Internal Medicine group.bmj.com 0 :1 —Less is More’ which includes 26 – .doi:10.1136/bmjqs-2014-003821 9. ‘Lists of Five’ from US specialty societies has been published The contributors of the publication have proposed their list of five applicable to Japanese setting Creating working groups in primary care and specialty care societies Netherlands Choosing Wisely—The Launched October 2012 Dutch Association of Medical Physician led Funds dedicated to quality Organisation covers four pillars of Netherlands 14 medical societies actively Specialists and Netherlands for medical specialist care in campaign include Wise Choices; Continued eisnW, Levinson

Table 1 Continued tal et Role of physician/

. healthcare provider M ulSaf Qual BMJ Country Name and goal Current status Organising group Role of patient Funder Special issues Downloaded from Improve quality of care by involved (29 endorsed) Organization for Health Research the Netherlands measuring clinical practice geographical measuring of Creating Dutch lists based on and Development Netherlands Organization for variation; knowledge gaps by

2014; unnecessary treatments; Choosing Wisely Dutch Patient and Consumer Health Research and effectiveness research; shared eliminating unproven treatments; 6 scientific societies created lists of Organization is partner Development (a decision making 0

:1– searching for knowledge gaps in wise choices, most of them did non-governmental Drawback: Although Medical

.doi:10.1136/bmjqs-2014-003821 9. effectiveness; creating value by already base that on evidence organisation) Specialist Societies did successfully

helping physicians and patients maps of practice variation create this campaign, covered by http://qualitysafety.bmj.com/ make wise(r) choices insurance companies and patient organisations GPs are not involved yet New To deliver better value for money Planning stages National Health Committee (NHC) Physicians input solicited Government Zealand in health services Adopting Choosing Wisely to Government by NHC engage physicians in two Health Technology Assessment Work open for public conditions (chronic obstructive organisation. comment pulmonary disease and ischaemic Makes recommendations to heart disease) Minister of Health

Clinical working groups on these onNovember11,2015-Publishedby topics Switzerland Smarter Medicine Launched May 2014 Swiss Society of Internal Medicine Medical society led. Swiss Society of Internal Swiss Society of Internal Medicine To reduce care that brings no or Top 5 list for ambulatory care Contact with consumer Patients not engaged yet Medicine funded two research projects on little benefit, causes side effects, general internal medicine complete organisation for partnership overuse or increasing cost USA Choosing Wisely Launched in 2012 ABIM Foundation and Consumer Physician led ABIM Foundation Implementation is distributed To foster conversation between 60 medical societies created lists Reports Patient/public education Consumer Reports across many types of physicians and patients about Major distribution to patients and Robert Wood Johnson organisations (network to learn unnecessary care public through patient material Foundation from one another) Campaign focuses on physician Implementation in a variety of Some societies have not chosen professionalism and leadership healthcare settings robust recommendations Regarded as highly successful but not measuring use (20% of all US

physicians know about Choosing group.bmj.com Wisely) Wales Prudent Healthcare Planning phase based on Bevan Bevan Commission is Being developed Government Early stages To ensure patients receive the Commission ‘Prudent Healthcare independent Have to align with existing Review Narrative best care from available resources Report’ (2013) and Provisional Prudent Healthcare has organisations and Principles 2014 Ministerial support recommendations (National Early stakeholder engagement re: Institute of Health and Care Choosing Wisely. Excellence (NICE) Workshop on four topics to test recommendations, etc) principles 5 Downloaded from http://qualitysafety.bmj.com/ on November 11, 2015 - Published by group.bmj.com Narrative Review

Table 2 Key elements of a choosing Wisely campaign High-level Concrete Anticipated Measurement goal objectives Associated activities Planned outputs outcomes approaches To reduce Change physician Raise physician awareness Medical journal article, Receptivity to learning Physician baseline attitude unnecessary attitudes to of the issue of unnecessary news stories, interviews how to approach survey care, harm and clinical practice care unnecessary care in waste daily practice Engage physicians in list Increased number of Members of specialties Physician survey and development and specialties sign on buy-into the initiative interviews of attitudes implementation Educate by inclusion in Educational materials for Informed trainees and Documented curriculum undergraduate and use in medical schools practitioners confident inclusion in medical school, postgraduate teaching and and for continuing in discussing residency programmes, and in continuing professional professional unnecessary care with continuing education development development patients Foster patient ‘More is not better’ public Public service messages, Public awareness of the Patient survey of awareness engagement and messaging posters, social media issue of unnecessary and acceptability of acceptance campaign care messaging Develop partnerships with Features in partner Patient and public gain Patient surveys and patient and public newsletters and on web confidence in the interviews of attitudes organisations sites campaign Change key Promote increased shared Increased frequency of Incorporation of shared Patient surveys of care clinical practices decision making discussions about decision making in experiences necessity practice Follow Choosing Wisely lists Better fit between need Reduced unnecessary Measurement of rates of in practice and care care necessary and unnecessary care for select services Promote Recruit partners among Incorporation into Enhanced adherence to Audit of clinical alignment with clinics, hospitals, regions standard orders and Choosing Wisely performance in a healthcare the healthcare and others clinical support systems guidance setting or region system Advocate for fit with Adjusted fee codes Reduced incentives for services Measurement of payment system overuse rates of necessary and unnecessary care for select assess the impact. For example, a required first step in conclusion that the only important metric of change is changing physicians’ attitudes and practice is to make the reduction in ordering unnecessary tests and physicians aware that decreasing the use of unneces- treatments. sary tests and treatments is critically important—in other words, that there is a ‘burning platform for PRINCIPLES OF THE CAMPAIGN change’. In order to create that sense of urgency, Based in part on this model, the authors articulated a medical journal articles, news stories, presentations at set of five principles (physician led, patient focused, medical meetings, and so on, are needed to reach phy- evidence based, multiprofessional, transparent) that sicians and get their attention. Information from should be incorporated into a Choosing Wisely cam- respected physician sources will lead to them becom- paign in any country (table 3). It was our view that ing more receptive or curious about how to change each of these was essential to a successful programme, their daily practice. To assess the starting point, phys- though the method to achieve it could be individua- ician attitudes can be measured with questions to lised to the circumstances of each country. assess physicians’ level of agreement with questions like ’Do you think the frequency of unnecessary tests, IMPLEMENTATION OF CHOOSING WISELY treatments and procedures in the healthcare system is In order to implement these principles, the partici- a problem?’ and ’Does the primary responsibility for pants offered suggestions for ‘best practices’ based on decreasing the use of unnecessary tests and treatments the early experience in some countries. First, it is crit- rest with physicians?’ ical to get the message about the campaign right—a The model includes efforts to align the other stake- compelling need to improve quality, prevent harm and holders in the healthcare system, like hospital or engage physicians and patients in conversations about regional health units, with the campaign. The reason the right care. In the USA, the words ‘Choosing for engaging stakeholders is the recognition that these Wisely’ were selected with careful consideration and partners are essential for implementation of the cam- seem effective in North America, but Switzerland is paign. This model illustrates that a multipronged using the words ‘Smarter Medicine’ and Italy calls approach to implementation and measurement is their campaign ‘Doing more does not mean doing required to capture change in a variety of dimensions. better’”... Second, recommendations made by phys- We think this is particularly important because stake- ician groups should be focused on tests, treatments holders of Choosing Wisely may leap to the erroneous and procedures that are frequent, feasible to change

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Table 3 Principles of a choosing Wisely campaign Principle Description Physician led ▸ As opposed to payor/government/health system led ▸ Important for trust of physicians and patients Patient focused ▸ Communication between the clinician and patient is key ▸ Process of shared decision making to tailor best care and prevent harm for individual patient Evidence based ▸ Up-to-date evidence demonstrates lack of benefit or net harm ▸ Important for physician and patient trust Multiprofessional ▸ Nurses, pharmacists also key to campaign Transparent ▸ Processes used to create list is public ▸ Conflicts of interest declared and in the domain of that specialty. In the USA and initiatives are in early stages, the results of these experi- Canada, the Choosing Wisely campaign encouraged ments are not yet published. each specialty group to choose items in their own control rather than suggesting that other physicians, like primary care, should change. All specialties and CHALLENGES primary care physicians are needed to make the cam- There are also some specific approaches that were paign successful. Third, implementation support is seen as a threat that could undermine Choosing needed to put the recommendations into practice at Wisely efforts. While it is possible that reducing the the point of care; one health system has embedded ordering of some unnecessary tests and treatments over 180 recommendations into the electronic phys- may reduce healthcare costs, portraying the pro- ician order entry system (Weingarten S, personal com- gramme as cost cutting can undermine both physician munication, 2014). Also, physicians and other health engagement and patient/public trust. Consistent with professionals need education and tools to help them that message, Choosing Wisely should not be a gov- have conversations about these services with patients. ernment or payor-run programme that could be seen Specific communication skills are needed to discuss as a ‘rationing’ exercise. Furthermore, the Choosing ‘harm’ and ‘what tests are not needed’. Instructional Wisely recommendations should not be used to deter- videotapes of exemplary conversations are available mine payment for individual services. While this on the US Choosing Wisely website (http://www. approach may seem appealing to payors, it would be choosingwisely.org/resource). Fourth, it is important difficult to implement as the items on the list are not to engage multiple stakeholders in the healthcare ‘never’ events but require clinical information usually system. Healthcare providers can implement some of not available to payors (like whether ‘red flags’ are these recommendations, but hospitals, large specialty present in low back pain). Additionally, such a ‘delist- clinics and others must align with the Choosing ing’ approach would undermine physician support. Wisely programme. Supportive health systems can One of the challenges in the early efforts in the enable the implementation in multiple ways (elec- USA and Canada has been whether physician special- tronic decision support, feedback to providers on ties are willing to put items on their lists that are spe- their ordering practices, academic detailing, recogni- cifically under their control. Some specialties tend to tion, etc). Conversely, health systems can undermine include items that tell primary care physicians what the programme if financial pressures encourage not to do rather than addressing overuse by their own overuse by health professionals. Fifth, all countries specialty colleagues. Furthermore, some have criticised agreed that inculcating the principles of Choosing the early lists for failing to include procedures that Wisely into medical education (undergraduate, post- generate revenue for the specialists.19 Leaders in the graduate and continuing medical education) was key. specialty need to encourage their colleagues to focus Training the next generation of health professionals on their own discipline and do the right thing by will ultimately change physician attitudes and beha- listing items that do not add value for patients. viours by shaping the views of physicians’ right from Measuring the impact of Choosing Wisely efforts is the beginning of their training. Evidence supports the complex and will require a variety of approaches enduring nature of formative education on the use of (table 2). Clearly one assessment is whether physicians tests and treatments.18 and health professionals are aware of Choosing We recognise that creating the lists is only a first step. Wisely and, more importantly, whether they are using Translating these simple ‘Don’t lists’ into action is a much the recommendations in their routine communication bigger challenge. Multiple experiments are springing up with patients. Since the campaign is still early in in the USA, particularly though a grant that funded local development with only 2 years of experience in the implementation (http://www.choosingwisely.org/grantees/) USA, measurement efforts are nascent. One recent and in Canada through an early adopters collaborative survey of physicians in the USA demonstrated that (http://www.choosingwiselycanada.org/). Since these >20% of them had heard of the CW campaign.20

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Beyond attitudes, measures of change in ordering Collaborators Additional members include Felicity Barclay; Dr practices are being undertaken by a variety of healthcare Jako Burgers; Dr Cule Cucic; Dr Marcel Daniels; Ian Forde; Dr Suzanne Geerlings; Dr Manfred Gogol; Dr Margje Haverkamp; systems in the USA and Canada. However, we acknow- Alastair Henderson; Helen Howson; Tai Huynh; Dr Job Kievit; ledge that there are multiple challenges in measuring Dr David Klemperer; Dr Shunzo Koizumi; Dr Robyn Lindner; progress on overuse of unnecessary care. First, it is more Dr Daniel Maughan; Karen McDonald; Dr Wilco Peul; Heleen Post; Dr Nicolas Rodondi; Dr John Santa; Rico Schoeler; Dr difficult in general to identify when a service was pro- Henk Smid; Professor Terence Stephenson; Dr Hans Trier; Teus vided inappropriately because the definition of appro- van Barneveld; Josine van der Kraan; Dr Sandra Vernero; priateness often includes knowing about symptoms and Professor Cordula Wagner. physical exam findings often not included in electronic Contributors All authors participated in the conception and design of the article. WL led the drafting of the article, but all health records and administrative databases. Therefore, authors participated in critical revisions and granted final identification of clinically meaningful measures has been approval of the submitted version. difficult and the measures that are routinely used are Competing interests None. often those that can be conveniently derived from Provenance and peer review Not commissioned; internally peer administrative sources rather than those that are the reviewed. most important. Additionally, when we measure overuse, we tend to focus on specificity—choosing to err on the side of underestimating overuse. For both REFERENCES these reasons, we often do not have a good sense of the magnitude of overuse in clinical practice. Recognising 1 Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA 2008;299:2789–91. the necessary complexity of evaluation efforts, an inter- 2 Institute of Medicine. Crossing the quality chasm: a new health national collaborative working group on evaluation was system for the 21st century. 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15 Korenstein D, Falk R, Howell EA, et al. Overuse of health care 19 Morden NE, Colla CH, Sequist TD, et al. Choosing wisely— services in the United States: an understudied problem. the politics and economics of labeling low-value services. Arch Intern Med 2012;172:171–8. N Engl J Med 2014;370:589–92. 16 Berwick DM, Hackbarth AD. Eliminating waste in US health 20 PerryUndem Research/Communication. Unnecessary Tests and care. JAMA 2012;307:1513–16. Procedures In the Health Care System. What Physicians Say 17 Keyhani S, Falk R, Howell EA, et al. Overuse and systems of About The Problem, the Causes, and the Solutions: Results care: a systematic review. Med Care 2013;51:503–8. from a National Survey of Physicians. 2014. http://www. 18 Sirovich BE, Lipner RS, Johnston M, et al. The association choosingwisely.org/wp-content/uploads/2014/04/042814_ between residency training and internists’ ability to practice Final-Choosing-Wisely-Survey-Report.pdf (accessed 5 Sep conservatively. JAMA Intern Med 2014;174:1640–8. 2014).

Levinson W, et al. BMJ Qual Saf 2014;0:1–9. doi:10.1136/bmjqs-2014-003821 9 Downloaded from http://qualitysafety.bmj.com/ on November 11, 2015 - Published by group.bmj.com

'Choosing Wisely': a growing international campaign

Wendy Levinson, Marjon Kallewaard, R Sacha Bhatia, Daniel Wolfson, Sam Shortt and Eve A Kerr

BMJ Qual Saf published online December 31, 2014

Updated information and services can be found at: http://qualitysafety.bmj.com/content/early/2014/12/31/bmjqs-2014-00 3821

These include: Supplementary Supplementary material can be found at: Material http://qualitysafety.bmj.com/content/suppl/2014/12/31/bmjqs-2014-00 3821.DC1.html References This article cites 15 articles, 2 of which you can access for free at: http://qualitysafety.bmj.com/content/early/2014/12/31/bmjqs-2014-00 3821#BIBL Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article.

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