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Tuesday, May 1, 2018

Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network

Choosing Wisely, a campaign to stimulate conversations between physicians and patients about unnecessary tests, treatments, and procedures, began in the United States in 2012. It was designed as a national campaign about overuse. Yet since its launch, the campaign has spread to more than 20 countries worldwide. Choosing Wisely has been hailed by some as a success, evident in its spread internationally and measured through structure and process indicators, such as recommendations developed, societies engaged, and physicians apprised. The conversation has been stimulated, and now delivery systems and clinical practices are beginning to develop interventions that go beyond conversations and recommendations. The success of the campaign in the next 5 years will be measured by the ongoing engagement of physicians in these interventions and, more importantly, associated outcomes. The effectiveness of quality improvement efforts by these delivery systems will determine how influential campaigns are in actually reducing unnecessary tests and treatments—a true measure of benefit.1

Choosing Wisely will also contribute to controlling rising health expenditures by engaging patients, and making them aware of the conflict between expense and proper diagnosis and treatment.  The issue of cost control thus far has been an upward-down plan.  Choosing Wisely now will create a downward-up path, and enable patients to help control costs.

The age of data analytics which has been empowered by health information technology has created an enormous mountain of health care, diagnoses, and treatment, making it possible to create treatments based upon risk and good outcomes along with the quality of care.  

Alignment With Norms and Values

Innovations that are compatible with norms and values of adopters are more likely to be successful. Choosing Wisely focuses on conversations between physicians and patients, the basis of clinical interactions. A concern in advancing campaigns is maintaining the focus on professionalism and ensuring physician autonomy in making decisions with patients.

The concepts of diffusion of innovation are relevant to understanding the success to date of Choosing Wisely campaigns and to informing strategies that would ensure future viability. This Viewpoint uses diffusion of innovation science to explore factors that facilitated the spread of Choosing Wisely campaigns and how these enabling factors can address challenges in dissemination and implementation.
There are various examples of movements to shift medical culture that had early momentum and resulted in significant changes but were met with major challenges around influence and outcomes. Nearly 2 decades ago, the quality and safety movement galvanized the medical community worldwide by identifying the extent to which preventable errors and lapses in safety were occurring. 
Contextual Factors That Influence Diffusion
Although there are concerns about government motivations, to date Choosing Wisely campaigns have aligned diverse groups of stakeholders in medicine and health care systems (such as patient organizations, national clinician societies, and health administrators) on shared goals. Health care reform in the United States and elsewhere—emphasizing payment reform and shifting from volume to value—has made the campaign even more relevant. In other single-payer health care systems, budgetary pressures provide similar impetus. As organizations continue to react to such changes and shape strategy, Choosing Wisely offers an approach that could align physician, patient, and payer interests.
In many countries, health system leaders and managers are partnering with physicians on implementation strategies of campaign recommendations. Although the evidence base for Choosing Wisely is still modest, there is a growing literature demonstrating reductions in utilization through implementation. For example, in Canada and the United States, pilot projects that include well-thought-out interventions to implement recommendations have returned good preliminary results.7 Ultimately, the key to sustained uptake of Choosing Wisely will be more systematic collection and diffusion of this kind of evidence at the system level.

AMA. Published online April 19, 2018. doi:10.1001/jama.2018.2202

Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network

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