Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

Furlan, Ludovico; Francesco, Pietro Di; Costantino, Giorgio; Montaño, Nixon Arboleda

doi:10.1111/joim.13472

Cited by 3 publications

(4 citation statements)

References 80 publications

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“…Examples included routine diagnostic imaging for low back pain, opioid overuse for non-cancer pain and several types of spinal surgery 2. In recognition of the impact on quality and safety of care and resource stewardship, reducing low-value care has become an international priority, motivating awareness campaigns across 25 countries 3…”

Section: Background and Rationalementioning

confidence: 99%

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Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Altinger,

Sharma,

Maher

et al. 2024

BMJ Open

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IntroductionOpioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural ‘nudge’ interventions on low-value care for ED patients with low back pain.Methods and analysisNUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.Ethics and disseminationThis study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.Trial registration numberACTRN12623001000695.

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Section: Background and Rationalementioning

confidence: 99%

“… 2 In recognition of the impact on quality and safety of care and resource stewardship, reducing low-value care has become an international priority, motivating awareness campaigns across 25 countries. 3 …”

Section: Background and Rationalementioning

confidence: 99%

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Altinger,

Sharma,

Maher

et al. 2024

BMJ Open

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“…Considerations of "too much medicine" and "choosing wisely, " highlight the importance of these potential problems. 5 Over the past decade, clinical researchers have developed models to estimate prognosis in patients with ambulatory HF, using a variety of variables and modeling methods. 6 Some have proved, in validation studies, to have acceptable discrimination (distinguish higher from lower-risk individuals) and calibration (avoiding over-and underestimation of risk).…”

mentioning

confidence: 99%

“…Considerations of “too much medicine” and “choosing wisely,” highlight the importance of these potential problems. 5…”

mentioning

confidence: 99%

Predicting 1-Year Mortality in Outpatients With Heart Failure With Reduced Left Ventricular Ejection Fraction: Do Empiric Models Outperform Physician Intuitive Estimates? A Multicenter Cohort Study

Alba

Buchan

Saha

et al. 2023

Circ: Heart Failure

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Background: Many studies have demonstrated that physicians often err in estimating patient prognosis. No studies have directly compared physician to model predictive performance in heart failure (HF). We aimed to compare the accuracy of physician versus model predictions of 1-year mortality. Methods: This multicenter prospective cohort study on 11 HF clinics in 5 provinces in Canada included consecutive consented outpatients with HF with reduced left ventricular ejection fraction (<40%). By collecting clinical data, we calculated predicted 1-year mortality using the Seattle HF Model (SHFM), the Meta-Analysis Global Group in Chronic HF score, and the HF Meta-Score. HF cardiologists and family doctors, blinded to model predictions, estimated patient 1-year mortality. During 1-year follow-up, we recorded the composite end point of mortality, urgent ventricular assist device implant, or heart transplant. We compared physicians and model discrimination (C statistic), calibration (observed versus predicted event rate), and risk reclassification. Results: The study included 1643 patients with ambulatory HF with a mean age of 65 years, 24% female, and mean left ventricular ejection fraction of 28%. Over 1-year follow-up, 9% had an event. The SHFM had the best discrimination (SHFM C statistic 0.76; HF Meta-Score 0.73; Meta-Analysis Global Group in Chronic Heart Failure 0.70) and calibration. Physicians’ discrimination differed little (0.75 for HF cardiologists and 0.73 for family doctors) but both physician groups substantially overestimated risk by >10% in both low- and high-risk patients (poor calibration). In risk reclassification analysis, among patients without events, the SHFM better classified 51% in comparison to HF cardiologists and 43% in comparison to family doctors. In patients with events, the SHFM erroneously assigned lower risk to 44% in comparison to HF cardiologists and 34% in comparison to family doctors. Conclusions: Family doctors and HF cardiologists showed adequate risk discrimination, with however substantial overestimation of absolute risk. Predictive models showed higher accuracy. Incorporating models in family and HF cardiology practices may improve patient care and resource use in HF with reduced left ventricular ejection fraction. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04009798.

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Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

et al. 2022

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In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient‐centered care. Such initiatives have paved the way to a new “way of thinking.” Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients’ needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while “thinking wisely,” physicians should also “act wisely,” being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.

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Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

Cited by 3 publications

References 80 publications

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Predicting 1-Year Mortality in Outpatients With Heart Failure With Reduced Left Ventricular Ejection Fraction: Do Empiric Models Outperform Physician Intuitive Estimates? A Multicenter Cohort Study

Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

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