Intended for healthcare professionals

Feature Shared Decision Making

Can doctors reduce harmful medical overuse worldwide?

BMJ 2014; 349 doi: (Published 03 July 2014) Cite this as: BMJ 2014;349:g4289

Re: Can doctors reduce harmful medical overuse worldwide? A local experience of Choosing Wisely

In the USA ABIM Foundation and Consumer Reports launched the Choosing Wisely campaign in 2012, inviting specialty Societies to own their role as “stewards of finite health care resources” [1]. In view of stimulating physicians/patients alliance on the topic of inappropriateness Howard Brodys [2] suggested Societies identify a top-5 list of diagnostic or therapeutic procedures that provide no overall benefit to patients and can harm them in most situations.

The purpose was to improve patients’ health through better treatment choices, lower risks and, where possible, lower costs. Nowadays 62 societies identified the top 5 list in the USA and are actively involved in implementing the recommendations.

In Italy Choosing Wisely was launched by Slow Medicine [3], a movement of physicians, health professional, patients and citizens aimed to promote a sober, respectful and fair medicine with the campaign “Doing more does not mean doing better” (Fare di più non significa fare meglio) [4]. Differently to the American project, in Italy costs of procedures were not taken into account to avoid the initiative should be interpreted as a way to ration healthcare for cost cutting purposes. Ten national specialty societies and associations already created a list of tests and treatments at risk of inappropriateness and many other ones are involved in the project [5].

As far as we know, the first experience of a local implementation of the Choosing Wisely method was adopted in an Italian hospital (the “Ospedale Santa Croce e Carle”, a tertiary 450 bed hospital in the city of Cuneo - Italy), where a scientific committee composed of the youngest physicians in each department coordinated a process to identify three practices at risk of inappropriateness, frequently prescribed in theirown departments. After a meeting explaining the Choosing Wisely campaign in the USA and in Italy, each member of the scientific committee was in charge to organize a few staff meetings in each department to identify which procedures were currently inappropriately prescribed by the team. All the proposals were openly discussed in the scientific committee to make them consistent and homogeneous.

Thirty-three departments identified 96 practices (63 tests and 33 treatments) at risk of inappropriateness [6] and worked to reduce their prescription; 37 were either equal or similar to those in Choosing Wisely and some were equal or similar to practices identified in the Slow Medicine campaign by the Italian specialty societies and associations. The main differences between the national and the local Italian level were that less cardiac tests and more drug prescriptions were referred as inappropriate at the local level. Actually, some of them are monitored to evaluate the impact of the project on prescriptions. Furthermore a second round of meetings has been planned one year later to update suggested practices and to involve nurses in identifying other inappropriate ones.

In conclusion, a local implementation of the Choosing Wisely campaign, originally launched for national specialty societies, is feasible and was well accepted by physicians, being involved in self-evaluating their own inappropriateness.

2. Brody H. Medicine’s ethical responsibility for health care reform: the Top Five list. N Engl J Med 2010; 362: 283-285.
4. Vernero S, Domenighetti G. Italy’s “Doing more does not mean doing better” campaign. BMJ 2014;349:g4703 doi: 10.1136/bmj.g4703.
5. Domenighetti G, Vernero S. Looking for waste and inappropriateness:if not now, when? Intern Emerg Med 2014; 9: S1–S7.

Competing interests: No competing interests

18 November 2014
Marco Bobbio
former Director of the Cardiovascular Department, Ospedale Santa Croce e Carle, Cuneo, Italy
Vernero Sandra, General Secretary, Slow Medicine Movement - Italy; Cappa Giorgetta, Ospedale Santa Croce e Carle, Cuneo, Italy
Ospedale santa Croce e Carle, Cuneo, Italy
via Pietra del Gallo 45 - 10025 Pino Torinese (TO), Italy