Potential limitations
One of the major concerns about the development of top five lists in the US is the potential for individual societies to choose low hanging fruit.
For example, the American Academy of Orthopaedic Surgeons included the use of an over the counter supplement but no major procedures, despite evidence of wide variation in elective knee replacement and arthroscopy rates among Medicare beneficiaries.

Currently, there is also no evidence that lists reduce use of low value medical practices.
One crucial and relevant marker of success would be universal awareness of the Choosing Wisely programme among doctors and patients.
However, despite much publicity in the medical literature, a random telephone survey of 600 US doctors recently conducted by the American Board of Internal Medicine found that only 21% had heard of Choosing Wisely.
The level of public awareness of the campaign, which is a fundamental component to its progress, has not been assessed.

Reducing wasteful and harmful healthcare will require commitment from both doctors and patients, in addition to objective evidence of effectiveness.
The NHS already has good systems for evidence appraisal and health technology assessment, but better and simpler tools are needed to facilitate informed discussion in clinical settings.
Without such robust and easily shared decision aids, systematically updated without bias, patients may be swayed by potential exaggerated claims in the media when new drugs or procedures are introduced.
Lastly, shared decision making does not guarantee lower resource use; greater involvement of patients in deciding their care will require a new set of consultation skills as well as a better range of decision aids.

Call to action and next steps
To ensure the development of a Choosing Wisely culture in clinical practice, the academy suggests:

Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often be the best approach
Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?”

Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education.

Commissioners UK, should consider a different payment incentive for doctors and hospitals. What about in other countries with high levels of Private Medical hospitals
Support from the media and medical publications will be vital because the public education campaign is crucial to the programme’s success. The academy will ensure that the programme is thoughtfully implemented and rigorously evaluated by demonstrating a reduction in wasteful practices within a fixed time scale. It will begin by asking specialty organisations to compile top five lists. All lists will be accompanied by an implementation plan and will be evaluated and monitored to assess their effect on reducing low value healthcare.

The academy has set up a steering group to provide policy advice and direction for the project. The group comprises individual experts, patient groups, college representatives and key stakeholders. It is time for action to translate the evidence into clinical practice and truly wind back the harms of too much medicine.

Full references available from me.

Thought provoking if not anything else!?

G Mohan.