Choosing Wisely

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Logo for the campaign Choosing Wisely logo.png
Logo for the campaign

Choosing Wisely is a United States-based health educational campaign, led by the ABIM Foundation (American Board of Internal Medicine), about unnecessary health care. [1]

Contents

The campaign identifies over 500 tests and procedures and encourages doctors and patients to discuss, research, and possibly get second opinions, before proceeding with them. [2] To conduct the campaign, the ABIM Foundation asks medical specialty societies to make five to ten recommendations for preventing overuse of a treatment in their field. The foundation then publicizes this information, and the medical specialty societies disseminate it to their members.

The campaign has garnered both praise and criticism, and some of its ideas have spread to other countries. It does not include evaluation of its effects on costs, on discussions or on medical outcomes. [3] Some doctors have said they lack time for the recommended discussions. [2]

History

Christine K. Cassel of Choosing Wisely explains the campaign, 2 August 2012

In 2002 the ABIM Foundation published Medical professionalism in the new millennium: a Physician Charter. [1] [4] The charter states that physicians have a responsibility to promote health equity when some health resources are scarce. [1] As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members. [1] [5] [6] In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists". [1] [7] [8] Analysis of the National Physician's Alliance project predicted that the health field could have saved US$6.8 billion in 2009 by cutting spending on the 15 services in the lists from three societies, [9] out of total US health spending that year of US$2.5 trillion. [10] US$5.8 billion of the savings were from one recommendation: using generic rather than brand name statin. [9]

Continuing this project, Choosing Wisely was created to organise the creation of more "lists of five," later ten, [11] and their distribution to more physicians and patients. [1] [12] Executive boards of societies, with or without participation by members, identify practices which their field may overuse. [13] [1] Each recommendation in the program must have the support of clinical guidelines, evidence, or expert opinion. [1]

To participate in Choosing Wisely, each society developed list of tests, treatments, or services which that specialty commonly overuses. [1] The society shares this information with their members, as well as organizations who can publicize to local community groups, and in each community patients and doctors can consider the information as they like. [1] The ABIM Foundation gave grants to help societies participate. [14]

As of April 2018, there were 552 recommendations targeting a range of procedures to either question or avoid without special consideration. [15] They can be searched online by key words, such as "back pain" but the numerous supporting footnotes on each recommendation are only in a pdf on the clinician page, without links to the papers. [11]

Examples

Some examples of the information shared in Choosing Wisely include the following:

Challenges

The Choosing Wisely campaign identifies the following difficulties in achieving its goals:

Reception

The American College of Emergency Physicians (ACEP) initially formed three independent task forces to evaluate whether to participate; by 2012 all three task forces recommended against participation because the recommendations do not recognize that emergency physicians need extra tests, since they do not know the patients, do not recognize that emergency physicians need to eliminate every life-threatening possibility, will lead to refusals by insurers to cover items on the lists, let other medical societies tell emergency physicians what to do, and because the campaign doesn't address tort reform to address defensive testing, and the campaign publicizes the items as "unnecessary tests" even though describing them as tests to discuss carefully. [24]

In 2012 The New York Times said that the campaign was likely to "alter treatment standards in hospitals and doctors' offices nationwide" and one of their opinion writers said that many tests were unnecessary. [25] CBS News said that "the evidence is on the initiative's side." [26] USA Today noted that the campaign was "a rare coordinated effort among multiple medical societies". [27]

While expressing the need for evidence-based healthcare recommendations, in 2012 The Economist found the Choosing Wisely recommendations to be weak because they are not enforceable. [28] In an editorial published in the Southwest Journal of Pulmonary and Critical Care, Richard Robbin and Allen Thomas expressed concern that the campaign could be used by payers to limit options for doctors and patients. However, they declare the Choosing Wisely recommendations a "welcome start." [29]

Also in 2012, Robert Goldberg, writing for The American Spectator , criticized the program saying that it was "designed to sustain the rationale and ideology that shaped Obamacare" (the Patient Protection and Affordable Care Act), that the lists were "redundant and highly subjective", and that participants in the effort would greedily benefit at the expense of others if the campaign succeeded. [30]

In February 2013 the Robert Wood Johnson Foundation provided USD $2.5 million in funding for the campaign, saying that the foundation wanted to "help increase the tangible impact of the Choosing Wisely campaign". [31]

A 2013 editorial in the journal of the Netherlands Society of Cardiology reviewed the recommendations and recommended that something similar be proposed by the society; the piece did criticize the overly didactic nature of the recommendations, comparing them to the Ten Commandments, and expressed concern about whether they adequately addressed the difficulties of assessing risks for each patient. [32] In 2013 critics in the Southwest Journal of Pulmonary & Critical Care said, "the present Choosing Wisely campaign has fundamental flaws—not because it is medically wrong but because it attempts to replace choice and good judgment with a rigid set of rules that undoubtedly will have many exceptions. Based on what we have seen so far, we suspect that Choosing Wisely is much more about saving money than improving patient care. We also predict it will be used by the unknowing or unscrupulous to further interfere with the doctor-patient relationship." [33]

In 2015 the campaign was criticized by Bob Lanier, executive director of a medical specialty society and past president of the Texas Medical Association Foundation, who said that the recommendations were compiled by societies' executive committees without good evidence and without following standards of practice or research, will lead to refusals by insurers to cover items on the lists, are biased against diagnostic testing, are an effort by supporters of single-payer healthcare to reduce costs so that single-payer healthcare becomes affordable, will encourage biased studies by authors funded by insurers and health delivery systems, to cut their costs, and were influenced by grants available from the ABIM Foundation. [13]

In 2015 a piece in Newsweek by Kurt Eichenwald described a controversy around the ABIM Foundation's lack of transparency about its finances and functioning. [34]

In 2016 campaign was described as an attempt to encourage doctors and patients to recognize the illusion of control or "therapeutic illusion" in choices to use treatments which have a basis outside of evidence-based medicine. [35]

In 2017 addiction specialists in Canada said the recommendation to wait for sobriety before treating depression was harmful and unjustified. [36]

A 2017 study reported that many patients and physicians found it challenging to use Choosing Wisely recommendations, particularly when the patient had symptoms, and the doctor recommended against a test. Barriers "included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists. [2] Cedars–Sinai Medical Center in Los Angeles put 100 of the 552 Choosing Wisely items in its electronic medical records. These give warnings to doctors, but only after they have finished talking to patients and order a procedure or drug, so too late to have the recommended discussion. [14]

Impact

The Choosing Wisely campaign makes no provision to scientifically research its own efficacy, but academic centers are making plans to independently report on the impact of the campaign. [37] The services targeted by the Choosing Wisely lists have broad variance in how much impact they can have on patients' care and costs. [38] Doctors analyzed many services listed as low value by Choosing Wisely and other sources, and found that 25% or 42% of Medicare patients received at least one of these services in an average year, depending on definitions. The services represented 0.6% or 2.7% of Medicare costs [39] and there was no significant pattern among types of physicians. [40]

The campaign has been cited as being part of a broader movement including many comparable campaigns. [41] The German Network for Evidence Based Medicine considered adapting concepts from the program into the German healthcare system. [42] In April 2014, Choosing Wisely Canada launched. [43] Choosing Wisely Canada is organized by the Canadian Medical Association and the University of Toronto, and is chaired by Dr. Wendy Levinson. By 2015 and following the Choosing Wisely precedent established in the United States, doctors in Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, New Zealand, Switzerland, and Wales were exploring whether and how to bring ideas from Choosing Wisely to their countries. [44] English doctors "are worried how patients will perceive the initiative." [14]

Related Research Articles

Internal medicine, also known as general internal medicine in Commonwealth nations, is a medical specialty for medical doctors focused on the prevention, diagnosis, and treatment of internal diseases in adults. Medical practitioners of internal medicine are referred to as internists, or physicians in Commonwealth nations. Internists possess specialized skills in managing patients with undifferentiated or multi-system disease processes. They provide care to both hospitalized (inpatient) and ambulatory (outpatient) patients and often contribute significantly to teaching and research. Internists are qualified physicians who have undergone postgraduate training in internal medicine, and should not be confused with "interns", a term commonly used for a medical doctor who has obtained a medical degree but does not yet have a license to practice medicine unsupervised.

<span class="mw-page-title-main">Physical examination</span> Process by which a medical professional investigates the body of a patient for signs of disease

In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. These data then become part of the medical record.

<span class="mw-page-title-main">Primary care physician</span> US term for medical professional providing first-line care

A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The term is primarily used in the United States. In the past, the equivalent term was 'general practitioner' in the US; however in the United Kingdom and other countries the term general practitioner is still used. With the advent of nurses as PCPs, the term PCP has also been expanded to denote primary care providers.

Defensive medicine, also called defensive medical decision making, refers to the practice of recommending a diagnostic test or medical treatment that is not necessarily the best option for the patient, but mainly serves to protect the physician against the patient as potential plaintiff. Defensive medicine is a reaction to the rising costs of malpractice insurance premiums and patients’ biases on suing for missed or delayed diagnosis or treatment but not for being overdiagnosed.

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.

David Lawrence Sackett was an American-Canadian physician and a pioneer in evidence-based medicine. He is known as one of the fathers of Evidence-Based Medicine. He founded the first department of clinical epidemiology in Canada at McMaster University, and the Oxford Centre for Evidence-Based Medicine. He is well known for his textbooks Clinical Epidemiology and Evidence-Based Medicine.

<span class="mw-page-title-main">Caregiver</span> Person helping another with activities of daily living

A caregiver, carer or support worker is a paid or unpaid person who helps an individual with activities of daily living. Caregivers who are members of a care recipient's family or social network, and who may have no specific professional training, are often described as informal caregivers. Caregivers most commonly assist with impairments related to old age, disability, a disease, or a mental disorder.

The American Board of Internal Medicine (ABIM) is a 501(c)(3) nonprofit, self-appointed physician-evaluation organization that certifies physicians practicing internal medicine and its subspecialties. The American Board of Internal Medicine is not a membership society, educational institution, or licensing body.

<span class="mw-page-title-main">National Physicians Alliance</span>

The National Physicians Alliance (NPA) was a 501(c)(3) national, multi-specialty medical organization founded in 2005. The organization's mission statement was: "The National Physicians Alliance creates research and education programs that promote health and foster active engagement of physicians with their communities to achieve high quality, affordable health care for all. The NPA offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice." In 2019, they merged with Doctors for America.

John E. "Jack" Wennberg was the pioneer and leading researcher of unwarranted variation in the healthcare industry. In four decades of work, Wennberg has documented the geographic variation in the healthcare that patients receive in the United States. In 1988, he founded the Center for the Evaluative Clinical Sciences at Dartmouth Medical School to address that unwarranted variation in healthcare.

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David M. Eddy is an American physician, mathematician, and healthcare analyst who has done seminal work in mathematical modeling of diseases, clinical practice guidelines, and evidence-based medicine. Four highlights of his career have been summarized by the Institute of Medicine of the National Academy of Sciences: "more than 25 years ago, Eddy wrote the seminal paper on the role of guidelines in medical decision-making, the first Markov model applied to clinical problems, and the original criteria for coverage decisions; he was the first to use and publish the term 'evidence-based'."

Unnecessary health care is health care provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending in 2012.

<span class="mw-page-title-main">Computed tomography of the head</span> Cross-sectional X-rays of the head

Computed tomography of the head uses a series of X-rays in a CT scan of the head taken from many different directions; the resulting data is transformed into a series of cross sections of the brain using a computer program. CT images of the head are used to investigate and diagnose brain injuries and other neurological conditions, as well as other conditions involving the skull or sinuses; it used to guide some brain surgery procedures as well. CT scans expose the person getting them to ionizing radiation which has a risk of eventually causing cancer; some people have allergic reactions to contrast agents that are used in some CT procedures.

Overscreening, also called unnecessary screening, is the performance of medical screening without a medical indication to do so. Screening is a medical test in a healthy person who is showing no symptoms of a disease and is intended to detect a disease so that a person may prepare to respond to it. Screening is indicated in people who have some threshold risk for getting a disease, but is not indicated in people who are unlikely to develop a disease. Overscreening is a type of unnecessary health care.

Preoperative care refers to health care provided before a surgical operation. Preoperative care aims to do whatever is right to increase the success of the surgery.

Penny Wise Budoff was an American physician. She was a family practitioner, and a clinical associate professor of family medicine at the State University of New York at Stony Brook. She is known for her research, which established that menstrual cramping is a physical phenomenon rather than a psychological one. She wrote two books on women's health.

<span class="mw-page-title-main">Wendy Levinson</span> Canadian physician and academic

Wendy Levinson MD is a Canadian physician and academic. She is the Chair of Choosing Wisely Canada, "a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures". She is also Professor of Medicine at the University of Toronto.

Conflict of interest in the health care industry occurs when the primary goal of protecting and increasing the health of patients comes into conflict with any other secondary goal, especially personal gain to healthcare professionals, and increasing revenue to a healthcare organization from selling health care products and services. The public and private sectors of the medical-industrial complex have various conflicts of interest which are specific to these entities.

Choosing Wisely Canada (CWC) is a Canadian-based health education campaign launched on April 2, 2014 under the leadership of Wendy Levinson, in partnership with the Canadian Medical Association, and based at Unity Health Toronto and the University of Toronto. The campaign aims to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to assist physicians and patients in making informed and effective choices to ensure high quality care.

References

  1. 1 2 3 4 5 6 7 8 9 10 Cassel, Christine. K. (of Choosing Wisely); Guest, James A. (of Consumer Reports) (2012). "Choosing Wisely - Helping Physicians and Patients Make Smart Decisions About Their Care". The Journal of the American Medical Association. 307 (17): 1801–1802. doi:10.1001/jama.2012.476. PMID   22492759.
  2. 1 2 3 Zikmund-Fisher, BJ; Kullgren, JT; Fagerlin, A; Klamerus, ML; Bernstein, SJ; Kerr, EA (February 2017). "Perceived Barriers to Implementing Individual Choosing Wisely Recommendations in Two National Surveys of Primary Care Providers". Journal of General Internal Medicine. 32 (2): 210–217. doi:10.1007/s11606-016-3853-5. PMC   5264674 . PMID   27599491.
  3. ↑ "Who We Are & History". ABIM Foundation. Retrieved 2020-07-07.
  4. ↑ ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. (5 February 2002). "Medical professionalism in the new millennium: a physician charter". Annals of Internal Medicine. 136 (3): 243–6. doi:10.7326/0003-4819-136-3-200202050-00012. PMID   11827500. S2CID   31458818.
  5. ↑ Brody, H. (2010). "Medicine's Ethical Responsibility for Health Care Reform — the Top Five List". New England Journal of Medicine. 362 (4): 283–285. doi:10.1056/NEJMp0911423. PMID   20032315.
  6. ↑ Brody, H. (2012). "From an Ethics of Rationing to an Ethics of Waste Avoidance". New England Journal of Medicine. 366 (21): 1949–1951. doi:10.1056/NEJMp1203365. PMID   22551106.
  7. ↑ Kuehn, B. M. (2012). "Movement to Promote Good Stewardship of Medical Resources Gains Momentum". The Journal of the American Medical Association. 307 (9): 895–903. doi:10.1001/jama.2012.218. PMID   22396505.
  8. ↑ Good Stewardship Working, G. (2011). "The "Top 5" Lists in Primary Care - Meeting the Responsibility of Professionalism". Archives of Internal Medicine. 171 (15): 1385–1390. doi:10.1001/archinternmed.2011.231. PMID   21606090.
  9. 1 2 Kale, MS; Bishop, TF; Federman, AD; Keyhani, S (14 November 2011). ""Top 5" lists top $5 billion". Archives of Internal Medicine. 171 (20): 1856–8. doi: 10.1001/archinternmed.2011.501 . PMID   21965814.
  10. ↑ "Table 1 National Health Expenditures". www.cms.gov. Retrieved 2018-12-05.
  11. 1 2 "All Choosing Wisely Recommendations" (PDF). Retrieved 2018-04-20.
  12. ↑ Dismuke, SE; Miller, ST (May 2013). ""Choosing wisely"--medicine's ethical responsibility for Healthcare Reform. The top five list". Tennessee Medicine. 106 (5): 23–6. PMID   23691867.
  13. 1 2 "Think Twice Before Choosing Wisely". www.texmed.org. March 2015. Retrieved 2018-05-22.
  14. 1 2 3 Vogel, Lauren (2015-08-11). "Choosing Wisely around the world". Canadian Medical Association Journal. 187 (11): E341–E342. doi:10.1503/cmaj.109-5111. ISSN   0820-3946. PMC   4527925 . PMID   26170270.
  15. ↑ "Search Recommendations". www.choosingwisely.org. Retrieved 2018-04-20.
  16. ↑
    • Graber, M. L. (2012). "Bringing Diagnosis into the Quality and Safety Equations - Bringing Diagnosis into Quality and Safety Efforts". The Journal of the American Medical Association. 308 (12): 1211–1212. doi:10.1001/2012.jama.11913. PMID   23011708.
    • Emanuel, E.; Tanden, N.; Altman, S.; Armstrong, S.; Berwick, D.; De Brantes, F. O.; Calsyn, M.; Chernew, M.; Colmers, J.; Cutler, D.; Daschle, T.; Egerman, P.; Kocher, B.; Milstein, A.; Oshima Lee, E.; Podesta, J. D.; Reinhardt, U.; Rosenthal, M.; Sharfstein, J.; Shortell, S.; Stern, A.; Orszag, P. R.; Spiro, T. (2012). "A Systemic Approach to Containing Health Care Spending". New England Journal of Medicine. 367 (10): 949–954. doi: 10.1056/NEJMsb1205901 . PMID   22852883.
  17. ↑
    • Quinn, K. (2012). "Reducing Radiology Use on an Inpatient Medical Service: Choosing Wisely". Archives of Internal Medicine. 172 (20): 1606–8. doi:10.1001/archinternmed.2012.4293. PMID   22928182.
    • Forman, H. P.; Larson, D. B.; Kazerooni, E. A.; Norbash, A.; Crowe, J. K.; Javitt, M. C.; Beauchamp, N. J.; Mendelson, E. B. (2012). "Masters of Radiology Panel Discussion: Hyperefficient Radiology—Can We Maintain the Pace?". American Journal of Roentgenology. 199 (4): 838–843. doi:10.2214/AJR.12.9648. PMID   22997376.
  18. ↑ Szabo, Liz (22 February 2013). "Doctors group says some tests should be used sparingly". USA Today . McLean, VA: Gannett. ISSN   0734-7456 . Retrieved 22 February 2013.
  19. 1 2 3 4 5 6 7 Volpp, K. G.; Loewenstein, George; Asch, David A. (2012). "Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing". The Journal of the American Medical Association. 308 (16): 1635–1636. doi:10.1001/jama.2012.13616. PMC   3994996 . PMID   23093160.
  20. ↑ Bloche, M. G. (2012). "Beyond the "R Word"? Medicine's New Frugality". New England Journal of Medicine. 366 (21): 1951–1953. doi:10.1056/NEJMp1203521. PMID   22551108.
  21. ↑
  22. ↑
  23. ↑ Zadro, Joshua R.; Farey, John; Harris, Ian A.; Maher, Christopher G. (2019). "Do choosing wisely recommendations about low-value care target income-generating treatments provided by members? A content analysis of 1293 recommendations". BMC Health Services Research. 19 (1): 707. doi: 10.1186/s12913-019-4576-1 . PMC   6844045 . PMID   31707993.
  24. ↑ Seaberg, David (2012-05-08). "Pro/Con: Why ACEP Should Not Join the 'Choosing Wisely' Campaign - Emergency Physicians Monthly". Emergency Physicians Monthly. Retrieved 2018-11-23.
  25. ↑ Rabin, Roni Caryn (April 4, 2012). "Doctor Panels Urge Fewer Routine Tests - NYTimes.com". The New York Times. AND Rosenthal, Elisabeth (2 June 2012). "Let's (Not) Get Physicals". The New York Times Company.
  26. ↑ Jaslow, Ryan (April 4, 2012). "Doctors unveil 'Choosing Wisely' campaign to cut unnecessary medical tests". CBS News . New York: CBS . Retrieved 10 October 2012.
  27. ↑ Hellmich, Nanci (4 April 2012). "Coalition of medical societies urges questioning treatments". USA Today . McLean, VA: Gannett. ISSN   0734-7456 . Retrieved 15 October 2012.
  28. ↑ "Evaluating medical treatments: Evidence, shmevidence". economist.com. 16 June 2012. Retrieved 16 October 2012.
  29. ↑ Robbins, Richard A.; Allen R. Thomas (2012). "Will Fewer Tests Improve Healthcare or Profits?". Southwest Journal of Pulmonary and Critical Care. 4: 111–113. Retrieved 10 October 2012.[ permanent dead link ]
  30. ↑ Goldberg, Robert M. (13 April 2012). "Obamacare's Medical Mercenaries". The American Spectator . Archived from the original on 9 July 2017. Retrieved 16 October 2012.
  31. ↑ Japsen, Bruce (21 February 2013). "Doctors Call Out 90 More Unnecessary Medical Tests, Procedures - Forbes". forbes.com. Retrieved 22 February 2013.
  32. ↑ Boer, M. -J.; Wall, E. E. (2012). "Choosing wisely or beyond the guidelines". Netherlands Heart Journal. 21 (1): 1–2. doi:10.1007/s12471-012-0352-0. PMC   3528861 . PMID   23203730.
  33. ↑ Robbins, Richard A.; Thomas, Allen R. (4 June 2013). "Choosing Wisely-Where Is the Choice?". Southwest Journal of Pulmonary & Critical Care. Archived from the original on 20 April 2014. Retrieved 19 November 2013.
  34. ↑ Eichenwald, Kurt (21 May 2015). "Medical mystery: making sense of ABIM's financial report". Newsweek.
  35. ↑ Casarett, David (31 March 2016). "The Science of Choosing Wisely — Overcoming the Therapeutic Illusion". New England Journal of Medicine. 374 (13): 1203–1205. doi:10.1056/NEJMp1516803. PMID   27028909.
  36. ↑ Tanguay, Robert L.; Lamba, Wiplove; Fraser, Ronald; Mills, Phillip; Azarbar, Ataa; el-Guebaly, Nady (2017-03-20). "Alcohol use disorder and depression: proposed rewording of Choosing Wisely recommendation". Canadian Medical Association Journal. 189 (11): E442–E443. doi:10.1503/cmaj.732873. ISSN   0820-3946. PMC   5359096 . PMID   28385718.
  37. ↑ Wang, Shirley S. (20 February 2013). "Group Urges Health-Test Curbs". The Wall Street Journal . New York: Dow Jones. ISSN   0099-9660 . Retrieved 22 February 2013.
  38. ↑ Morden, N. E.; Colla, C. H.; Sequist, T. D.; Rosenthal, M. B. (2014). "Choosing Wisely — the Politics and Economics of Labeling Low-Value Services". New England Journal of Medicine. 370 (7): 589–92. doi:10.1056/NEJMp1314965. PMC   4104300 . PMID   24450859.
  39. ↑ McWilliams, J. Michael; Chernew, Michael E.; Elshaug, Adam G.; Landon, Bruce E.; Schwartz, Aaron L. (2014-07-01). "Measuring Low-Value Care in Medicare". JAMA Internal Medicine. 174 (7): 1067–1076. doi:10.1001/jamainternmed.2014.1541. ISSN   2168-6106. PMC   4241845 . PMID   24819824.
  40. ↑ McWilliams, J. Michael; Zaslavsky, Alan M.; Jena, Anupam B.; Schwartz, Aaron L. (2018-12-03). "Analysis of Physician Variation in Provision of Low-Value Services". JAMA Internal Medicine. 179 (1): 16–25. doi:10.1001/jamainternmed.2018.5086. PMC   6583417 . PMID   30508010.
  41. ↑ Tiefer, L.; Witczak, K.; Heath, I. (2013). "A call to challenge the "Selling of Sickness"". BMJ. 346: f2809. doi:10.1136/bmj.f2809. PMID   23674139. S2CID   28573883.
  42. ↑ Strech, Daniel (30 May 2013). "Eine Choosing Wisely Initiative für Deutschland?". Informationsdienst Wissenschaft (in German). Retrieved 7 June 2013.
  43. ↑ Glauser, W. (2014). "Choosing Wisely campaign well received". Canadian Medical Association Journal. 186 (8): E239–E240. doi:10.1503/cmaj.109-4779. PMC   4016078 . PMID   24710907.
  44. ↑ Levinson, W.; Kallewaard, M.; Bhatia, R. S.; Wolfson, D.; Shortt, S.; Kerr, E. A.; Burgers, J.; Cucic, C.; Daniels, M.; Forde, I.; Geerlings, S.; Gogol, M.; Haverkamp, M.; Henderson, A.; Howson, H.; Huynh, T.; Kievit, J.; Klemperer, D.; Koizumi, S.; Lindner, R.; Maughan, D.; McDonald, K.; Peul, W.; Post, H.; Rodondi, N.; Santa, J.; Schoeler, R.; Smid, H.; Stephenson, T.; Trier, H.; van Barneveld, T.; van der Kraan, J.; Vernero, S.; Wagner, C. (2014). "'Choosing Wisely': a growing international campaign". BMJ Quality & Safety. 24 (2): 167–174. doi:10.1136/bmjqs-2014-003821. ISSN   2044-5415. PMID   25552584. S2CID   5951837.

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