Choosing Wisely : Decision Making and Scientific Evidence

The medical practice is associated with dozens of decision-making actions in the daily routine. In 2014, Linder et al.1 published an article stating that doctors suffer from a condition known as decision fatigue, defined as a reduction in the ability to make choices resulting from fatigue. In the study, the authors demonstrated that medical appointments at the end of a working day were more associated with the prescription of inappropriate treatment1.


Cláudio Tinoco Mesquita
Universidade Federal Fluminense -Hospital Universitário Antônio Pedro -Setor de Medicina Nuclear -Niterói, RJ -Brazil Manuscript received on September 14, 2015; approved on September 14, 2015; revised on September 14, 2015.The medical practice is associated with dozens of decision-making actions in the daily routine.In 2014, Linder et al. 1 published an article stating that doctors suffer from a condition known as decision fatigue, defined as a reduction in the ability to make choices resulting from fatigue.In the study, the authors demonstrated that medical appointments at the end of a working day were more associated with the prescription of inappropriate treatment 1 .

EDITORIAL
Making decisions is part of the life of any professional, especially health professionals, and the need to provide support to better decision-making has led to many initiatives.One of them is called Choosing Wisely and aims to align to good medical practices, hence increasing the dialogue between doctors and patients.Its main objective is to reduce the use of medical procedures that are not supported by proper scientific evidence.
In an article published in 2010, Michael Porter 2 defined value in healthcare.For him, high-value procedures are those that lead to greater benefits in the outcomes of patients in the context of maintaining economic sustainability for the health system 2 .As the value of a procedure is based on its results, the procedures that lead to the best outcomes are more likely to add more value to the health system, hence emphasizing the need for efficiency (Figure 1).
In the equation of value in healthcare, the likelihood of improved clinical outcomes and procedure efficiency has a significant impact on value.The cost of procedure is relativized by the results that it determines and is crucial to the sustainability of the healthcare system.
In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely 3 initiative, aimed at reducing low-value procedures, i.e., those that add little or no improvement to outcomes, but that increase costs for the healthcare system.This initiative involved the medical societies that were asked to develop lists of the five procedures with low or no value (tests, treatments or procedures), in different specialties, which could be considered unnecessary or potentially risky for patients.More than 60 medical societies in the United States have joined the campaign, along with many other countries such as the United Kingdom, France, Italy, Canada, Japan and, now, Brazil.
In Brazil, the initiative is taken by the Brazilian Society of Cardiology which pre-selected 15 items to be voted by its members in order to select the top five most important figure items to be included in Choosing Wisely 3 .This initiative is highly relevant for improving the quality in healthcare systems and has been well received by the scientific community, since decisions involving the selection of procedures from the top five on the list are underpinned by the principles of evidence-based medicine.
The American College of Cardiology has recently changed its list of five procedures discouraged, based on new evidence pointing to greater benefits with full coronary artery bypass grafting in multivessel patients admitted with acute myocardial infarction with ST segment elevation compared to treatment to the culprit lesion only 4 .
Another relevant issue is to determine whether low value-added healthcare prevails or not.In a recent study, Colla et al. 5 analyzed the use of low-value cardiovascular tests in Medicare patients, which consists of individuals older than 65 5 .The prevalence of low-value tests account for about 10% of procedures.There was a wide geographic variation, with areas of prevalence of 6% compared to areas where 24% of the procedures were connected to low added value.Interestingly, this variation remains steady over time indicating that regional characteristics may contribute to these practices.
In Brazil, Oliveira et al. 6 found that only 5% of myocardial scintigraphy tests were considered inappropriate, using the criteria of the American College of Cardiology.Considering the regional characteristics, further studies analyzing other regions and other medical procedures are required.
Medical journals should play an important role in disseminating the Choosing Wisely concepts, as argued by Malhotra et al. 7 when the initiative was launched in the UK.The International Journal of Cardiovascular Sciences encourages its readers to think about this issue and the researchers contributing to the journal should develop studies in the area in order to increase scientific knowledge and understanding of this important topic.
Keywords: Quality assurance, health care; Quality improvement; Diagnostic techniques, cardiovascular

Potential Conflicts of Interest
This study has no relevant conflicts of interest.

Sources of Funding
This study had no external funding sources.

Academic Association
This study is not associated with any graduate programs.

Figure 1
Figure 1 Equation of value in healthcare