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 Toronto 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 https://mc.manuscriptcentral.com/bmj Page 1 of 8 BMJ 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, University of Toronto. Toronto, Ontario. 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 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 8 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 https://mc.manuscriptcentral.com/bmj Page 3 of 8 BMJ 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 Switzerland 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 Australia 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, India 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.