Intended for healthcare professionals


Choosing Wisely in a time of resource constraints

BMJ 2024; 385 doi: (Published 12 April 2024) Cite this as: BMJ 2024;385:q166
  1. Karen B. Born, assistant professor1,
  2. Wendy Levinson, professor2,
  3. C S Pramesh, professor3,
  4. Eve A. Kerr, professor4
  1. 1Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
  4. 4Department of Internal Medicine, University of Michigan, Ann Arbour, Michigan, United States

Healthcare systems globally are facing multiple intersecting and overlapping crises including unprecedented resource constraints and a burnt out, demoralised workforce.1 Clinicians are being asked to do more with less in the face of backlogs in access to services alongside rising health inequalities and increases in patient complexity.

Evidence based ways to curb wasteful spending and encourage sustainability are important as healthcare systems grapple with ongoing crises, brace for new eventualities, and aim to become more resilient. There is increased urgency, now more than ever before, to avoid waste in healthcare by eliminating overuse in healthcare. Choosing Wisely campaigns, now in over 30 countries globally, offer an approach to reducing overuse and waste based on clinician developed evidence based recommendations.

As part of the Choosing Wisely campaign in each country, national clinician specialty societies develop recommendations about overused or unnecessary tests, treatments, and procedures. Campaign efforts have been led by grassroots groups or organisations with a great deal of local innovation and adaptation. For example, a coalition of oncologists in Sub-Saharan African countries and India have developed Choosing Wisely lists to reduce overuse in cancer care in low resource settings.2 They have published recommendations in global oncology journals, presented at local, national, and regional conferences and disseminated recommendations through regional oncology and scientific societies.3 Raising awareness is a first step towards practice change.

Global campaign principles, published nearly a decade ago, should be updated to reflect on how efforts to reduce overuse are being implemented and evaluated across a diverse set of clinical challenges and settings. Knowing that information alone is not sufficient to drive practice change, support for evidence based approaches and tools for practice change are needed. Further, clinicians cannot tackle overuse in isolation. There is a need for administrators, decision makers, and evaluators to leverage their own approaches to reduce overuse including investments in clinical support systems, payment, and policy changes.

New principles can also help tackle ongoing efforts to decrease overuse.

Establish priorities to stop or reduce overuse

A strength of Choosing Wisely campaigns is the ability to develop a coalition among diverse groups of clinician societies and engage with them through developing recommendations. Now, establishing high-yield overuse priorities can bring together and mobilise clinicians, decision-makers, and patients. For example, the Choosing Wisely Canada campaign has developed focused campaigns that cross-cut community, specialist, and non-physician clinician lists and are seen as minimising harm to patients, saving healthcare costs and reducing waste, a win for all stakeholders. These include tools to reduce antibiotic prescriptions for viral illness, a laboratory appropriateness consortium to reduce unnecessary testing, and a partnership with national blood agencies to reduce red blood cell transfusions.4 Campaigns should select the most important priority areas choosing across specialties to make the biggest impact on the healthcare system.

Engage patients and the public in avoiding overuse

Campaign recommendations and tools have emphasised the importance of shared decision making in the clinician-patient encounter.5 Shared decision-making is increasingly seen as a robust strategy to drive population health improvements, from increased vaccine uptake to reducing unnecessary antibiotics.6 However, individual clinicians need support to implement shared decision-making. For example, investments in patient and public education, and revising performance measures so that they do not encourage overuse, alongside tools to support sometimes difficult and challenging conversations in an era of rapidly changing evidence and practice, are needed.7

Utilise system levers for change

Choosing Wisely has spread globally. While it was initially a grassroots campaign, tackling urgent de-implementation priorities may necessitate engagement with local health system decision-makers who can influence policy or regulation to drive change, necessitating a more “top down” approach. Strategies to reduce surgical backlogs, for example, can draw from well established approaches to reducing unnecessary preoperative tests, which include changes to order sets and drawing on appropriateness criteria.8

Leverage virtual care

The recent rapid uptake of telemedicine tools, spurred by the covid-19 pandemic, has several benefits for clinicians, patients, and health systems and should not be reversed.9 Virtual care, when appropriate, can drive efficiencies and reduce wasted time and resources associated with in-person clinical encounters. However, virtual care needs to be supported for both clinicians and patients. Efforts to offer support and mitigate barriers to virtual care are important to ensure equitable adoption at the population level.10

Choosing Wisely campaigns have planted the seeds for change by raising awareness about overuse and clearly the approach has resonated with clinicians. However, awareness alone cannot drive change. There is a window of opportunity to build on awareness of overuse, the burning platform for change and the groundswell of clinician leadership driving innovations to make transformative change.


  • Acknowledgments: The authors would like to thank the following individuals who contributed to the initial genesis of this article following a working group of the Choosing Wisely international collaboration: Niek Klazinga, Minna Johansson, Stefan Hjørleifsson, Sandra Vernero and Luis Correia.

  • Competing Interest: None declared.