Can we make wiser choices?

Ketil Størdal, Stefán Hjörleifsson About the authors

Norway is well qualified to measure the use of health services. Such measurement can increase the impact of the Choosing Wisely Norway campaign.

In September 2018, the Norwegian Medical Association launched the Choosing Wisely Norway campaign in order to reduce unnecessary tests and treatments that at worst are harmful to the patient. The decision to launch the campaign was partly based on the large, unexplained variations in the use of health services revealed in Norwegian health atlases (1).

A questionnaire survey of Norwegian GPs, paediatricians and radiologists indicates that 15–20 % of medical practice in Norway is considered to be overtreatment (personal statement, medical student Kristin Kjær). A growing number of specialist medical associations are drawing up recommendations for the Choosing Wisely Norway campaign, which is supported by the majority of major health professions in Norway. The Ministry of Health and Care Services has granted NOK 1 million to fund a part of the campaign geared to increasing public awareness. But can we document the effect of measures to reduce the number of unnecessary tests and treatments?

Choosing Wisely, the international campaign on which the Norwegian version is based, is now established in over 20 countries, but so far there has been little measurement of its impact. The unitary Norwegian health service and the nationwide health registers present excellent opportunities to track changes in the use of health services. We believe measurement can be important in inspiring change both nationally and locally. There are good examples demonstrating that it is possible to document the impacts of targeted cessation of implementation (reducing the use of unnecessary health services) in Norway. The use of antibiotics has fallen by 23 % from 2012 to 2018 (2). Far fewer neonates receive antibiotics in neonatal departments (3), and meniscus operations declined by 53 % from 2013 to 2017 (1).

We believe measurement can be important in inspiring change both nationally and locally

It remains to be seen whether the campaign will lead to corresponding changes in practice. Together with the Centre for Clinical Documentation and Evaluation and the Norwegian Institute of Public Health, the Norwegian Medical Association is now preparing a health atlas to measure national changes in some of the areas affected by the campaign’s recommendations. Some health authorities have taken the initiative to implement and evaluate new practices, and several specialist medical associations have worked independently to measure changes. In addition, the centre for quality in GP surgeries (SKIL) developed a course based on the campaign, using own practice-related data, so that GPs can follow the development of their own practices and compare themselves with others.

The Choosing Wisely Norway campaign not only consists of specific recommendations regarding tests and treatments where research communities agree; the campaign also has the goal of debate on medical overactivity in general. We believe it is essential to discuss how financial incentives can result in overactivity. Activity-based financing was introduced specifically to increase activity. An unfortunate effect of such stimulation measures may be that procedures are carried out on patients unnecessarily. In such cases, it is essential to change the financial incentives to avoid harming patients.

Our professional responsibility requires our course to be adjusted when medical interventions do more harm than good

We also believe that it is difficult to justify private health screening that is being marketed on an inadequate scientific basis even though this is not a direct burden on public funding. One example of such screening is the full body ultrasound scan. The annual ‘health check’ is another example – Cochrane’s recent comprehensive meta-analysis showed that mortality is not affected by regular health checks (4). Should healthy people who are concerned about their health as the result of the random findings of questionable screening really be prioritised by the public health service for assessment of these findings? Shouldn’t private health screening companies be responsible for the follow-up of such screening, as concluded by the Royal College of General Practitioners in the UK (5)? Or do we need stricter regulation of marketing? The Choosing Wisely Norway campaign should promote discussion and self-policing. Our professional responsibility requires our course to be adjusted when medical interventions do more harm than good.

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