Helping patients choose wisely

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).

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.