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Response to ‘Choosing Wisely should bring the cost of unnecessary care back into the discussion’; Choosing Wisely’: a growing international campaign
  1. Karen B Born1,
  2. Wendy Levinson2
  1. 1 Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario
  2. 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Wendy Levinson, Department of Medicine, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B1W8; wendy.levinson{at}

Statistics from

There are now approximately 20 countries worldwide that have launched or are in the process of launching Choosing Wisely campaigns.

As Haverkamp and colleagues have identified,1 Choosing Wisely campaigns have galvanised physicians worldwide to acknowledge their collective responsibility in reducing overuse and reducing harm associated with unnecessary care. And yes, cost is a tension in the campaign, and it would be naïve to say it is not a consideration. However, we maintain that in order to engage physicians in reducing unnecessary care, the focus cannot be on costs, but rather on reducing unnecessary care at each clinical encounter to improve quality and avoid harm.

Physicians' clinical decisions are largely responsible for unsustainable healthcare spending and the great deal of waste we see in healthcare systems worldwide. However, research highlights that physicians struggle with the acceptability of efforts to curb healthcare costs by influencing how they deliver direct patient care.2 Efforts to ‘ration’ patient care at the bedside are viewed with derision by practising physicians who are concerned primarily with patient outcomes and preserving their clinical autonomy. Patients and the general public also are very wary of anything that smacks of rationing care to save money for the system.

This is why Choosing Wisely campaigns do not focus on saving costs, but rather on improving quality and on conversations between clinicians and patients as a means to reduce unnecessary care. The promise of the conversation is that shared decision making will reduce unnecessary care, ultimately improving quality of care and patient outcomes, and in some cases saving dollars downstream.3

The focus on conversations, however, has not as per the authors’ assertion meant that campaigns do ‘not fully cover the problem because there are also instances of truly wasteful medical interventions that should not be up for discussion’. Choosing Wisely campaigns have spurred increasing physician awareness about overuse and have highlighted wasteful and unnecessary care.

This is reflected in the clinician-specialty society lists that have been generated worldwide and in the thousands of recommendations in these lists. Importantly, recommendations span clinical decision making that happens ‘behind the curtain’ and away from the bedside. For examples, recommendations such as those focused on reducing unnecessary transfusions, or preoperative testing prior to low-risk surgery, reflect broader systems and habits of physician practice that are unrelated to the conversation, but are quite wasteful. In Canada, there has been traction implementing these recommendations by changing order sets or introducing medical directives.4 ,5 Patients do not demand receiving two units of blood rather than one when being transfused in hospital, nor do they demand preoperative ECGs when having a consult for a low-risk surgery. These wasteful practices have been embedded into our healthcare system, and Choosing Wisely campaigns have driven some success in changing these practices. Such implementation efforts can lead to cost savings or the redirection of dollars to other areas of clinical need. This is not unique to Canada, and there is a growing body of literature detailing successful implementation efforts associated with Choosing Wisely recommendations that have reduced unnecessary laboratory tests and blood transfusions, for example6 ,7

Haverkamp and colleagues also appeal to campaigns to collaborate further with governments. In fact, this is already happening ‘behind the scenes’ as they suggest. In Canada, for example, Choosing Wisely Canada was launched with a grant from the Ontario Ministry of Health and Long-Term Care and is currently funded by Health Canada along with provincial and territorial ministries of health. We are independent from government and work in partnership with independent national clinical societies and associations. Our accountability to government is not to save dollars, but to raise physician and patient awareness about overuse, improve quality and reduce harmful or wasteful care. Our goals are complementary with government goals of improving value and sustainability while maintaining a high-quality healthcare system. In Canada, we were very clear with governments in our single-payer system, that they needed to give the Choosing Wisely campaign complete autonomy to allow physicians and other health professionals to lead the programme. There is a similar arrangement in Australia. The Choosing Wisely Australia campaign is an initiative of NPS Medicine Wise, which is funded by the Department of Health, but is an independent, not-for-profit organisation at arm's length from government.

The authors' letter acknowledges the tensions Choosing Wisely campaigns face, as campaigns are taking place in a broader healthcare environment where government and payers are struggling to contain healthcare costs. However, rethinking our strategy, which until now, has engaged a broad coalition of clinicians to tackle overuse, would be harmful to the ongoing engagement of clinicians in the campaign and the fidelity of campaigns. Rather, we see that campaigns do indirectly impact costs and that this indirect lever of influence, through physician conversations about unnecessary care and increased awareness of unnecessary care, is a stronger lever than a more direct focus on costs. As such, we are committed to staying the course, rather than pivoting to shift our focus. Costs are in the background, but the conversation between clinicians and patients remains at the centre of Choosing Wisely campaigns.



  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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