Journal articles

Journal articles

Choosing Wisely: An international movement toward appropriate medical care - The Commonwealth Fund, 1 April 2019

A hot dog with too much mustard on it. A washing machine overflowing with soap suds. A suitcase with clothes spilling out of it. These images aren’t what you expect to see when you go to your doctor — but in primary care waiting rooms across Canada, posters with these images hang on the walls. The posters, accompanied with the message “More Is Not Always Better,” are intended to prompt patients to talk to their physicians about what kind of care is right for them.

Behind the eye-catching posters is Choosing Wisely, an international movement that began in the United States and has since spread around the world. It was launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation to advance a national dialogue on how to avoid unnecessary medical tests, treatments, and procedures. Today, more than 20 countries have developed campaigns based on a simple but compelling premise: conversations between doctors and patients can help patients choose care that is based on evidence, truly necessary, not duplicative, and free from harm.

Choosing Wisely in Australian hospitals: lessons from the field - MJA Insight, 18 March 2019 

Choosing Wisely is an international campaign that encourages conversations about what tests, treatments and procedures are truly necessary. In doing so, it seeks to support a culture shift in how clinicians and consumers think about health care and complements an increasing focus on the delivery of value in health care across Australia.

Choosing Wisely Australia, facilitated by NPS MedicineWise, launched in 2015 and boasts a multidisciplinary membership that includes physicians, GPs, physiotherapists, pharmacists and nurses. The success of Choosing Wisely to date, having spread to 20 countries, has been attributed to six core principles, as well as a focus on professional values and the role of clinicians in resource stewardship, and on improving conversations to reduce unnecessary care.

Helping patients choose wisely - BMJ 2018 ; 361, 15 June 2018

New UK recommendations emphasise shared decision making.

Overdiagnosis and overtreatment are common, harmful to patients, and expensive. Doctors and patients tend to overestimate the benefit and underestimate harm of interventions. 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.

Drowning in data: the argument for no unnecessary tests 

A defining characteristic that widens the gap between practice and evidence in modern medicine is the meteoric rise of diagnostic testing.

Eastern Health, one of Melbourne's large public Health Services, created No Unnecessary Tests (NUTs), a program requesting that patients only undergo tests that are clinically indicative and not ones that remain un-supported by evidence or deferred to an ambulatory setting. This article explores how Eastern Health identifies the likely hotspots of unnecessary testing, their underlying causes and explains implementation of the adapted interventions to fit them.
Choosing Wisely Campaigns A Work in Progress - Journal of the American Medical Association, Vol. 208, 19 April 2018

Choosing Wisely focuses on conversations between physicians and patients, the basis of clinical interactions.

The spread of Choosing Wisely internationally demonstrates how well-received the campaign is; with the aim now being to demonstrate effectiveness in improving outcomes and making a difference on measures of quality and safety pertaining to both clinicians and patients. This viewpoint explores factors that facilitated the spread of the Choosing Wisely campaign and how these enabling factors can address changes in dissemination and implementation.

Choosing Wisely Australia: changing behaviour in health care - Medical Journal of Australia, Vol. 208, February 2018

Challenging the notion that “more is better” in our health care system - by Dr Robyn Lindner, Client Relations Manager,                              NPS MedicineWise.

The key to addressing low value care in Australia’s health care system is reducing unnecessary tests, treatment and procedures. With consumer demand reported as a main driver of unnecessary tests and treatments, Choosing Wisely Australia encourages health care providers to have conversations with patients around the necessity for and risks of certain health care practices.

Benzodiazepine Use in Older Adults in the United States, Ontario, and Australia from 2010 to 2016
​Report: Annual trends in benzodiazepine incidence and prevalence in older adults between 2010 and 2016 in three countries.

Choosing Wisely: Law's Contribution as a Cause of and a Cure for Unwise Health Care Choices - Journal of Law and Medicine, June 2017

The provision of unnecessary healthcare is a serious problem in Australia and involves two key legal issues. First, doctors' fear of litigation drives defensive practices - ordering tests and procedures, making referrals, and prescribing drugs to reduce perceived legal risks, rather than to advance patient care. Second, suboptimal communication and decision making processes undermine a patient's right ot make informed healthcare choices. This article critically analyses these problems and proposes solutions. 

Choosing Wisely: A Special Report On The First Five Years

For information on the accomplishments of the first five years of the Choosing Wisely campaign in The US, check out this special report.

Countering cognitive biases in minimising low value care – Medical Journal of Australia, Vol. 206, May 2017
Professionally led initiatives, such as the Choosing Wisely Australia campaign ( and EVOLVE (Evaluating Evidence, Enhancing Efficiencies;, aim to raise awareness of, and reduce, low value care. This is care that confers little or no benefit, may instead cause patient harm, is not aligned with patient preferences, or yields marginal benefits at a disproportionately high cost. In this article, we discuss cognitive biases that predispose clinician decision making to low value care. We used PubMed listings of original articles from 1990 to 2015 related to cognitive bias in clinical decision making, including a recent systematic review, files of relevant publications held by the authors and sentinel texts in cognitive psychology as applied to clinical practice (Appendix). We believe that these biases need to be understood and addressed if campaigns such as Choosing Wisely and EVOLVE are to achieve their full potential.
Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care – The Milbank Quarterly, March 2017
As much as 30% of US health care spending may be unnecessary. The Choosing Wisely campaign, now active in a dozen countries, addresses this problem in part through public education campaigns. This article explores Americans’ understanding of low-value care in 2015, assesses the impact of media messaging, and tests alternative message framing.

Clinicians’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests – JAMA Internal Medicine, March 2017
Clinicians rarely had accurate expectations of benefits or harms, with inaccuracies in both directions. However, clinicians more often underestimated rather than overestimated harms and overestimated rather than underestimated benefits. Inaccurate perceptions about the benefits and harms of interventions are likely to result in suboptimal clinical management choices.

Evidence for overuse of medical services around the world – The Lancet January 2017
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity.

Adding Value by Talking More – New England Journal of Medicine November 2016
The prevailing fee-for-service payment model has led U.S. health care administrators and physician practices to impose severe constraints on the time physicians spend talking, for which they are reimbursed poorly or not at all. New value-based reimbursement models, however, such as bundled payments, accountable care organizations, and shared savings plans, provide powerful incentives for physicians to regain control over the quantity and quality of time they spend talking. As we have helped dozens of organizations to estimate total care-cycle costs, we’ve identified many situations in which having physicians and other clinical personnel talk more with patients and each other can be the least expensive and most effective approach for delivering better patient care.
Evolve osteoporosis and other guidelines avoiding cognitive bias – Internal Medicine Journal, October 2016
Standardised critical appraisal of clinical guidelines is more likely to have an impact on low-value care than some of the Royal Australasian College of Physicians’ current Evolve (Choosing Wisely) recommendations, which are directed to other specialties rather than the speciality that derived it. Cognitive bias in clinical guidelines is illustrated using the example of bone mineral density scans for monitoring the effectiveness of treatment for osteoporosis.

Perceived barriers to implementing individual Choosing Wisely recommendations in two national surveys of primary care providers – Journal of General Internal Medicine , September 2016
While Primary Care Providers found many Choosing Wisely recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming Primary Care Provider’s perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.

The best decisions – Good Practice Issue 7, July 2016
The Choosing Wisely Australia campaign is designed to help Australian GPs determine the most beneficial tests and procedures for their patients.

A survey of primary care patients’ readiness to engage in the de-adoption practices recommended by Choosing Wisely Canada – BMC Research Notes, June 2016
The majority of primary care patients seem ready to de-adopt low-value practices. Provision of education in clinic waiting rooms can help improve knowledge around unnecessary care.

Choosing Wisely at Austin Health – Australian Hospital + Healthcare Bulletin, Winter 2016
The Choosing Wisely initiative was launched in Australia just over 12 months ago and we have recently seen the second wave of recommendations announced in March. These have attracted much interest, as expected, from clinicians, the public and media. All agree that the messages that accompany the recommendations from Choosing Wisely - that it is about delivering evidence based quality care - are important in all areas of health care.

Physician Perceptions of Choosing Wisely and Drivers of Overuse – American Journal of Managed Care, May 2016
Little is known regarding physicians’ views on health service overuse or their awareness of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. Through the Survey on Overuse and Knowledge of Choosing Wisely, physician views on hypothesized drivers of overuse and Choosing Wisely were assessed.

Health Literacy: A summary for Consumers – Australian Commission on Safety and Quality in Health Care, July 2015
We used to think that health literacy was just about how well a person could find, understand and use health information — their skills and abilities and what they know about health. But it is actually much more than this, because the way health information and services are provided affects what you know and what you do about your health.

Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care – BMJ Quality & Safety, June 2015
The Choosing Wisely campaign began in the USA in 2012 to encourage physicians and patients to discuss inappropriate and potentially harmful tests, treatments and procedures. Since its inception, the campaign has grown substantially and has been adopted by 12 countries around the world. Of great interest to countries implementing the campaign, is the effectiveness of Choosing Wisely to reduce overutilisation. This article presents an integrated measurement framework that may be used to assess the impact of a Choosing Wisely campaign on physician and provider awareness and attitudes on low-value care, provider practice behaviour and overuse of low-value services.
‘Choosing Wisely’: a growing international campaign – BMJ Quality & Safety, December 2014
Much attention has been paid to the inappropriate underuse of tests and treatments but until recently little attention has focused on the overuse that does not add value for patients and may even cause harm. Choosing Wisely is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments and procedures. The campaign began in the United States in 2012, in Canada in 2014 and now many countries around the world are adapting the campaign and implementing it. This article describes the present status of Choosing Wisely programs in 12 countries. It articulates key elements, a set of five principles, and describes the challenges countries face in the early phases of Choosing Wisely. These countries plan to continue collaboration including developing metrics to measure overuse.

Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care – Academy of Medical Royal Colleges November 2014
A doctor’s primary motivation for reducing waste is that it enables the savings to be used more effectively elsewhere. This process creates a higher value health care system where resources: cash, carbon and staff time, are released from some parts of the system to develop new services or support struggling services. Reducing waste in today’s climate of constrained resource is really about creating the health care system that we want to have. It is not just about cutting corners or reducing spending. As responsible stewards, doctors can provide a more effective use of constrained economic and environmental resources.

Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign – Academic Medicine, July 2014
Wise management of health care resources is a core tenet of medical professionalism. To support physicians in fulfilling this responsibility and to engage patients in discussions about unnecessary care, tests, and procedures, in April 2012 the American Board of Internal Medicine Foundation, Consumer Reports, and nine medical specialty societies launched the Choosing Wisely campaign. The authors describe the rationale for and history of the campaign, its structure and approach in terms of engaging both physicians and patients, lessons learned, and future steps.

Communicating information about “what not to do” to consumers – BMC Medical Informatics & Decision Making, December 2013
Telling consumers that more is not better is not a popular or easy message to deliver. The message is most likely to be "sticky" but is best received if it comes from trusted sources (e.g., physicians), focuses on safety when justified, is communicated in plain language, and uses both mass media and individual consumer approaches. Changing the culture of health care in an era of health reform is an essential part of the transformation needed if we are to allocate finite resources fairly in hopefully fair markets while assuring that better quality products and services at lower prices dominate.

Last reviewed 06 May 2019