Choosing Wisely in the UK: an initiative to reduce the harms of too much medicine

Do I really need this test or procedure? What are the risks?
Are there simpler safer options? What happens if I do nothing?

This post content is published by The BMJ, aiming to lead the debate on health, and to engage doctors, researchers and health professionals to improve outcomes for patients.

A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK.

The idea that some medical procedures are unnecessary and can do more harm than good is as old as medicine itself. In Mesopotamia 38 centuries ago, Hammurabi proclaimed a law threatening overzealous surgeons with the loss of a hand or an eye. In 1915, at the height of a surgical vogue for prophylactic appendicectomy, Ernest Codman offended his Boston colleagues with a cartoon mocking their indifference to outcomes and asking, “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?” Looking at the rates of tonsillectomy in London boroughs in the 1930s, John Alison Glover discovered that they were entirely governed by the policy of school doctors and bore no relation to need or outcomes. John (Jack) Wennberg established the science of outcomes research when in 1973 he described patterns of gross variation in the use of medical and surgical procedures in the United States, which lacked any clinical rationale but was closely related to supply.

Diagnosis drives treatment, and in recent years the term overdiagnosis has been used to describe various situations where diagnoses lead to unnecessary treatment, wasting resources while increasing patient anxiety. Overdiagnosis can be said to occur when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.” Overtreatment includes treatment of these overdiagnosed conditions. It also encompasses treatment that has minimal evidence of benefit or is excessive (in complexity, duration, or cost) relative to alternative accepted standards. A recent report by the Academy of Medical Royal Colleges argued that doctors have an ethical responsibility to reduce this wasted use of clinical resource because, in a healthcare system with finite resources, one doctor’s waste is another patient’s delay.

Choosing Wisely in the NHS

Even before the inception of the NHS, the British tradition has generally been one of late adoption and cautious use of new medicines, procedures, and technologies. Nevertheless, the UK shows similar patterns of variation in use of medical and surgical interventions to those in the US, though less extreme in absolute terms. The National Institute for Health and Care Excellence (NICE) was set up in 1999 in part to address these unwarranted variations in clinical practice and has identified over 800 clinical interventions for potential disinvestment. However, engaging clinicians with stopping familiar or ingrained practices requires a different approach to that for introducing new treatments.

An initiative recently developed in the US and Canada called Choosing Wisely aims to change doctors’ practice to align with best practice by getting them to stop using various interventions that are not supported by evidence, free from harm, and truly necessary, including those that duplicate tests or procedures already received. Choosing Wisely asks medical organisations (such as medical royal colleges in the UK) to identify tests or procedures commonly used in their specialty, the necessity of which should be questioned and discussed. These are compiled into lists, and the “top five” interventions for each specialty should not be used routinely or at all. So far, more than 60 US specialist societies have joined in the Choosing Wisely initiative. It has also been adopted by other countries, including Australia, Germany, Italy, Japan, Netherlands, and Switzerland—a clear sign that wasteful medical practices are a problem for all health systems.

The Academy of Medical Royal Colleges, which represents all medical royal colleges in the UK, is launching a Choosing Wisely programme in collaboration with other clinical, patient, and healthcare organisations. Participating organisations will work together to develop top five lists of tests or interventions with questionable value. The academy, royal colleges, and partners, including The BMJ, will then promote dissemination of this information and Choosing Wisely conversations between clinicians and patients. These new conversations will rebalance discussions about the risks and benefits of tests and interventions, such that doctors and patients will be supported to acknowledge that a minor potential benefit may not outweigh potential harm, the minimal evidence base, and substantial financial expense and therefore that, sometimes, doing nothing might be the favourable option.

Tackling the underlying causes of overtreatment

A culture of “more is better,” where the onus is on doctors to “do something” at each consultation has bred unbalanced decision making. This has resulted in patients sometimes being offered treatments that have only minor benefit and minimal evidence despite the potential for substantial harm and expense. This culture threatens the sustainability of high quality healthcare and stems from defensive medicine, patient pressures, biased reporting in medical journals, commercial conflicts of interest, and a lack of understanding of health statistics and risk.

The system has no incentive to restrict doctors’ activity; the NHS in England has a system of payment by results, which in reality is often a payment by activity and encourages providers to do more both in primary and secondary care. General practice is increasingly pressured to focus less on open dialogue with patients about treatment options and more on fulfilling the demands of the Quality and Outcomes Framework (QOF, a pay for performance instrument) and adhering to local commissioning decisions.

The quality measures in both primary and secondary care are based on guidelines produced by NICE, but doctors should not consider these as tramlines because decisions need to be made with reference to individual patient circumstances, the wishes of the patient, clinical expertise, and available resources. Some people would choose to take a hypothetical pill with no side effects daily, even for a few weeks’ gain in life expectancy, whereas others would prefer not to, even if they were told it would add 10 years to their lifespan. It is instructive to note that a large and comprehensive longitudinal study recently concluded that higher reported achievement incentivised under QOF has not reduced premature death in the population.

We suggest that guideline committees should increasingly turn their efforts towards the production of tools that help clinicians to understand and share decisions on the basis of best evidence. Rather than prespecifying the outcome of such dialogue, and trying to get medicine “just right,” they should try to ensure that decisions are based on the best match between what is known about the benefits and harms of each intervention and the goals and preferences of each patient.

More informed decision making can also alleviate, perhaps disproportionate, fears for those patients who may not want treatment. A recent study revealed that when patients were told the lack of prognostic benefit for angioplasty, only 46% elected to go ahead with the procedure versus 69% who were not explicitly given this information. Responding to similar concerns about getting patients’ consent for elective coronary angioplasty in the UK, NHS England’s cardiology lead, Huon Gray, stated, “It is important that doctors are clear with their patients about this.”

It is easy to misunderstand health statistics, and doctors can find themselves needing to manage unrealistic expectations of patients who may find it difficult to obtain reliable information. Communicating relative risks as opposed to absolute risk or numbers needed to treat can often unintentionally mislead. As Gerd Gigerenzer, director of Harding Centre for Risk Literacy in Berlin, summarised in 2009, “It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks, to protect patients against unnecessary anxiety and manipulation.”

Doctors’ health illiteracy is well documented. Misunderstanding of statistics often leads to a belief that screening is more beneficial than it actually is and, in some cases, to no acknowledgment of its potential harms. In a study of 150 gynaecologists, one third did not understand the meaning of a 25% risk reduction from mammography. Many believed that if all women were screened 25% of women (or 250 fewer out of every 1000) would die of breast cancer, when actually the best evidence based estimate is actually one less death per 2000 women (from Cochrane’s analysis of randomised studies including 500 000 women).

Both medical and surgical overtreatment can place patients at high risk of adverse events. Shared decision making can help to reduce this overtreatment and may be particularly beneficial to disadvantaged groups, significantly improving health outcomes and reducing health inequalities.

Potential limitations

One of the major concerns about the development of top five lists in the US is the potential for individual societies to choose low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included the use of an over the counter supplement but no major procedures, despite evidence of wide variation in elective knee replacement and arthroscopy rates among Medicare beneficiaries. Currently, there is also no evidence that lists reduce use of low value medical practices. One crucial and relevant marker of success would be universal awareness of the Choosing Wisely programme among doctors and patients. However, despite much publicity in the medical literature, a random telephone survey of 600 US doctors recently conducted by the American Board of Internal Medicine found that only 21% had heard of Choosing Wisely. The level of public awareness of the campaign, which is a fundamental component to its progress, has not been assessed.

Reducing wasteful and harmful healthcare will require commitment from both doctors and patients, in addition to objective evidence of effectiveness. The NHS already has good systems for evidence appraisal and health technology assessment, but better and simpler tools are needed to facilitate informed discussion in clinical settings. Without such robust and easily shared decision aids, systematically updated without bias, patients may be swayed by potential exaggerated claims in the media when new drugs or procedures are introduced. Lastly, shared decision making does not guarantee lower resource use; greater involvement of patients in deciding their care will require a new set of consultation skills as well as a better range of decision aids.

Call to action and next steps

To ensure the development of a Choosing Wisely culture in clinical practice, the academy suggests:

  • Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often be the best approach
  • Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?
  • Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education
  • Commissioners should consider a different payment incentive for doctors and hospitals

Support from the media and medical publications will be vital because the public education campaign is crucial to the programme’s success. The academy will ensure that the programme is thoughtfully implemented and rigorously evaluated by demonstrating a reduction in wasteful practices within a fixed time scale. It will begin by asking specialty organisations to compile top five lists. All lists will be accompanied by an implementation plan and will be evaluated and monitored to assess their effect on reducing low value healthcare.

The academy has set up a steering group to provide policy advice and direction for the project. The group comprises individual experts, patient groups, college representatives and key stakeholders. It is time for action to translate the evidence into clinical practice and truly wind back the harms of too much medicine.

Sources and more information
  • Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine, BMJ 2015;350:h2308, 12 May 2015.
  • Doctors urged to stop ‘over-treating‘, BBC News Health, 13 May 2015.

Germany aims to stop nudging the public on screening

Breast cancer screening pamphlets mislead women

screening-saves-lives image
Breast cancer screening pamphlets mislead women ; all women and women’s organisations should tear up the pink ribbons and campaign for honest information. Image via Province of British Columbia.

Policy on screening people for cancer poses a dilemma: should we aim for higher participation rates or for better informed citizens? The dilemma is that both cannot be had. A focus on informing citizens risks lowering participation rates, because well informed people may realise that for most cancers it is unclear whether the benefits of screening exceed its harms. Historically, screening policies opted for increasing participation and accordingly took measures that made people overestimate the benefits and underestimate the harms. But that is set to change, at least in Germany.

Read Towards a paradigm shift in cancer screening: informed citizens instead of greater participation, The BMJ 2015;350:h2175, by Gerd Gigerenzer, 05 May 2015.

By the same author, read All women and women’s organisations should tear up the pink ribbons and campaign for honest information, BMJ 2014;348:g2636, 25 April 2014.

Reckoning with Risk

Learning to Live with Uncertainty

Reckoning with Risk
Watch @DES_Journal diaporama and health books album on Flickr. Reckoning with Risk, Learning to Live with Uncertainty.

However much we want certainty in our lives, it feels as if we live in an uncertain and dangerous world. But are we guilty of wildly exaggerating the chances of some unwanted event happening to us? Are we misled by our ignorance of the reality of risk?

Far too many of us, argues Gerd Gigerenzer – prominent statistician, expert in uncertainty and decision-making. – are hampered by our own innumeracy, while statistics are often presented to us in highly confusing ways. With real world examples, such as the incidence of errors in tests for breast cancer or HIV, or in DNA fingerprinting, and the manipulation of statistics for evidence in court, he shows that our difficulty in thinking about numbers can easily be overcome.

In Reckoning with Risk: Learning to Live with Uncertainty – see Amazon customer reviews –  Gerd Gigerenzer, author of Risk Savvy: How to Make Good Decisions, who explained how simple heuristics can improve medical decision making over much more complex solutions, now clarifies our common misunderstandings surrounding risk and statistics and illustrates how we can learn to make sense of statistics and turn ignorance into insight.

On Flickr®

How simple heuristics can improve medical decision making over much more complex solutions

Dr. Gerd Gigerenzer talks about making medical decisions

Heuristics in Medical Decision Making ; video interview of Gerd Gigerenzer – prominent statistician, expert in uncertainty and decision-making.

How are heuristics helpful in real-word situations? Dr. Gigerenzer describes how simple heuristics can improve medical decision making over much more complex solutions. By ignoring much of the available information, simple heuristics often are more stable and robust than strategies that have been optimized based on small data samples. Gerd Gigerenzer explains how their approach has changed the way in which a hospital in Michigan decides on emergency care for heart patients.

More information

Risk Savvy: How to Make Good Decisions

A Risk and Statistics book by Gerd Gigerenzer

Risk Savvy book cover image
A risk and statistics guide to making better decisions.

An eye-opening look at the ways we misjudge risk every day and a guide to making better decisions with our money, health, and personal lives

In the age of Big Data we often believe that our predictions about the future are better than ever before. But as risk expert Gerd Gigerenzer shows, the surprising truth is that in the real world, we often get better results by using simple rules and considering less information.

In Risk Savvy, Gerd Gigerenzer reveals that most of us, including doctors, lawyers, financial advisers, and elected officials, misunderstand statistics much more often than we think, leaving us not only misinformed, but vulnerable to exploitation. Yet there is hope. Anyone can learn to make better decisions for their health, finances, family, and business without needing to consult an expert or a super computer, and Gigerenzer shows us how.

Risk Savvy is an insightful and easy-to-understand remedy to our collective information overload and an essential guide to making smart, confident decisions in the face of uncertainty.

On Flickr®

Our Common Misunderstandings surrounding Risk and Statistics

We need to know how to deal with risk and uncertainty. You have to think yourself. And that’s the key message

What Does a 30% chance of rain mean?
Understanding Risk, with Gerd Gigerenzer.

In the good old times people learned how to read and to write. That’s no longer sufficient in the high tech twenty-first century. We also need to know how to deal with risk and uncertainty. And that is what I mean with risk savvy.

Here is a simple example. You hear on the weather report that there is a 30 percent chance of rain tomorrow. Thirty percent chance of what? Now I live in Berlin and most Berliners believe that it means that it will rain in 30 percent of the time, that is seven to eight hours. Others think it will rain in 30 percent of the region. Most New Yorkers believe that’s all nonsense. It means it will rain on 30 percent of the days for which this prediction has been made, that is, most likely not at all. Many psychologists think that people can’t learn how to deal with risk but in this case it’s the experts, the meteorologists who have not learned how to communicate risk in an instinctive way that is to say to what class 30 percent refers. Time or region or days? And if you have some imagination you can think about other classes. For instance, one woman in New York said I know what 30 percent means. Three meteorologists think it rains and seven not.

Now getting soaked is a minor risk. But are we risk savvy when it comes to more important things. For instance, 20 year olds drive with their cell phone glued to their ears not realizing that they decrease their reaction time to that of a 70 year old. Or many Americans, about 20 percent, believe that they are in the top one percent income group. And as many believe they will soon be there. Or take health. So about an estimated one million children get every year unnecessary computer tomography CT scans. And that’s really because they’re not really clinically indicated. Which is not just a waste of time but also danger to the kids because a CT scan can have the radiation of a hundred chest x-rays and may lead in a small number of these kids later to cancer.

We deal everyday with risks but we haven’t learned how to understand them. And the problem is not simply in the human mind but also in experts who really don’t know what the risks are or don’t know how to communicate. Or in other areas like if it’s about finance or health have interests other than yours. So the key message is this. Everyone can learn to deal with risk. In that case everyone can learn to ask the question probability of what. And second, if you believe that you’re safe by your delegating the responsibility of your wellness and health to experts then you may be disappointed because many experts do not know how to communicate probabilities or try to protect themselves against you as in health care as a potential plaintiff. So you have to think yourself. And that’s the key message.

More information

Are Doctors confused by Statistics?

Do doctors really understand test results?

BBC Health News
Some doctors have a poor grasp of statistics, making it hard for patients to make the right treatment choices.

A new book – Risk Savvy: How to Make Good Decisions – by Gerd Gigerenzer – one prominent statistician, expert in uncertainty and decision-making – says they have a poor, imperfect grasp of statistics… and that this makes it hard for patients to make informed decisions about treatment…

Read Do doctors understand test results? by William Kremer, BBC World Service, news/magazine-28166019, 7 July 2014.

Watch How simple heuristics can improve medical decision making over much more complex solutions and Our Common Misunderstandings surrounding Risk and Statistics videos.