Reducing overuse in healthcare: advancing Choosing WiselyBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6317 (Published 05 November 2019) Cite this as: BMJ 2019;367:l6317
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The BMJ and the Choosing Wisely international collaboration have partnered on a series of articles describing evidence-based changes to practice to reduce overuse in healthcare.
We welcome submissions from international teams of authors on priority overuse topics related to Choosing Wisely campaign recommendations.
If you are interested, please contact Navjoyt Ladher, Head of Education at The BMJ, for further information.
Competing interests: Navjoyt Ladher is an employee of The BMJ. Karen Born is paid in her role as knowledge translation lead at Choosing Wisely Canada
This article interested me as I recently delivered a session on cognitive bias in which we covered the concept of action bias and the potential harm of active strategies. Action bias is the tendency towards active management rather than a watchful waiting strategy. The phenomenon was initially studied in goal keepers during penalty shoot outs- statistically the optimal position for the goal keeper in a penalty shoot out is the centre of the goal yet they always dive, often before the direction of the kick can be determined. One explanation for this is the expectation of action by the team and the crowd (1). In addition the potential outcome also influences the drive to act- imagine the repose of the crowd if the goal keeper remained motionless in the centre while the opposition scored a goal, there would be anger at the inaction of the goal keeper at a critical time. Finally, action provides a sense of control, there is a degree of satisfaction in "doing something" to address a problem.
One study in Primary care illustrated action bias in healthcare(1). The study utilised case vignettes of unusual but non-threatening symptoms, it asked GP's for their differential diagnosis, their confidence in their differentials, their management strategy and their confidence in their management strategy. 87% of GPs chose an "active management strategy"(1). "Active management strategies included either a trail of treatment, an investigation, a referral to a specialist or a referral to A&E(1). Only 13% chose a watchful waiting strategy.
The potential for harm can be demonstrated if you imagine using a test without thinking about the test sensitivity and specificity. If a test has 100% sensitivity (i.e. will always identify those with the disease) and 95% specificity (i.e. 5% will have positive test results but no disease)(2). So if there is 3% prevalence of the disease, and the test is 100% accurate, for every 100 patients tested there will be 8 positive tests but only 3/8 (37.5%) will have the disease(2). So what do you do with this result- there is potential that it will lead to further testing or treatment of patients who do not have the disease.
Although this seems clear as a concept, it is difficult to put into practice when faced with a patient (who may also have an action bias).
The article states that much more research is required to understand the drives behind overuse and to design interventions to affect physician and patient behaviour. As illustrated above, the drive to act can be very strong and is influenced by personal, professional, social and cultural factors.
1) A Kinderman, U Ilan, I Gur, T Bdolah-Abram, M Brezis. Unexplained Complaints in primary care: Evidence of action Bias. The journal of family practice. Aug 2013 Vol 62. 408-412
2) ED O'Sullivan, SJ Schofield. Cognitive Bias in Clinical Medicine. Journal of the Royal College of Physicians of Edinburgh. Sept 2018 Vol 48 225-232
Competing interests: No competing interests
Bring on the patients!
We in a European Federation of Laboratory Medicine taskforce are at an early stage of examining "disruptive technology and patient engagement".
Mobile technology, interoperability and increasing citizens' IT skills are improving patients' opportunity to choose.
Sarah Redmond posted in 2015: "NHS England and the Health Foundation are working with six healthcare organisations across England to trial the use of the Patient Activation Measure (PAM) tool. They recently published a report covering the early findings with the final evaluation expected in autumn 2017."
"What is ‘patient activation’?"
"Patient activation describes the knowledge, skills and confidence a person has in managing their own health and healthcare. Measuring knowledge, skills and confidence provides an organisation with information it can use to reshape its services to support people where they are in their journey."
"The evidence on patient activation suggests that people with long term conditions with higher levels of knowledge, skills and confidence understand their role in the care process and feel capable of fulfilling that role. It is also suggested they are more likely to engage in positive health behaviours and to manage their health conditions more effectively.
Patient activation is closely linked to other concepts such as ‘self-efficacy’ and ‘readiness to change’, but patient activation is argued to be a broader and more general concept, reflecting attitudes and approaches to self management and engagement with health and healthcare, rather than being tied to specific behaviours."
"The Patient Activation Measure (PAM) is a measurement scale of patient activation based on patients’ responses to questions which include measures of an individual’s knowledge, beliefs, confidence and self-efficacy. The resulting score places a patient at one of four levels of activation, each of which reveals insight into a range of health-related characteristics, including attitudes, motivators, behaviours and outcomes. The four levels of activation are:
Level 1: disengaged and overwhelmed
Level 2: becoming aware, but still struggling
Level 3: taking action
Level 4: maintaining behaviours and pushing further
Evidence suggests that PAM scores are predictors of health outcomes, improved service utilisation, and reduced cost. The report does not go into the definition of these in more detail and it is unclear, in particular, on the definition of health outcomes. However, there is a list of references which can be accessed at the back of the report."
Our small research study in 2014 showed a reduction in GP attendances and telephone calls from patients who could access their own records online and make their own choices. 
1 Fitton C, Fitton R, Hannan A, Fisher B, Morgan L, Halsall D. The impact of patient record access on appointments and telephone calls in two English general practices: a population based study. London Journal of Primary Care 2014;6(1):8-15.
Competing interests: No competing interests