Helping patients choose wiselyBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2585 (Published 15 June 2018) Cite this as: BMJ 2018;361:k2585
- Jack Ross, clinical fellow, Choosing Wisely UK1,
- Ramai Santhirapala, clinical lead, Choosing Wisely UK1,
- Carrie MacEwen, chair1,
- Angela Coulter, health policy analyst and researcher2
- 1Academy of Medical Royal Colleges, London, UK
- 2Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Correspondence to: J Ross
Overdiagnosis and overtreatment are common, harmful to patients, and expensive.12 Doctors and patients tend to overestimate the benefit and underestimate harm of interventions.34 Choosing Wisely is a medically led campaign focusing on engaging doctors and patients in decisions about potentially unnecessary medical tests, treatments, and procedures. It started in the US in 2012 and has now been taken up in 22 countries worldwide, including the UK.5
The funding system in the UK means that NHS doctors have fewer financial incentives to overuse medical care than those working in fee-for-service systems, and the National Institute for Health and Care Excellence (NICE) has identified clinical interventions deemed to be of low value since 1999.6 Yet there is still evidence of wide clinical variation—for example, the first NHS Atlas of Variation showed a 27-fold difference in the rate of diagnostic knee arthroscopy procedures across the country.7 This variation is not usually because any specific investigation or treatment is redundant but because different clinical thresholds are used and they are not sufficiently tailored for individual patients’ needs. A new strategy involving patients and the public was needed.8
The UK campaign was launched by the Academy of Medical Royal Colleges in 2016, with 12 colleges and faculties producing lists of medical interventions that should not be carried out at all, or without a joint decision with the fully informed patient.9 Problems noted during the first round included overcomplicated procedures for submitting recommendations, little real patient involvement in selecting the top five priorities, and an absence of plans for measuring effect.
Most of these problems have been tackled in the second round of recommendations, published on 15 June. Some colleges and specialty societies have produced new recommendations while others have joined in for the first time, including the Royal College of Physicians, the British Society of Antimicrobial Chemotherapy, and the British Society for Rheumatology. Instructions were simplified after feedback from the first round, and much greater emphasis was placed on patient involvement, patient information, and support for shared decision making. Local audits on specific recommendations are planned.
It will take time to implement and measure the success of Choosing Wisely, though there is growing international evidence of benefit. For example, US hospitals have reported reductions in unnecessary cardiac monitoring,10 inappropriate tests,11 imaging,12 and blood transfusions.13
One of the main barriers to tackling the problem of overuse is that doctors are concerned patients will find it difficult to accept fewer interventions.14 However, informed patients often opt for less intervention, not more.
The quality of discussion between the doctor and the patient,15 combining the doctor’s skill in evidence based medicine with the patient’s goals and preferences, can be an effective way to ensure more appropriate care. Changing the conversation from “What’s the matter with you?” to “What matters to you?”16 often leads to more conservative choices without reducing satisfaction. Evidence shows that interventions that facilitate shared decision making lead to fewer elective surgical procedures, fewer inappropriate prostate specific antigen (PSA) tests, and reduced use of antibiotics for upper respiratory tract infections.1718
This is reflected in the latest guidance from Choosing Wisely UK, which suggests four questions that patients could ask their clinician to help them make more informed choices: What are the benefits? What are the risks? What are the alternatives? And what will happen if I do nothing?
In developing the second round of 60 new recommendations, the Academy of Medical Royal Colleges encouraged colleges and specialty societies to involve patients in selecting their “top five” lists and to suggest patient information packages or decision aids to facilitate shared decision making in these target areas.19 The recommendations were written in plain English to enhance accessibility and public understanding (box 2).
Sample recommendations for Choosing Wisely
Royal College of Ophthalmologists: Referral for cataract surgery should be based on shared decision making about how surgery may affect quality of life. It should not be restricted because of visual acuity alone
British Society for Antimicrobial Chemotherapy: Discuss the use of antibiotics with patients who are close to the end of life
Royal College of Pathologists: It is important to fully discuss and understand the reasons for a genetic test before agreeing to have a sample taken for testing
British Society for Rheumatology: Bisphosphonate therapy should be reviewed with every patient after three to five years, and a treatment holiday considered. This should follow shared decision making, including discussion of the risks and benefits of continued treatment
Royal College of Anaesthetists and Royal College of Surgeons (England): All patients considering an operation should have shared decision making to discuss their individual chance of benefit or harm and to identify their personal preference
Various factors conspire to drive up demand for inappropriate or wasteful treatments, including knowledge gaps, cognitive biases, risk aversion, poor coordination between specialties, commercial pressures, uncritical media coverage, and overoptimistic clinicians.20 Patients and the public need help to understand the limitations of medical care and to avoid inappropriate or harmful interventions. This will require greater investment in providing them with understandable and reliable health information than we have seen hitherto. Education in how to critically appraise medical advice would also help.21 Dealing with overuse cannot be left to doctors alone. The public also needs to be included in this important effort.
We thank Sue Bailey for her help as chair of Choosing Wisely UK and Joan Reid and Rose Jarvis for their advice on the article
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that all authors are members of the Choosing Wisely steering group.
Provenance and peer review: Commissioned; not externally peer reviewed.