During the last decade, considerable attention has focused on addressing the underuse of evidence-based processes of care, improving patient safety and achieving more patient-centred care. Much less attention, however, has focused on the problems related to the overuse of medical tests and treatments—care that can lead to harm and consumes resources without adding value for patients.1 ,2

Clinicians know that most care can unintentionally harm their patients—adverse drug reactions, cumulative radiation exposure from diagnostic imaging, complications or errors during procedures—are all unfortunate potential outcomes of medical care. The patient safety movement has taken on the challenge of reducing such adverse outcomes of care through checklists, bundles, teamwork training, improved communication, well-designed informatics systems and a variety of other strategies.3 ,4 But when the interventions leading to patient injuries are not even clinically indicated, the fundamental quality improvement target becomes unnecessary care itself.

Eliminating unnecessary medical care and optimising value has received increasing attention from health systems in the past decade. Critical evidence shows that in some countries, particularly the USA, an estimated 30% of all medical spending is unnecessary and does not add value in care.5 ,6 Some countries have appointed task forces to identify ways to eliminate waste in healthcare, seeking to deliver quality care at lower cost, optimising the value derived from investments in healthcare.

Choosing Wisely, a campaign that started in the USA, has garnered attention worldwide as a potentially promising approach to the vexing problem of unnecessary care by focusing on value of care and potential risks to patients rather than using cost as the motivating factor.7 Choosing Wisely was launched in April 2012 by the American Board of Internal Medicine (ABIM) Foundation to encourage physicians and patients to talk about medical tests and procedures that may be unnecessary, and in some instances, can cause harm.8–11 One of the key elements of Choosing Wisely in the USA is that it is a physician-led campaign, with medical specialty societies creating lists of tests, treatments and procedures in their discipline for which there is strong scientific evidence of overuse and significant potential harm or cost. Based on the early success of Choosing Wisely, many countries sought to learn more about the creation and implementation of the campaign, and some have begun to develop their own versions of Choosing Wisely. Leaders from 12 countries met in June 2014 to learn from one another about each country's campaigns and to consider potential collaborative efforts.

The goals of this article are to share the present experiences from these countries in planning or implementing Choosing Wisely and to articulate common principles for reducing unnecessary care.

What are different countries doing?

Leaders from Australia, Canada, Denmark, England, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, Wales and the USA shared their early experiences with Choosing Wisely programmes. Table 1 summarises the present status in these countries and describes the specific goals, lead organisation, role of physicians and other healthcare providers, role of patients, funding source and additional special issue.

Choosing Wisely has been most fully developed in the USA where over 60 medical societies have created lists of five common tests, treatments or procedures where there is strong scientific evidence that they do not benefit patients or may even cause harm.12 ,13 Typically list items are worded in this fashion—'Don't order imaging tests for patients with low back pain, unless red flags are present' (see online supplementary appendix A for a sample list). Modelled on the US initiative, Choosing Wisely Canada was launched in April 2014 and 21 societies have released lists to date.14 Italy adopted the principles of Choosing Wisely, incorporating them into a campaign called 'Doing more does not mean doing better', launched by ‘Slow Medicine’ (an independent organisation linked to the Slow Food movement), and the Netherlands recently launched the ‘Choosing Wisely Netherlands Campaign’. In both Italy and the Netherlands, the Choosing Wisely programme is part of a larger campaign directed at reducing low-value care. Other countries have well-established organisations that assess the quality of evidence and make recommendations to physicians, like the National Institute for Clinical Evidence in England. These countries are considering how to incorporate Choosing Wisely into their existing quality improvement efforts.

Choosing Wisely depends on changing physician attitudes and practices and patients'/public knowledge and attitudes. There was a broad agreement that the central goal of a Choosing Wisely campaign is to change the culture of medical care that has historically supported overuse of unnecessary tests, treatments and procedures.15–17 Despite the differences between the countries, all recognised that common factors have contributed to the physician practice of ordering unnecessary services, including patient expectations, fears of missing a possible diagnosis or malpractice concerns, reimbursement incentives, the way physicians are taught and avoiding the challenging conversation of telling patients they do not need specific tests or treatment.2 While the relative weight of these factors differs in each country, they are remarkably similar overall. Hence, we agreed that our goals could only be achieved by a fundamental shift in the attitudes, knowledge and behaviours of physicians related to diagnosis and treatment. A change from ‘more is better’ to ‘more is NOT always better’ in physician attitudes and behaviours seems critical. There was agreement that the key mechanism for change lies in the communication between physicians and patients during routine clinical encounters.

But physicians cannot do it alone. Fundamentally patients, and the public, also hold the view that ‘more is better’ in medical care and a Choosing Wisely campaign can only be effective with significant patient and public engagement. There was consensus that educational efforts targeted to patients and public are required to engage them in a real dialogue about the use of unnecessary tests and treatments and ultimately to change their attitudes. Emphasising the centrality of the physician–patient relationship to help patients make the right decisions for their situation is important to a campaign's success. Terms like ‘right care’, ‘avoiding harm’ and ‘wise choices’ seem to resonate with patients in multiple countries. Other terms like ‘value’, ‘waste’, ‘sustainability’ and ‘use of finite resources’ were considered problematic in some countries as they may appear to focus on the needs of the population rather than what might be best for the individual person. Most countries found that bringing cost into the discussion diminishes both physician and patient engagement. However, the financing of healthcare in different countries may influence how the messaging is received; for example, in some countries, the concept of value or waste reduction may be acceptable or desirable to the public.

While ultimately each country does seek to manage their healthcare expenditures, we felt that both physician and public support will more likely be garnered with an articulated goal of quality of care. In reality, simply saving money is not the goal of Choosing Wisely—rather the goal is to provide high-quality care, prevent harm and decrease the use of unnecessary care. In some cases, cost savings may result from those choices and, in other cases, care may be more appropriate, more timely or less inconvenient for patients.

Key elements of change

In an effort to create clarity on the ways a Choosing Wisely campaign could influence physician attitudes and behaviours and patient/public attitudes, the participants created a model (table 2). In this model, the highest level goal is to reduce unnecessary care, avoid harm and decrease waste. The actual objectives are to influence the system at multiple levels: change physician attitudes, increase patient acceptance that more is not always better, change actual clinical practice and align the broader healthcare system with these goals. Each of these leverage points will require specific types of activities, leading to outputs and anticipated outcomes. Each suggests a type of measurement to assess the impact. For example, a required first step in changing physicians’ attitudes and practice is to make physicians aware that decreasing the use of unnecessary tests and treatments is critically important—in other words, that there is a ‘burning platform for change’. In order to create that sense of urgency, medical journal articles, news stories, presentations at medical meetings, and so on, are needed to reach physicians and get their attention. Information from respected physician sources will lead to them becoming more receptive or curious about how to change their daily practice. To assess the starting point, physician attitudes can be measured with questions to assess physicians’ level of agreement with questions like 'Do you think the frequency of unnecessary tests, treatments and procedures in the healthcare system is a problem?' and 'Does the primary responsibility for decreasing the use of unnecessary tests and treatments rest with physicians?'

The model includes efforts to align the other stakeholders in the healthcare system, like hospital or regional health units, with the campaign. The reason for engaging stakeholders is the recognition that these partners are essential for implementation of the campaign. This model illustrates that a multipronged approach to implementation and measurement is required to capture change in a variety of dimensions. We think this is particularly important because stakeholders of Choosing Wisely may leap to the erroneous conclusion that the only important metric of change is the reduction in ordering unnecessary tests and treatments.

Principles of the campaign

Based in part on this model, the authors articulated a set of five principles (physician led, patient focused, evidence based, multiprofessional, transparent) that should be incorporated into a Choosing Wisely campaign in any country (table 3). It was our view that each of these was essential to a successful programme, though the method to achieve it could be individualised to the circumstances of each country.

Implementation of Choosing Wisely

In order to implement these principles, the participants offered suggestions for ‘best practices’ based on the early experience in some countries. First, it is critical to get the message about the campaign right—a compelling need to improve quality, prevent harm and engage physicians and patients in conversations about the right care. In the USA, the words ‘Choosing Wisely’ were selected with careful consideration and seem effective in North America, but Switzerland is using the words ‘Smarter Medicine’ and Italy calls their campaign ‘Doing more does not mean doing better’”... Second, recommendations made by physician groups should be focused on tests, treatments and procedures that are frequent, feasible to change and in the domain of that specialty. In the USA and Canada, the Choosing Wisely campaign encouraged each specialty group to choose items in their own control rather than suggesting that other physicians, like primary care, should change. All specialties and primary care physicians are needed to make the campaign successful. Third, implementation support is needed to put the recommendations into practice at the point of care; one health system has embedded over 180 recommendations into the electronic physician order entry system (Weingarten S, personal communication, 2014). Also, physicians and other health professionals need education and tools to help them have conversations about these services with patients. Specific communication skills are needed to discuss ‘harm’ and ‘what tests are not needed’. Instructional videotapes of exemplary conversations are available on the US Choosing Wisely website (http://www.choosingwisely.org/resource). Fourth, it is important to engage multiple stakeholders in the healthcare system. Healthcare providers can implement some of these recommendations, but hospitals, large specialty clinics and others must align with the Choosing Wisely programme. Supportive health systems can enable the implementation in multiple ways (electronic decision support, feedback to providers on their ordering practices, academic detailing, recognition, etc). Conversely, health systems can undermine the programme if financial pressures encourage overuse by health professionals. Fifth, all countries agreed that inculcating the principles of Choosing Wisely into medical education (undergraduate, postgraduate and continuing medical education) was key. Training the next generation of health professionals will ultimately change physician attitudes and behaviours by shaping the views of physicians’ right from the beginning of their training. Evidence supports the enduring nature of formative education on the use of tests and treatments.18

We recognise that creating the lists is only a first step. Translating these simple ‘Don't lists' into action is a much bigger challenge. Multiple experiments are springing up in the USA, particularly though a grant that funded local implementation (http://www.choosingwisely.org/grantees/) and in Canada through an early adopters collaborative (http://www.choosingwiselycanada.org/). Since these initiatives are in early stages, the results of these experiments are not yet published.

Challenges

There are also some specific approaches that were seen as a threat that could undermine Choosing Wisely efforts. While it is possible that reducing the ordering of some unnecessary tests and treatments may reduce healthcare costs, portraying the programme as cost cutting can undermine both physician engagement and patient/public trust. Consistent with that message, Choosing Wisely should not be a government or payor-run programme that could be seen as a ‘rationing’ exercise. Furthermore, the Choosing Wisely recommendations should not be used to determine payment for individual services. While this approach may seem appealing to payors, it would be difficult to implement as the items on the list are not ‘never’ events but require clinical information usually not available to payors (like whether ‘red flags’ are present in low back pain). Additionally, such a ‘delisting’ approach would undermine physician support.

One of the challenges in the early efforts in the USA and Canada has been whether physician specialties are willing to put items on their lists that are specifically under their control. Some specialties tend to include items that tell primary care physicians what not to do rather than addressing overuse by their own specialty colleagues. Furthermore, some have criticised the early lists for failing to include procedures that generate revenue for the specialists.19 Leaders in the specialty need to encourage their colleagues to focus on their own discipline and do the right thing by listing items that do not add value for patients.

Measuring the impact of Choosing Wisely efforts is complex and will require a variety of approaches (table 2). Clearly one assessment is whether physicians and health professionals are aware of Choosing Wisely and, more importantly, whether they are using the recommendations in their routine communication with patients. Since the campaign is still early in development with only 2 years of experience in the USA, measurement efforts are nascent. One recent survey of physicians in the USA demonstrated that >20% of them had heard of the CW campaign.20

Beyond attitudes, measures of change in ordering practices are being undertaken by a variety of healthcare systems in the USA and Canada. However, we acknowledge that there are multiple challenges in measuring progress on overuse of unnecessary care. First, it is more difficult in general to identify when a service was provided inappropriately because the definition of appropriateness often includes knowing about symptoms and physical exam findings often not included in electronic health records and administrative databases. Therefore, identification of clinically meaningful measures has been difficult and the measures that are routinely used are often those that can be conveniently derived from administrative sources rather than those that are the most important. Additionally, when we measure overuse, we tend to focus on specificity—choosing to err on the side of underestimating overuse. For both these reasons, we often do not have a good sense of the magnitude of overuse in clinical practice. Recognising the necessary complexity of evaluation efforts, an international collaborative working group on evaluation was created at this meeting. In addition, the Organisation for Economic Co-operation and Development, which provides measures of quality across multiple countries, is working with us to develop metrics that might be used to compare countries on specific measures of overuse and considering the development of potential cross-country metrics.

An additional major challenge is that of educating patients and the public. Launching a major public education campaign is a massive undertaking, yet educating patients must be part of this campaign. In North America, materials targeted to explaining common tests—“When you need them and when you don't’—have been produced in English, French and Spanish and can be modified for use in other countries (http://consumerhealthchoices.org/).

Next steps and conclusion

The elements and principles we have outlined can serve as a framework for other countries seeking to undertake similar efforts. Ultimately, this international collaboration will lead to studies of physician attitudes across countries and potential shared metrics of overuse. The challenges of both creating the campaign and, more importantly, implementing it are large but the campaign has gained support from physician groups in North America and now increasingly around the world. There are a burgeoning number of efforts to implement the campaign in clinical settings and to measure the impact. For an effort that only begun 2 years ago, this is encouraging uptake. A key goal of Choosing Wisely is to stimulate a conversation about overuse; it is clearly stimulating this conversation in many countries.