Shared decision-making between health professionals and patients as to what care is necessary is the focus of the Choosing Wisely New Zealand campaign, launched this month by the Council of Medical Colleges as part of its commitment to improving the quality of health care.
Choosing Wisely New Zealand is part of an international Choosing Wisely initiative that began in the US in 2012 by the American Board of Internal Medicine Foundation, Consumer Reports and nine medical specialty societies.1 Subsequently, a number of countries including Canada, Italy, the Netherlands, Australia and England have developed their own versions of Choosing Wisely.2 The goal of Choosing Wisely is to provide high-quality care, prevent harm and reduce the use of unnecessary care. In some instances, cost savings may result from those choices, whereas in others, care may be more appropriate, more timely or less inconvenient for patients.2 The campaign is underpinned by professional values and responsibilities, and inter-health professional and health professional-patient conversations to reduce unnecessary care.
With the complexity of tests, treatments and procedures available to modern medicine, many do not always add value. Some are rendered redundant as others take their place but continue to be used in practice. Interventions that are not supported by evidence do not lead to high-quality care and may even cause harm. Reasons for unnecessary interventions include lack of time for shared decision-making,3 fear of missing a diagnosis or complaints, financial incentives, the way doctors are taught, patient expectations and avoiding the challenging conversation of telling patients they do not need specific tests or treatment.2 An understanding of what lies behind unnecessary care is required to inform ways of reducing use of these interventions.4
Doctors in New Zealand work in a sector where there are resource limitations, so they have a responsibility to ensure the allocation of health resources is based on need and evidence.5 In a system where resources are constrained, it is unethical as well as inefficient to provide interventions which have no clinical value.
Effective Choosing Wisely programmes are clinician led.6,7 Health professionals can start to challenge themselves and their colleagues on the way they think about health care, questioning the notion ‘more is always better’. They can start a conversation with their colleagues about what care is truly needed—identifying which practices are helpful and which are not.
Already a number of medical colleges, specialty societies and associations in New Zealand have come together to identify practices that warrant scrutiny, examining the evidence and drawing on the expert opinion of their members to develop a list of five recommendations of tests, treatments and procedures to question. Over 50 recommendations have been developed so far that are relevant to practice in New Zealand. These lists are available from the Choosing Wisely New Zealand website (www.choosingwisely.org.nz). Each recommendation is based on the best available evidence. These lists are not prescriptive but are intended as a guide to start a conversation about what is appropriate and necessary for an individual patient. Recommendations must be reviewed on an ongoing basis to ensure credibility.6
International experience has identified that multidisciplinary health professional involvement is also key to a successful Choosing Wisely campaign.2 The Council of Medical Colleges has had initial discussions with national health professional organisations representing pharmacists, allied health professionals, nurses and midwives. Working with other health professionals will be a priority over the next year.
Patient/consumer engagement is central in reducing unnecessary interventions and hence the Council of Medical Colleges has partnered with Consumer NZ in the campaign. Some patient/consumer educational material has been developed to inform people why more care is not necessarily better and why certain interventions are no longer recommended. Health professionals need to hold conversations with patients to ensure they understand the evidence relating to the care being proposed so patients can make informed choices.
Patients/consumers should be encouraged to ask the four Choosing Wisely questions as part of their decision-making about their care:
- Do I really need to have this test, treatment or procedure?
- What are the risks (of having or not having it)?
- Are there simpler, safer options?
- What happens if I do nothing?
Implementation is best carried out at a local level from the bottom-up.7 This may involve an individual department or service selecting relevant recommendations that have already been developed, modifying these recommendations to suit local circumstances or deriving their own recommendations. Stinnett-Donnelly et al (2016) have developed a framework to assist selection based on complexity, value and controversy. The Council of Medical Colleges has produced guides to help colleges, specialty societies, associations and health care services develop and implement their own recommendations about interventions whose necessity should be questioned and discussed. Reported variations in doctors’ attitudes across adult primary care recommendations suggest implementation efforts will need to be adapted to the identified barriers in implementing each Choosing Wisely recommendation.3 Support for doctors in dealing with uncertainty associated with conservative management and that addresses drivers of unnecessary care may be beneficial.4
The impact of Choosing Wisely depends on how effective dissemination and uptake of the recommendations is. Evaluation is critical and needs to occur concurrently. This needs to be considered when developing and implementing a recommendation as, in some instances, the data needed for evaluation may not be readily available. Evaluation is easier if data can be obtained from pre-existing electronic systems and does not require manual record review, which is more resource-intensive. A range of measurement tools for assessing health professionals’ awareness, attitudes and behaviour, and patient engagement and acceptance have also been identified.8
Evidence about the effectiveness of Choosing Wisely is starting to emerge. In Canada, provision of Choosing Wisely educational material in primary care waiting rooms improved knowledge around unnecessary care.9 Changes in frequency of Choosing Wisely services over the first two to three years have been mixed.7,10 Factors that affected success include senior leadership support, a bottom-up approach by clinical champions and financial incentives to cap hospital revenue expansion.7 Additional measures such as decision-making tools that assist informed discussion with patients and electronic best practice alerts rather than just the provision of information may be required to affect change.7,11 Decisions should be made on the best match between evidence about the benefits and harms of each intervention and the goals and preferences of the patient.11 Don’t do something because it can be done; do it if it is necessary for your patient.