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Choosing wisely – less can be more

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Choosing Wisely is an international initiative to reduce unnecessary tests, treatments, and procedures. The campaign started in the United States in 2012, in Canada two years later, and in the United Kingdom in 2016.

Choosing Wisely has expanded to more than 20 countries, including European countries, Brazil, Japan, India, Australia, and New Zealand. Choosing Wisely UK was launched in 2016 by the Academy of Medical Royal Colleges to identify tests, treatments, and procedures of questionable value. These interventions should be discussed carefully with patients before being carried out.

What is the aim of choosing Wisely?

Choosing Wisely aims to help clinicians align with best practices by avoiding interventions that are not supported by evidence. Interventions should be necessary and free from harm. Choosing Wisely reminds clinicians not to duplicate tests or procedures that have already been performed. The campaign is aimed at engaging healthcare professionals (HCPs) and patients (with families) in conversations about unnecessary interventions.

Choosing Wisely is underpinned by six core principles:

  • Health profession led
  • Clear emphasis on improving the quality of care and on harm prevention
  • Multidisciplinary involvement in care provision
  • Patient-focused communication between health professionals and patients
  • Evidence-based
  • Transparency in the process and supporting evidence

Why is Choosing Wisely important?

Diagnosis drives treatment.

Overdiagnosis occurs when a given diagnosis leads to unnecessary treatment and wastage of resources, all whilst fuelling patients’ anxiety.

Overtreatment occurs with treatments that have little evidence of benefit or are excessive (in complexity, duration, or cost) relative to alternative accepted standards.

A report by the Academy of Medical Royal Colleges stated that “doctors have an ethical responsibility to reduce wastage of clinical resource because, in a healthcare system with finite resources, one doctor’s waste is another patient’s delay.”

Dr Jeremy Friedman, a Canadian paediatrician, buttressed this by stating, “In Canada, we are privileged to live in a wealthy country with tremendous resources, but we should not always do things just because we can.” The COVID-19 pandemic has magnified the importance of resource stewardship.

The focus of Choosing Wisely UK is now on shared decision-making (SDM) to encourage patients to get the best from conversations with their HCPs by asking four questions.

  1. What are the Benefits?
  2. What are the Risks?
  3. What are the Alternatives?
  4. What if I do Nothing?

Shared decision-making is a collaborative process. Healthcare practitioners work together with patients to choose tests, treatments and care management or support based on clinical evidence and the patient’s informed preferences and values.

What factors drive over-investigation?

Children are considered especially fragile, and the disease course can be dynamic. This may reinforce the belief that more is better, leading to excessive investigations and overtreatment.

There is limited knowledge of the drivers of over-investigation and overtreatment in paediatric care. Fear of litigation or missing serious conditions, fear of criticism, and following outdated guidelines not reflecting current evidence-based knowledge drive practices that minimise the space for mindful and patient-oriented evaluations.

Time constraints, such as strict schedules and limited duration of visits at general practitioners’ (GP) or paediatricians’ clinics, may also drive medical overactivity. Families and patients may drive over-investigation. Repeated GP and hospital attendance might stimulate increased testing and unnecessary prescriptions.

A survey on the overuse of medical resources in paediatrics showed perceived family and patient expectations as the most important drivers for overtreatment.

Other drivers included the use of national guidelines or recommendations and reducing perceived uncertainty. This intolerance of uncertainty is associated with excessive testing. Despite diverse cultural and economic environments, the patterns and drivers for increased investigations were similar. Fear of a medical error is a frequent reason for over-investigation.

What are the consequences of over-testing?

A culture of “more is better,” where clinicians believe or feel they have to do something, has propagated unbalanced decision-making. This culture stems from defensive medicine, work pressure and commercial conflicts of interest and threatens the sustainability of high-quality healthcare.

Malhotra et al. (2015) highlighted that a poor understanding of statistics often results in a belief that screening is more beneficial than it actually is. There is limited acknowledgement of the potential harms of any given test. This raises the question: What are routine bloods? There should be no such thing as routine bloods. Targeted blood testing is the way to go.

Wasteful practices are multifactorial – from individual behaviour and practices of professionals to wider inefficiencies of systems. These have significant negative consequences on the patient, healthcare system and the environment.

Unnecessary blood testing can be the starting point for a diagnostic dilemma, anxiety to families and increased healthcare costs.

Choosing Wisely in Paediatric Care

A trainee-led project in a UK tertiary paediatric emergency department looked at the usefulness of blood tests in 101 children. 70% had liver function tests. 47% had a bone profile. 44% had cultures, and 32% had a clotting profile done. Over half of these blood tests had no clear clinical indication. None of these tests picked up anything clinically significant.

Regan et al. designed a project to reduce unnecessary biochemistry tests (liver and bone profiles) on a paediatric cardiology ward. When renal function tests were clinically indicated, doctors ordered a combined biochemical test (i.e., combinations of renal, bone and liver profiles, other electrolytes and C-reactive protein). The authors identified a lack of understanding of the usefulness of tests by those requesting them. The education-based Quality Improvement Project (QIP) looked to reduce requests of these costly, unnecessary combined biochemical tests by supporting and encouraging staff to switch to a simpler renal function assay.

You are the paediatric doctor on call.

You receive a referral for a 7-year-old Josh, who presented to the emergency department (ED) with a 5-day history of fever, cough, and borderline oxygen saturation.

The ED clinician made an impression of a chest infection.

A chest radiograph was requested, and blood samples were sent for full blood count, urea and electrolyte, liver blood test, C-reactive protein, clotting profile, and blood culture. Clinical and radiological findings supported the diagnosis of pneumonia.

You wondered how useful the liver function tests and blood cultures were.

What exactly are Liver Function Tests?

Liver blood tests have historically been referred to as liver function tests (LFTs), but the predominant abnormality relates not to liver dysfunction but to elevations of hepatobiliary liver enzymes (due to liver injury). Bilirubin, albumin, and INR are true tests of liver function.

Liver blood tests may produce abnormal results with unclear clinical significance. Often, they are requested in response to non-specific symptoms where there is little potential link between symptoms and the likelihood of liver disease.

Liver blood tests in isolation are neither specific diagnostic tools nor specific exclusion tools.

A QIP performed in a paediatric intensive care unit aimed to reduce unnecessary LFT requests by implementing a blood test request form and a table of common investigations to facilitate and document discussion between the nursing and medical teams.

Another QIP conducted in a tertiary children’s ED demonstrated a significant reduction in unnecessary LFTs. This was achieved by targeted education and regular reminders on the utility of LFTs.

A common downside of performing LFTs is the high rate of repeated blood sampling due to borderline abnormal results which can be difficult to interpret by clinicians.

What about blood cultures?

Febrile illness is almost always the reason cited for cultures. They are often performed with other blood tests, irrespective of the patient’s clinical presentation.

Practice patterns often promote the overuse of ordering blood cultures in an effort to prevent a child from needing a second poke or to try to reduce diagnostic uncertainty. Blood cultures are commonly drawn for certain focal infections such as pneumonia, skin and soft tissue infections (SSTIs), asthma, bronchiolitis as well and UTIs.

A single-centre study in a paediatric ED described the poor utility of blood culture in community-acquired pneumonia or lower respiratory tract infection. Of the 105 blood cultures sent from 105 patients, only two were positive (one Streptococcus pneumoniae and one coagulase-negative Staphylococcus). The author noted that about a third of the children were discharged before the blood culture result was known (most likely 48 hours).

Therefore, if there is a clinical impression of mild infection or a low probability of bloodstream infection, performing a blood culture is rarely indicated.

Take home messages

Choosing Wisely is a global movement to reduce overuse in healthcare.

Effective communication and shared decision-making are integral elements of choosing wisely.

Rebalance discussions about the risks and benefits of tests; doing nothing might be the favourable option.

Understanding the utility of blood tests will reduce duplication of normal tests on paediatric wards.

References

Adamson J. Is blood culture a useful investigation in children admitted to hospital with community-acquired pneumonia? Archives of Disease in Childhood 2018;103:A137-A138.

Alasdair Munro. Paediatric blood cultures- We’re doing it wrong. Don’t Forget the Bubbles, 2019

Born K, Kool T, Levinson W. Reducing overuse in healthcare: advancing Choosing Wisely. BMJ. 2019 ;367:l6317.

https://choosingwisely.co.uk/about-choosing-wisely-uk/

Kene Maduemem, Anand Kanani. Choosing Wisely: My liver is fine – QIClearn

Kene Maduemem. Shared Decision Making. Don’t Forget the Bubbles, 2022

Levinson W, Kallewaard M, Bhatia RS, et al. Choosing Wisely International Working Group. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015 ;24(2):167-74. 

Lina Jankauskaite, Grechukha Y, Kjær KA, et al. Overuse of medical care in paediatrics: A survey from five European countries in the European Academy of Paediatrics.  Front Pediatr. 2022 Sep 13;10:945540. 

Maduemem K, Magnusen E, Shafiq A, et al. Tap it: trainee led initiative to reduce unnecessary blood testing in the emergency department. Archives of Disease in Childhood 2020;105:A86-A87.

Magnusen E, Maduemem K, Shafiq A, et al. ‘TAP it’: trainee led initiative to reduce unnecessary blood testing in a paediatric emergency department. Emergency Medicine Journal 2020;37:851-85

Malhotra A, Maughan D, Ansell J, et al. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ. 2015 May 12;350:h2308

Malhotra A, Maughan D, Ansell J, et al. Choosing Wisely in the UK: reducing the harms of too much medicine. Br J Sports Med. 2016 ;50(13):826-8. 

Regan W, Hothi D, Jones K. Sustainable approach to reducing unnecessary combined biochemistry tests on a paediatric cardiology ward. BMJ Open Qual. 2018 Oct 15;7(4):e000372. 

Sinitsky L, Brierley J. Reducing the number of unnecessary liver function tests requested on the Paediatric Intensive Care Unit. BMJ OpenQuality 2017;6:u214071.w5561. 

Authors

  • Chibuko is a Paediatric registrar currently at Royal Stoke Hospital in the United Kingdom. He has an interest in Paediatric Emergency Medicine and Simulation based teaching.

  • Kene is a Consultant in Paediatric Emergency Medicine in the West Midlands, UK. He is also a postgraduate allergy student. He is passionate about choosing wisely, and cultural intelligence in paediatric care. His interests are allergy, primary care, and health equity.

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