Reducing harm from overuse of healthcare
========================================

* Karen Born
* Wendy Levinson
* Loren de Freitas

BMJ series calls for article proposals aligned with Choosing Wisely recommendations

Reducing overuse and waste in healthcare has been identified as an essential part of providing high quality care for health systems globally.1 Unnecessary tests, treatments, and procedures can have serious implications for individual patients, healthcare systems, and the planet. Individuals can be directly harmed through, for example, diagnostic and testing cascades that can cause side effects and lead to substantial anxiety for patients, caregivers, and families. Unnecessary medication can lead to drug interactions, and overprescribing is a driver of public health crises such as antimicrobial resistance2 and the prescription opioid abuse epidemic.3

At the health systems level, overuse or unnecessary tests, treatments, and procedures wastes finite resources and diverts services, treatments, and effort away from those most in need of care. Overuse is not confined to high income countries; it is increasingly well documented even in low and middle income settings.4 Minimising overuse and waste in lower income settings can help direct scarce resources towards evidence based practices in areas of greatest need.4

Waste in healthcare also contributes to the climate crisis, harming people and the planet through the multiple adverse effects of climate change such as air pollution, microplastics in water sources, and an increase in vectorborne diseases.56789 Healthcare is a resource intensive industry that generates a substantial proportion of global carbon emissions, alongside tons of material waste from single use plastics.10 Strategies to reduce healthcare emissions include reducing the estimated 30% of all care that is overused and unnecessary.11

## Changing practice

The urgent need to reduce the serious harms of overuse in healthcare led to a global movement, Choosing Wisely, launched in the United States in 2012 and now active in more than 30 countries across six continents, including the UK.12*The BMJ,* in partnership with the Choosing Wisely international collaboration, led by the Choosing Wisely Canada campaign, has introduced a “Change” series in the Education section. Articles in the series highlight evidence based strategies and tools to help change practice and reduce unnecessary tests, treatments, and procedures. The articles indicate why and how practice needs to change, usually focusing on one aspect of care, and are aligned with recommendations made by national Choosing Wisely campaigns.

Choosing Wisely campaigns are national grassroots efforts, led by clinicians in partnership with patients, other clinicians, and professional societies. They provide evidence based recommendations about changes to practice and develop tools to help clinicians implement those recommendations in partnership with patients.13 Campaign recommendations are available in dozens of languages and published on national, open access websites (box 1). Specialty specific recommendations are often published in medical journals.14 They are brief, clearly written, and aimed at specialists, generalists, and the public. Most include a simple, declarative statement about a test, treatment, or procedure that is overused followed by a brief rationale to support the recommendation (including key supportive evidence) and specification of when an intervention is appropriate, taking clinical judgment into consideration. 

Box 1 
### International Choosing Wisely campaigns

*   Italy: [https://choosingwiselyitaly.org/en/](https://choosingwiselyitaly.org/en/)

*   Norway: [https://www.legeforeningen.no/kloke-valg/](https://www.legeforeningen.no/kloke-valg/)

*   Japan: [https://choosingwisely.jp/](https://choosingwisely.jp/)

*   Brazil: [https://www.choosingwisely.com.br/](https://www.choosingwisely.com.br/)

*   Canada: [https://choosingwiselycanada.org/](https://choosingwiselycanada.org/)

*   Israel: [http://www.choosingwisely.org.il/](http://www.choosingwisely.org.il/)

*   UK: [https://choosingwisely.co.uk/](https://choosingwisely.co.uk/)

*   Netherlands: [https://demedischspecialist.nl/themas/thema/verstandige-keuzes](https://demedischspecialist.nl/themas/thema/verstandige-keuzes)

RETURN TO TEXT

*The BMJ* series aims to help clinicians and patients minimise overuse in their own practice and treatment, and we invite readers to submit proposals for articles on topics aligned with a Choosing Wisely recommendation from their specialty, society, or country. Articles work best when the evidence supporting change is robust and the implications for clinicians and patients are clear. Recent examples include articles on avoiding chest radiography in infants with typical bronchiolitis and reducing the use of routine inpatient blood testing.1516

We encourage proposals from diverse author groups and particularly value coauthors who are patient advocates, representatives, or leaders in the relevant area. Proposals should have no more than four authors (or five, if at least one author is a patient). All authors must be free of financial links to relevant commercial companies,17 and we ask for full declarations of interest from all authors alongside article proposals. Readers interested in contributing should submit proposals through the BMJ Education Article Proposal form ([https:/bit.ly/3m9lN9g](https://bit.ly/3m9lN9g)) alongside a competing interests form ([https://bit.ly/2QM6cNn](about:blank)). Article proposals are discussed every fortnight, and prospective authors should expect to receive a response to their proposal within three weeks of submission. 

We hope readers will find this series useful, relevant, and influential in changing practice, and look forward to your proposals.

## Footnotes

*   Competing interests: *The BMJ* has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: LDeF is part of a Choosing Wisely emergency medicine committee in Trinidad and Tobago. Further details of *The BMJ* policy on financial interests are here: [https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf](about:blank).

*   Provenance and peer review: Commissioned; not externally peer reviewed.

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