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Choosing Wisely: When More is Not Better

In the U.K., the Academy of Medical Royal Colleges, in collaboration with BMJ (formerly the British Medical Journal) and other healthcare organizations, recently launched the Choosing Wisely® campaign with a goal of facilitating a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures to improve health care quality. A paper published in BMJ on May 12, 2015 marks the start of the initiative.1

In 2012, the American Board of Internal Medicine Foundation (ABIM) launched Choosing Wisely program asking medical organizations to identify “top five” tests or procedures commonly used in their specialty with questionable risk/benefit profiles which should be evaluated and discussed with patients before using them.2 So far, more than 60 U.S. specialist societies have joined in the initiative and it has been adopted in Australia, Germany, Italy, Japan, Netherlands, and Switzerland – a clear indication that unnecessary medical interventions are a concern for many health systems.3

In the U.S. as much as 20% of money spent in healthcare brings no benefit to patients.4 In the U.K., a new report issued by the Academy of Medical Royal Colleges has identified nearly £2bn in cost savings the National Health Service (NHS) could realize if it provided more appropriate care in just 16 areas of clinical practice.5

Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations to help patients choose care that is:6

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

Over-diagnosis refers to various clinical situations where diagnoses lead to unnecessary treatment, which wastes resources and compromises patient safety. It occurs when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.”7 Over-diagnosis leads to medical interventions which are either excessive in terms of duration, complexity, or cost or have minimal evidence of benefit.8,9 A recent report by the Academy of Medical Royal Colleges emphasized that doctors have an ethical responsibility not to waste clinical resources because, in a healthcare system with finite resources, such waste could lead to another patient’s lack of treatment or delay.5

Moreover, medical and surgical overtreatment can place patients at higher risk for adverse events.10 Patients may be swayed by potentially exaggerated marketing claims when new drugs or procedures are introduced. Shared patient-physician decision making can help reduce this overtreatment11 and may be particularly beneficial to disadvantaged groups, significantly improving health outcomes and reducing health inequalities.12 It can also alleviate fears for those patients who may not want treatment.13 A recent study revealed that when patients were informed regarding lack of prognostic benefit for angioplasty, only 46% decided to go ahead with the procedure vs. 69% who were not explicitly given this information.14

The NHS has a system of payment by results – Quality and Outcomes Framework (QOF) – which in reality is often a payment by activity which encourages clinicians to do more both in primary and secondary care. The system has no incentive to restrict doctors’ activity who feel pressured to adhere to local commissioning decisions at the expense of open dialogue with patients. It is important to note that a recent comprehensive longitudinal study concluded that the QOF initiatives have not reduced premature death in the population.15

Reducing wasteful healthcare will require commitment from both doctors and patients. One of the major concerns about the development of “top-five” lists is the potential for individual societies to choose low hanging fruit. For example, the American Academy of Orthopedic Surgeons included the use of an over-the-counter supplement but no major procedures, despite evidence of wide variation in elective knee replacement and arthroscopy rates among Medicare beneficiaries.16

Currently, there is also no evidence that developing lists reduces use of low-value medical practices.17 Moreover, shared decision making does not guarantee lower resource use.18 One crucial and relevant marker of success would be universal awareness of the Choosing Wisely program among doctors and patients.

Call to action and next steps

To develop a Choosing Wisely culture in clinical practice, the academy suggests:

  • Doctors should provide patients with resources that increase their understanding about potential harms of interventions
  • Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler or safer options? What happens if I do nothing?”
  • Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication
  • Commissioners should consider different payment incentives for doctors and hospitals

Do you believe the Choosing Wisely initiative can help reduce healthcare waste?