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