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Low value cardiac testing and Choosing Wisely
  1. R Sacha Bhatia1,2,3,
  2. Wendy Levinson3,4,
  3. Douglas S Lee2,3
  1. 1Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada
  2. 2Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
  3. 3University of Toronto, Toronto, Ontario, Canada
  4. 4Saint Michael's Hospital, Toronto, Ontario, Canada
  1. Correspondence to Dr R Sacha Bhatia, Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network and Women's College Hospital, University of Toronto, 76 Grenville Street, 6th Floor, Toronto, Ontario M5S 1B2, Canada; sacha.bhatia{at}

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Just a few years prior to the famous Institute of Medicine (IOM) reports on safety and quality, an earlier IOM report classified all quality problems in healthcare as falling into three broad categories: underuse, overuse and misuse.1 Until recently, however, the focus on quality has been almost exclusively on the underuse and misuse, and overuse has received much less attention.2 This focus is particularly surprising, as much of the early work in healthcare quality focused on overuse. In particular, early research done on the geographical variation of healthcare service delivery implied that a significant proportion of healthcare services, such as surgical procedures, were not necessary.3 ,4 Despite this early research, the majority of quality improvement efforts over the past decade were directed towards improving patient safety and addressing care gaps related to the underuse of health services.

More recently, with healthcare systems worldwide struggling to contain rising costs, overuse of healthcare services is beginning to receive more attention. In an effort at bringing attention to the generally accepted notion that excessive use of low-value care is a contributor to those costs, and that overuse of tests and treatments may lead to potential patient harm, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign in 2012. This physician-designed and led campaign focuses on developing ‘top 5 lists’ of tests, treatments and procedures in various specialties that were deemed to be unnecessary and potentially harmful.5 This campaign now has 60 US specialty societies, but participation is growing internationally, including Canada, the Netherlands, Italy, Japan and others.

A major question asked by clinicians, health policy experts and payers (either government or health insurers) is: what is the prevalence of low-value care in clinical practice? Colla and colleagues have examined the question in this study. The …

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