A hot dog with too much mustard on it. A washing machine overflowing with soap suds. A suitcase with clothes spilling out of it. These images aren’t what you expect to see when you go to your doctor — but in primary care waiting rooms across Canada, posters with these images hang on the walls.
The posters, accompanied with the message “More Is Not Always Better,” are intended to prompt patients to talk to their physicians about what kind of care is right for them.
Behind the eye-catching posters is Choosing Wisely, an international movement that began in the United States and has since spread around the world. It was launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation to advance a national dialogue on how to avoid unnecessary medical tests, treatments, and procedures. Today, more than 20 countries have developed campaigns based on a simple but compelling premise: conversations between doctors and patients can help patients choose care that is based on evidence, truly necessary, not duplicative, and free from harm.
While Choosing Wisely began in the United States, the Commonwealth Fund recognized the value of bringing countries together in an international collaboration to reduce low-value care, share strategies and best practices, and build momentum through joint efforts.
“When we first invested in the idea of the Choosing Wisely international collaboration five years ago, there were six countries at the annual international meeting,” said Robin Osborn, vice president at the Fund for international health policy and practice innovations. “Seeing over 20 countries enthusiastically engaged underscores how high a priority reducing low-value care is across countries, and how much we can all learn from each other.”
Choosing Wisely has its roots in the Physician Charter, which lays out physicians’ professional responsibilities, including to be honest with patients, improve the quality of care, and promote just distribution of finite resources. (The charter was authored by the ABIM Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine in 2002.)
Starting in 2010, U.S. medical specialty societies began asking their members to identify five tests and treatments that were overused and did not provide meaningful benefit for patients. Then in 2012, the ABIM Foundation formally launched the Choosing Wisely campaign, focused on supporting conversations between patients and physicians.
Overuse of Medical Services
Overuse, or the provision of medical services that may harm patients more than benefit them, is a pervasive problem. Unnecessary services can harm patients both physically and psychologically, and waste resources, according to a 2017 paper in The Lancet. For example, overprescription of antibiotics has important consequences, such as increasing antimicrobial-resistant bacteria; inappropriate use of surgery — common in high-income countries — puts patients at risk of surgical complications. Overuse, duplication, and use of low-value care arise because of changing medical practices, conflicting evidence about what’s effective, lack of coordination among providers, patient demand, and reimbursement systems that encourage medical services based on volume, not value.
Over the past few decades, industrialized countries have sought to address this through academic research, for example, at Dartmouth Medical School, and through initiatives to tackle wasteful spending, for example at the Organisation for Economic Co-operation and Development (OECD). Medical professionals and government agencies, both in the U.S. and abroad, have recognized that overuse of medical care is harmful to patients and drives up medical costs. Choosing Wisely isn’t the first attempt to address this — and it certainly won’t be the last — but it has provided a unique framework that has gained traction in many countries.
Why Choosing Wisely Has Wide Appeal
“It is hard to imagine something that would be adapted in countries as different as Norway and India, or Japan and Canada,” said Wendy Levinson, M.D., professor of medicine at the University of Toronto and chair of Choosing Wisely Canada. “It’s because Choosing Wisely goes back to the core essence of being a clinician — having conversations with your patients — that is remarkably transferrable across countries,” she said.
The campaigns are led by clinicians — primarily physicians, but they are opening up to other clinicians — and are firmly rooted in professionalism. “It’s about quality. It’s about safety. It’s about doing no harm,” said Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation.
Many think the campaigns’ physician leadership has been vital to its acceptance in their countries. “Doctors feel at home with Choosing Wisely . . . they feel they are in charge, and can make a difference,” said Bente Kristin Johansen, who is a physician, works at the Norwegian Medical Association, and is spearheading Choosing Wisely Norway.
Part of what makes Choosing Wisely broadly appealing is its reliance on grassroots campaigns. Different medical societies craft recommendations for appropriate care that are relevant to their specialty, and distinct from the top-down directives that may come from hospital administrators or insurance companies. In Canada, for example, over 300 recommendations have been released since 2014, with nearly 70 clinician societies engaged.
In response to requests from hospitals that wanted to implement Choosing Wisely programs, the Australian campaign developed a set of principles for health care organizations to follow to be designated a Choosing Wisely Champion Health Service. One guideline is that the initiative must be clinician-led, patient-centered, and evidence-based. “But what they do is entirely up to them. It’s all about the local context, and deciding what the critical issues are for them,” said Robyn Lindner of NPS MedicineWise, who helped launch Choosing Wisely Australia.
There are, however, some common themes that resonate with clinicians in different countries, for example, “don’t do imaging for low-back pain within the first six weeks, unless red flags are present.”
Choosing Wisely campaigns are led by physicians, but one of their primary objectives is to engage patients in making decisions about their own medical care. Many countries have developed a short set of questions that patients are encouraged to ask their clinicians. In the United Kingdom, for example, these questions have been distilled into four short ones:
What are the benefits?
What are the risks?
What are the alternatives?
What if I do nothing?
This sort of patient engagement is challenging — even in Canada, home to one of the most mature campaigns. “Our main strategy has been to try to reach patients through family doctors’ offices, at the point of care,” said Levinson, explaining the rationale behind the hot dog and other posters. A 2016 survey revealed that only 11 percent of the public knew about Choosing Wisely Canada, which Levinson attributes to the “modest” success of patient engagement efforts.
Learning from earlier campaigns, Norway placed patient engagement at the center of its strategy from the beginning. “We emphasize that this is a bottom-up campaign. We have invited patients to have a conversation or ask their doctors about their diagnosis — we can’t start without the patient,” said Johansen.
Getting a New Campaign Off the Ground
Choosing Wisely Norway wanted to get patient feedback prior to its launch, so leaders held two focus groups to test campaign material. The focus groups enabled the campaign to hone its message to help members of the public understand overuse and test their receptiveness to the concept of avoiding unnecessary care. “The patient perspective is very important to us,” said Bente Kristin Johansen, who is spearheading Choosing Wisely Norway.
Another part of the campaign’s outreach strategy has been to visit hospitals across Norway to introduce them to Choosing Wisely and gauge their interest in participating in the campaign.
One challenge for the campaign was resistance from medical societies because Choosing Wisely Norway opened a discussion about what doctors had done wrong in the past — overdiagnosing and overtreating patients for years, Johansen explained. But once the initial resistance was overcome, 45 medical societies in Norway welcomed the campaign, and about half of these have developed, or are developing, recommendations.
World health leaders say that this combination of health professionals and patients lies at the heart of the campaign’s success. “[Choosing Wisely] can marry new waves of professionalization of medicine with the empowerment and positioning of the patient as the coproducer of health,” said Niek Klazinga, M.D., of the Health Care Quality and Outcomes program at the OECD.
How Choosing Wisely Fits with the Priorities of International Organizations
Choosing Wisely campaigns fit into a growing global movement to control national spending on health care while still providing high-value care to patients. The movement has received attention from the Organisation for Economic Co-operation and Development (OECD) because it engages both patients and physicians.
“Health care is delivered in the interaction between patients and physicians,” said Niek Klazinga, M.D., of the OECD. “The whole set up of Choosing Wisely is to engage both parties on the decision, and to take the optimal decision [about care] at an early stage,” he said.
The campaigns fit with the OECD’s interest in the economic drivers of health system performance, and ongoing attempts to tackle wasteful spending. While Choosing Wisely doesn’t focus on cost — which is a priority for the OECD — Klazinga doesn’t see this as a problem. “Choosing Wisely creates a neutral space to determine what is high value, what makes sense . . . then the resulting use of resources will also be value-based,” he said.
Choosing Wisely Is Not a Cost-Cutting Measure
If fewer resources are spent on unnecessary care, does this mean that Choosing Wisely campaigns are reducing medical costs? After all, three Choosing Wisely recommendations made it into a 2017 OECD report on tackling wasteful spending in health care: reducing the use of unnecessary prescription of antibiotics, benzodiazepines, and MRIs for low-back pain.
Choosing Wisely leaders say that while campaigns are aware of the rising cost of medical care in developed countries, and in particular the U.S., lowering spending is not the priority. “Cost has never been the primary focus; it’s been about appropriateness. It’s about providing the right care,” said Brian Wong, M.D., medical education lead of Choosing Wisely Canada. In fact, many campaigns are concerned that adding cost to a movement centered on improving communication between physicians and patients could be counterproductive.
Changing the Culture of Medical Education in Canada
STARS (Students and Trainees Advocating for Resource Stewardship) seeks to engage medical students at Canada’s 17 medical schools to advocate for increased awareness and more curricular content about health care overuse.
STARS launched when the medical schools sent two student representatives to attend a daylong event in November 2015 to learn about resource stewardship and Choosing Wisely Canada.
Students started a range of initiatives at their medical schools, including forming interest groups to advocate for changing the formal curriculum, organizing lunchtime presentations, and interprofessional conferences.
“In medical education, one of the ways for learners to demonstrate knowledge is that they’ve thought through all the possibilities,” said Brian Wong, M.D., of Choosing Wisely Canada. “One of the ways to do that very explicitly is to order all the tests.” The culture in medical education may inadvertently teach students to overprescribe tests and medication, and the goal of STARS is to change this by addressing both the formal and the “hidden” curriculum, explained Wong.
STARS has also resonated globally. Similar medical education initiatives have been launched in Japan, the Netherlands, New Zealand, Norway, and the United States.
“The challenge is to find an intervention without generating mistrust between patients and doctors,” said Luca Gabutti, M.D., a member of the steering committee of the campaign in Switzerland. Gabutti explained that while the Swiss public is concerned about medical costs, individual patients don’t want to feel as though cost is the determining factor in whether they receive a test or procedure.
Other campaign leaders agree. “This is not about saving money, it’s about improving quality of care. But we are transparent that this is about resource stewardship, and if we do this well and stop doing things that aren’t appropriate, that will free up resources that may be invested into things that are of high value,” said Lindner, from Australia.
There, some modest reductions in low-value care indicate that in the future, resources could be redirected to other services. Gold Coast University Hospital, one of largest clinical teaching and research facilities in Queensland, Australia, reduced unnecessary pathology tests over 15 months, from 96,000 public pathology tests a month to 93,500, despite a 10 percent increase in patient volume.
Challenges: Is Choosing Wisely Working?
Flexibility: The Double-Edged Sword
For the past five years, an international roundtable conference has offered country leads the opportunity to come together and learn from the diverse initiatives of their peers across the globe. Levinson, in Canada, regularly receives inquiries from other countries seeking to start Choosing Wisely campaigns — including developing ones, like Brazil and India.
Countries are free to adapt their campaigns to the constraints of their own health care infrastructure, but this makes it challenging to share lessons about implementation. This is where the campaign’s flexibility can become a double-edged sword: since Choosing Wisely initiatives tend to be highly localized, their success is limited to how effectively a particular hospital or doctor implements a recommendation.
Once an initiative is implemented, the next challenge is how to measure its impact, apart from other attempts to improve the quality of care.
Some initiatives have seen cost savings. One implemented at Chelsea and Westminster Hospital, a 430-bed teaching hospital in London, showed a reduction in postoperative pathology testing using a peer-to-peer benchmarking tool, reducing costs by GBP 1.19 (USD 1.56) per patient.
But given that cost containment is not a focus of the campaigns, it is more important to measure changes in physician and patient attitudes, and how these translate into behavior. These changes are difficult to measure, and to causally attribute to Choosing Wisely campaigns, but anecdotal evidence offers some indication that change is afoot.
An annual evaluation survey in Australia showed a 16 percent increase from 2015 to 2016 in the number of general practitioners and specialists who reported seeing Choosing Wisely recommendations. The survey also showed that those who reported awareness of Choosing Wisely Australia also reported taking action that aligned with the campaign’s recommendations.
Using a National Implementation Organization to Launch Choosing Wisely Efforts
Choosing Wisely Australia is facilitated by NPS MedicineWise, an independent nonprofit organization with a mission to promote high-quality use of medicines and tests, and help people make better health care decisions. “The advantage is that we are a national implementation organization. We have experience in looking at where there are evidence-practice gaps, identifying potential drivers behind why people are doing things that aren’t evidence-based, and providing tools that might assist in changing behavior,” said Robyn Lindner, client relations manager at NPS MedicineWise.
NPS MedicineWise has launched a national education program around appropriate imaging for knee and ankle injuries that promotes several Choosing Wisely Australia recommendations. “We highlighted some important decision tools that can help general practitioners better decide whether imaging is appropriate,” said Lindner. NPS MedicineWise is undertaking a full evaluation of this program, but an early survey shows that 40 percent of GPs surveyed said they have changed practice.
And as awareness about the campaigns spread, so too does public engagement. “The best kind of anecdotal evidence is racks of patient information designed by the campaign in doctors’ offices around the country . . . you kind of get a feeling that there are conversations being encouraged by physician practices,” said Wolfson.
However, empowering patients to participate in decisions about the use of medical tests and procedures remains a challenge.
Physicians have a limited amount of time to spend with each patient, and patients may defer to their judgment rather than seek to make their own informed decisions.
“There are still attitudinal barriers . . . an element of, ‘I can’t possibly question what my doctor has told me is best for me,’” said Ramai Santhirapala, an anesthesiologist at Guy’s and St Thomas’ NHS Foundation Trust, London and clinical lead of the U.K. campaign.
Moving from “Do Not Do” Lists to Shared Decision-Making
Shortly after Choosing Wisely U.K. launched, the campaign’s leaders realized that “do not do” lists may be publicly perceived as rationing of medical care and professionals may perceive it as restricting professional autonomy. “That’s not the philosophy Choosing Wisely is built on — it’s about improving conversations. And one way to do that in the U.K. is through shared decision-making,” said Ramai Santhirapala, an anesthesiologist and clinical lead of Choosing Wisely U.K.
Shared decision-making has been defined as physicians and patients working in partnership. Evidence shows that shared decision-making increases patient satisfaction and decreases unwarranted variation in care. If a patient feels they are part of the decision to follow a medical regimen, they are more likely to comply with it. “Shared decision-making doesn’t negate professional autonomy or clinical expertise, but also incorporates the fact that the patient is the only person who walks in their shoes.”
In addition to patient well-being, physicians involved in more appropriate care or shared decision-making tend to have greater job satisfaction.
Many campaigns have employed creative tactics to engage patients. In June 2018, the Swiss campaign put out a call for kids ages 11 to 18 to make 60-second videos on how the use of medical care had affected them and their families. Submissions included video cartoons as well as one video drawing attention to the overuse of sleeping pills, antibiotics, and other medication that featured all the siblings in one family.
“This is a nice way to enhance discussion in families, at the school level, and to promote some discussion with doctors,” said Gabutti.
Another challenge for the more developed campaigns is scaling initiatives. Once a local hospital or community is successful in implementing a Choosing Wisely intervention, how do you replicate it across a larger jurisdiction or even the entire country?
The Canadian campaign is launching a nationwide initiative to improve the appropriateness of the use of red blood cell transfusions. Levinson outlined some of the considerations in selecting this issue: “Is it seen frequently across the country? Is it feasible to scale up in a reasonable timeframe, and won’t cost too much money?”
In smaller countries with relatively homogenous populations, like Switzerland or the Netherlands, it is easier to identify a common national issue. In the Netherlands, for example, the increasing longevity of older adults has prompted a national discussion about the appropriate use of end-of-life care. But this hasn’t translated into a nationwide Choosing Wisely initiative.
In a country as diverse as the U.S., with wide variance in health care delivery from state to state or even hospital to hospital, finding an issue that has national resonance is challenging. Individual health systems have adopted Choosing Wisely initiatives, but there has not yet been a local, state, or federal initiative.
Adaptation for Patients Lacking Access to Care
As countries grapple with the issue of unnecessary variation in medical care, it’s important to consider that some groups — low-income people, racial and ethnic minorities, residents of rural communities — have historically suffered from a lack of access to adequate care.
For patients belonging to such groups, talking about overuse of tests and procedures, or even resource stewardship, may sound tone-deaf. “You have to have a different conversation — not about what not to have, but more emphasis on what you should have, and what you shouldn’t,” said Wolfson, adding that the U.S. campaign is working toward reaching African American and Hispanic communities.
Attention to culturally appropriate care is also under way in Australia. When the campaign first launched, it received feedback from indigenous health groups that had concerns about messaging around “what not to do,” given that one of the issues in these populations can be underuse of appropriate medical services. These groups may be, in part, underutilizing health services because of language and other cultural barriers, and the campaign has therefore focused on promoting conversations between patients and providers rather than “do not do” lists.
“We are finding there is a higher prevalence of people who have English as a second language being less likely to question their doctor,” said Lindner. “We don’t want to force people to ask questions, but then we need to help clinicians to be aware that they need to provide the space and support in these conversations, knowing that their patients may not be comfortable asking the questions themselves.”
After two intense days of high-energy conversation at the Choosing Wisely fifth international roundtable in Zurich in 2018, the campaign leads were preparing to return home, with a renewed sense of urgency to advancing efforts around appropriate medical care.
For those representing more mature campaigns, the conference offered an opportunity to discuss how peers were measuring the effectiveness of their efforts. For newer campaigns, the successes and mistakes of more seasoned participants provided a blueprint of best practices and lessons learned.
“In the first meetings, we were discussing, ‘how do we make a list?’ and ‘how do we get doctors involved?’” said Levinson. “At this meeting, we can really see how the conversation has shifted. The group has now matured, more countries are farther along, and have more to offer each other,” she said.