CMAJ News Choosing Wisely around the world ore countries are joining an international campaign to M combat overuse in health care. The Choosing Wisely campaign began in 2012 in the United States to change the “more-is-better” culture of medicine by creating checklists of tests and treatments that doctors should ques- tion with their patients. For example, the campaign recommends against pre- scribing antibiotics for viral infections. The checklists sparked a conversa- tion about appropriate care that has since gone global, including the launch of Choosing Wisely Canada in 2014. The Netherlands, England, Japan, Aus- tralia, New Zealand, Germany, Italy, Switzerland, Wales and Denmark have launched similar campaigns. “It’s estimated that a third of all medi- serdar415/iStock cal care is waste, meaning it doesn’t have More medical organizations worldwide are encouraging physicians and patients to talk value and can be harmful,” says Dr. about unnecessary diagnostic tests and care. Wendy Levinson, chair of the Canadian campaign. “That’s highly relevant to Since 2013, the ABIM (American Now, “the gap for us is broader doctors; we don’t get up in the morning Board of Internal Medicine Foundation) patient education and engagement in the to save money for the health care system, has also awarded $2.5 million in grants creation of our materials,” says Levinson. but we do get up to deliver good quality for projects to raise public and physi- Consumer Reports, an American non- care and prevent harm to our patients.” cian awareness about Choosing Wisely. profit consumer organization, has shoul- This month, the foundation announced a dered this role south of the border, but no Early progress new round of grants for health system equivalent exists in Canada, she says. The US and Canada served as the test- initiatives to implement at least three ing grounds for Choosing Wisely, and campaign recommendations, including Starting in England have seen the most progress to date. reducing the use of antibiotics for viral The North American method — create In America, over 100 national, infections by at least 20% over the next lists, raise awareness and foster grass- regional and state medical organizations three years. roots implementation — has become have released more than 70 lists of tests Canada has seen similar success since the model for other countries’ cam- and procedures they say are overused. launching its campaign in April 2014, paigns. Health organizations across the country says Levinson. More than 40 medical The United Kingdom’s Academy of have used these recommendations. societies have joined and 29 have pub- Medical Royal Colleges is among the Notably, Cedars–Sinai Medical Cen- lished lists of tests and procedures to latest Choosing Wisely adopters. Pru- ter in Los Angeles slashed unnecessary question, including 49 new recommen- dent use of health resources isn’t a new health care costs by more than $4 mil- dations released June 2. concept in the UK. Since 1999, the lion in one year by programming over Some hospitals have developed National Institute for Health and Care 100 Choosing Wisely recommendations point-of-care tools specifically to imple- Excellence has recommended more into its electronic medical records ment Choosing Wisely recommenda- than 800 clinical interventions for (EMR) system. For example, the system tions. Others have focused on education divestment based on variations in clini- reminds physicians not to prescribe ben- campaigns. By implementing an EMR cal practice (an indicator of overuse). zodiazepines for insomnia in patients intervention like the one at Cedars– But there are still major challenges over 65, because these drugs increase Sinai, North York General Hospital in to changing practice at the bedside, says the risk of falls. As a result, prescribing Toronto has cut emergency department Dr. Angelika Zarkali, clinical lead on of benzodiazepines to older patients laboratory testing by 40%, without a the campaign for England’s National dropped 30%. change in outcomes. Health Service. “We don’t have as ©2015 8872147 Canada Inc. or its licensors CMAJ, August 11, 2015, 187(11) E341 News much an issue of physician commercial produced five recommendations mostly promoting shared decision-making interest as the States might, but we do aimed at curbing unnecessary testing, with patients, evaluating quality and have very easy access to treatment, and such as tumour-marker screening for efficiency of care and identifying varia- sometimes it’s easier for physicians to asymptomatic adults. tions in practice. order than to explain.” Internal surveys Now, “we are setting up a working Dr. Marjon Kallewaard, director of show that 80% of physicians agree with group inside the Japanese Society for quality for the association, says the the campaign, but many are worried Quality and Safety in Health Care,” says research arms of the campaign are partic- how patients will perceive the initiative, Tokuda. In addition to publishing patient ularly important. “About half of health says Zarkali. and physician recommendations, “we care isn’t evidence-based,” she estimates. The UK campaign launched in May would like to organize an Asian collabo- “Now half of the specialty societies have and is still assembling specialty-society ration for campaigns between Japan, programs in which they study the most partners. South Korea and other countries.” important things we don’t know, and where in daily practice we don’t have an Screening in Japan The Netherlands answer for the patient.” Japan is another recent adopter, and a Most international campaigns have been In addition to reducing unnecessary champion for Choosing Wisely in Asia. underway for only a few months, but the care, knowledge-gap studies also stand to Dr. Yasuharu Tokuda of the Japan Netherlands is one exception. The Dutch save health systems a lot of money, Community Health Care Organization Association of Medical Specialists Kallewaard predicts. “In gynecology, for started the campaign in 2014, largely started work in 2013 and began publish- every Euro invested in these studies, the in response to rampant direct-to-con- ing lists of procedures to avoid in 2014. output is three.” — Lauren Vogel, CMAJ sumer preventive screening. The first The campaign has four parallel initia- Choosing Wisely conference in Japan tives for recommending “wise choices,” CMAJ 2015. DOI:10.1503/cmaj.109-5111 E342 CMAJ, August 11, 2015, 187(11) .