Choosing Wisely campaigns globally: A shared approach to tackling the problem of overuse in healthcare.

Choosing Wisely, a campaign which launched in the United States in 2012, has now spread to over 20 countries around the world. Choosing Wisely campaigns share a core set of principles, which inform how campaigns operate and engage with physicians, clinicians, patients, and other stakeholders. This article will address the origins and motivation of Choosing Wisely campaigns, and what factors have supported their spread. It will also discuss how leaders of Choosing Wisely campaigns are collaborating on shared priorities.

INTRODUCTION

Choosing Wisely, a campaign which launched in the United States in 2012, has now spread to over 20 countries around the world. Choosing Wisely campaigns share a core set of principles, which inform how campaigns operate and engage with physicians, clinicians, patients, and other stakeholders. This article will address the origins and motivation of Choosing Wisely campaigns, and what factors have supported their spread. It will also discuss how leaders of Choosing Wisely campaigns are collaborating on shared priorities.

HISTORY: A CAMPAIGN ROOTED IN PROFESSIONALISM TO ADDRESS OVERUSE

The concept of Choosing Wisely campaigns emerged from a partnership between three physician organizations—the ABIM Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine. These organizations partnered to articulate professional commitments of physicians and healthcare professionals in the modern era. This led to the publication of “The Physician Charter” in 2002, which included fundamental principles of patient welfare, patient autonomy, and social justice.1 To maintain the fidelity of medicine's social contract during the turbulent and complex modern era, the Charter set forth that physician professionalism was reaffirming active dedication to principles of professionalism, which entails not only a personal commitment to patient welfare but also shared efforts to improve the healthcare system. A core principle was the “just distribution of finite healthcare resources” and physician responsibility for the “scrupulous avoidance of superfluous tests and procedures.” Given the broader context of increasing healthcare costs, and a growing awareness and data on the harm of unnecessary tests, treatments, and procedures, this affirmed physician responsibilities as stewards of limited healthcare resources.

Following this publication were articles in high impact American medical journals that were a call to action for physicians to demonstrate the principles of the Charter in practice. Through these calls to action, the concept of Choosing Wisely was born.2

Choosing Wisely was launched by the ABIM Foundation in 2012 as a national campaign to advance dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures. The campaign partners with national clinician specialty societies to develop lists of recommendations that identify tests, treatments, and procedures that are commonly done, but medically unnecessary, and can harm patients. Lists focus on evidence‐based tests, treatments, and procedures that “should be questioned” and that are within their specialty. These lists are distributed through multiple channels, and content related to the lists is shared with a broad group of stakeholders who are involved in dissemination, education, and implementation of recommendations.

CHOOSING WISELY AROUND THE WORLD

The problem of overuse is global and not unique to the United States. Reports from the United States and Canada have identified that up to 30% of all medical tests, treatments, and procedures may be unnecessary and offer no clinical value to patients.3 A 2017 special edition of the Lancet identified addressing overuse as an important front in global quality and patient safety efforts.4 The magnitude of overuse and variation across countries is demonstrative of overuse as a significant quality problem in health care. The Organization for Economic Cooperation and Development (OECD) has identified addressing overuse as a priority, noting that 1 in 10 patients in OECD countries is unnecessarily harmed at the point of care and that wasteful and ineffective spending on health is widespread.5 Choosing Wisely has been cited as a potential approach to addressing the problem of overuse.

Choosing Wisely campaigns have been founded in Canada, Italy, Australia, Switzerland, the Netherlands, England, Germany, Austria, Japan, New Zealand, Wales, Brazil, Israel, France, and Norway. There are other countries, such as South Korea, Denmark, Singapore, Portugal, Poland, Spain, South Africa, and Saudi Arabia that are planning to launch Choosing Wisely campaigns. Generally, national physician associations or organizations in partnership with patient associations and clinician societies have launched campaigns.

The approach of clinician leadership and professionalism as a means to address the problem of overuse has resonated. It is suggested that the campaign has spread widely because of (a) the perceptions of the campaign as an innovation within medicine; (b) the role of physician leadership as key component of campaigns; and (c) the context of campaigns bringing together diverse stakeholders committed to a common problem.6

A shared set of principles have been published, and countries which wish to use the name Choosing Wisely for their national campaigns must agree in writing to follow them.7 These principles are vital to ensure that campaigns are focused on improving quality and patient safety, and not on cost cutting or rationing of healthcare services. Table 1 describes these principles.

Table 1

Principles of a Choosing Wisely campaign (adapted from Levinson et al7)

Principle	Description
Physician‐led	Physician organizations and associations lead Choosing Wisely as a professionalism initiative. This also ensures that governments and health systems do not use campaign to cut or control costs.
Patient‐focused	Central to campaigns is shared decision making, where clinicians and patients discuss whether a test or treatment is really necessary.
Evidence‐based	Recommendations need to cite evidence that shows where common tests and treatments may cause harm, or do not offer benefits to patients. This is central for both physician and patient trust.
Multiprofessional	Physicians deliver care in partnership with other professionals, who should be engaged in the campaign as partners.
Transparent	The processes used to create lists of recommendations need to be transparent to mitigate potential conflicts of interest.

COLLABORATION ACROSS CHOOSING WISELY CAMPAIGNS

The vision of Choosing Wisely International is to catalyze a global conversation on overuse. Choosing Wisely started with the recognition that there was a groundswell of interest from global physician associations in the campaign.

Choosing Wisely International has been organized by the Choosing Wisely Canada campaign and leaders from campaigns in more than 20 countries participate. Choosing Wisely International includes research and practical collaborations, as well as an annual meeting of campaign leaders. In addition, representatives from international organizations and associations with alignment to Choosing Wisely participate in this collaboration. This has included representatives from the Organization for Economic Cooperation and Development (OECD), World Bank, International Society for Quality in Health Care (ISQuA), and Cochrane International.

The Choosing Wisely International roundtable meetings have been productive in fostering international collaboration and partnership in the implementation, measurement, and research associated with campaigns. The results of the collaboration are seen through published articles on research and shared priorities and have informed campaign strategies. For example, published articles have included frameworks on measurement of campaigns,8 as well as patient and public engagement efforts.9 Campaigns have also collated recommendations and used priority setting tools to establish the most common recommendations across countries. This “top 10 list” of Choosing Wisely recommendations draws from published recommendations from the United States, Canada, Italy, the Netherlands, Japan, Switzerland, and Australia (Table 2). The top 10 recommendations were considered those that had the most potential to avoid harm to patients, occur most frequently, and can be measured. This list brings together high impact recommendations related to overuse of medications, imaging, and procedures and covers primary care, hospital care, and community care sectors.

Table 2

Top 10 list of Choosing Wisely recommendations

1. Don't do imaging for low back pain within the first 6 weeks, unless red flags are present.

2. Don't routinely prescribe antibiotics for acute mild‐to‐moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

3. Don't use benzodiazepines or other sedative‐hypnotics in older adults as first choice for insomnia, agitation, or delirium.

4. Don't maintain long‐term Proton Pump Inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop/reduce PPI at least once per year in most patients.

5. Don't perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high‐risk markers are present.

6. Don't use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.

7. Don't perform routine preoperative testing before low‐risk surgical procedures.

8. Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.

9. Don't place, or leave in place, urinary catheters for incontinence, convenience, or monitoring in noncritically ill patients.

10. Don't perform annual stress cardiac imaging as part of routine follow‐up in asymptomatic patients.

In addition to academic and published outputs of collaborations for Choosing Wisely International, there has been significant knowledge sharing and exchange across campaigns related to overall campaign strategy and approaches. At the 2017 International Meeting, a strategic plan was developed to further formalize the collaborations and develop working groups to advance areas of shared priorities.

Choosing Wisely International helps to facilitate the sharing of ideas, learning, and resources. Choosing Wisely International fulfills this role through maintenance of campaign principles as well as fostering the international learning community and collaboration on areas of shared interest and priorities. This has resulted in the formation of five working groups to help to steer Choosing Wisely International to advance campaigns nationally, and advance areas of shared global interest and concern.

The working groups are related to:

Sharing the experience—focused on advancing campaign principles and sharing knowledge and experience

Patient and public engagement—sharing knowledge and experience around patient and public engagement and shared decision making

Medical education—using medical education as a means to embed and spread Choosing Wisely in medical culture

Measurement and evaluation—working to shine a spotlight on the problem of overuse by using data on overuse

Governance—establishing guidelines for membership and participation in Choosing Wisely International working groups, committees, and meetings

WHAT'S NEXT FOR CHOOSING WISELY INTERNATIONAL?

Choosing Wisely campaigns around the world are at different stages of maturity. This remains a young campaign, with the earliest campaigns launching about 6 years ago, with countries joining in since that time and continuing to launch. Early stages of the campaign focus on building awareness of the problem of overuse and engaging relevant stakeholders to develop lists and join the campaign. Campaigns that are underway will focus on building lists of recommendations and disseminating them to clinicians, patients, and the public to raise awareness about the recommendations. More advanced campaigns are focused on implementation of recommendations into practice, and translating this into measurable practice changes with impact on patient outcomes. This is a challenging, but important task. Influencing clinical practice and demonstrating change are difficult but important next steps to tackling the problem of overuse. Choosing Wisely International aims to help facilitating campaigns at various stages and working with partners to advance shared goals. It is hopeful that through partnerships, collaborations, and shared efforts, Choosing Wisely campaigns globally can help reduce overuse and harms associated with unnecessary care, and improve quality and patient safety for patients.

CONFLICT OF INTEREST

The authors have stated explicitly that there are no conflicts of interest in connection with this article.