Many organizations have already created projects or campaigns to promote Less is More or "the right amount" of medicine.
See the projects below for a taste of what is already happening. Be it research, policy development, government lobbying, or collection of information, a lot of work has been undertaken.
Many groups refer to "Less is More" Medicine by different names; look in the Glossary if you need some help sorting it out.
If you are interested in the movement to tackle overdiagnosis, overtreatment, and overtesting around the world, check out the slides from the Preventing Overdiagnosis 2016 presentation: "Around the world in 80 names"
US specialty societies developed lists of Five Things Physicians and Patients Should Question in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures.
These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.
- a one-pager explanation and summary of Choosing Wisely
- lists of things doctors and patients should question
- example: Imaging Tests for Lower Back Pain: When you need them - and when you don't
Choosing Wisely Canada [also in French]
- "In association with the Canadian Medical Association, a campaign to help physicians and patients engage in conversations about the overuse of tests, treatments and procedures and support physician efforts to help patients make smart and effective choices to ensure high quality care."
- Check out their amazing app!
- Several toolkits, including "Bye-bye PPI" (to reduce proton-pump inhibitor use) and "Why Give One When Two Will Do?" (decreasing unnecessary transfusions) are available to help you apply the Choosing Wisely recommendations in your institution or practice
- Provincial chapters:
- "Choosing Wisely Australia® is helping the medical community & consumers start an important conversation about improving the quality of healthcare by eliminating unnecessary and sometimes harmful tests, treatments, and procedures."
- Participating specialist societies have made lists of recommendations and Family medicine recommendations are among the first
- Chaired by Dr Miguel Pizzanelli, the focus of this interest group is Quaternary Prevention: "Action taken to identify patient at risk of overmedicalization, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable"
- Journal of the American Medical Association (JAMA) Internal Medicine collection of articles that relate to overuse, including Teachable Moments from the Do No Harm project
The Lown Institute [USA]
- Overuse 101, a resource explaining the hows and whys of this movement [NEW!]
- The Right Care Alliance Blog - Right Care Weekly
- The Declaration of the Right Care Movement - you can sign it too!
- Conferences; in 2013 the theme was From Avoidable Care to Right Care (in 2012 it was Avoiding Avoidable Care)
- The Triple Aim: Better Health and Better Care at Lower Cost; the foundation for change
- How Will We Do That?™ Building Low-Cost, High-Quality Health Care Regions in America
- Healthy Employees, Lower Premiums and Costs
*NEW* Taking Action on Overuse [USA]
- Taking Action on Overuse offers the 'How To' roadmap for doing less of the health care interventions that are not useful. Unnecessary diagnostic tests, treatments or hospitalizations can drive up health care costs, and in some cases, actually harm patients. Reducing this low-value care requires that health care organizations actively engage in the challenging work of sustained culture, organizational and behavior change.
- Blog covering a variety of topics relating to MDM, "the practice of medicine that seeks to design effective treatment programs for patients while minimizing the burden of treatment. This should lead to treatment programs that fit with patients’ goals and contexts and that therefore patients can make a ‘normal’ part of their life."
Burden of Treatment [France & USA]
- Development of an Instrument to assess Treatment Burden
- An exploration of Shared Decision Making advancing the cause through research, policy, and patient decision aids. "We believe that the only way to ensure high quality medical decisions are being made is for a fully informed patient to participate in a shared decision making process with their health care provider."
- a (free) example of a shared-decision making toolkit, from their partnership with Health Dialog. Health Crossroads' Is a PSA Test Right for You
The Do No Harm Project [USA]
- The University of Colorado: Denver, School of Medicine have curated some essential reading and clinical vignettes, and they are asking for more contributions from clinical trainees
UCSF Center for Healthcare Value [California, USA]
- The University of San Francisco (USCF) has several initiatives relating to high-value health care
- "Caring Wisely" is a campaign of Quality Improvement (QI) initiatives; grants are offered for projects at their campuses that "reduce the cost of healthcare while improving health or leaving it unchanged, without simply transferring costs to others."
- Reducing unnecessary blood transfusions and nebulizer use are some of the things they've tackled so far
- A group of orthopedists who believe that the concerns and problems of our patients are the raison d'etre of the profession, advocating for patients and communicating this vision within the profession and to outside policy makers; they place a strong emphasis on the value of primary care
Providers for Responsible Ordering [Baltimore, USA]
- A collection of health care providers from Baltimore started this initiative, which now has many chapters, to reduce the use of unneccesary tests; see their toolbox for help reducing chest x-rays, telemetry, and cardiac enzyme testing
- The NPA has done a lot of work in the area of preventing overdiagnosis and empowering patients to find the right amount of care. They are a partner in the Tandem Health project/app, created Top 5 lists (in good stewardship) which served as a model for the Choosing Wisely Campaign, and promote responsible prescribing (by limiting influence of the pharmaceutical industry) through The Unbranded Doctor.
The Dartmouth Institute [USA]
- Multiple projects related to creating a better system of care, including:
- The High Value Healthcare Collaborative (mission: to improve healthcare value – defined as quality and outcomes over costs, across time – for its service population, in a sustainable manner, while serving as a model for national healthcare reform)
- The Centre for Informed Choice (dedicated to a simple proposition: that patients deserve to be equal partners in making choices about their health care)
- Overdiagnosis - the Institute is one of the major organizers for the annual Preventing Overdiagnosis conference
- and The Science of Effective Risk Communication
- a Face Book group dedicated to exploring the sociology of diagnosis, exploring and describing the social forces that shape disease as well as the consequences of diagnosis
Safely Doing Less (in Pediatrics) [USA]
- A potentially emerging initiative of the American Academy of Pediatrics (see Safely Doing Less: A Missing Component of the Patient Safety Dialogue)
- The revised (2014) bronchiolitis guidleines, for example, reflect an emphasis on the theme of not doing tests or treatments that will not help children
NEW: Saskatchewan Health Quality Council: Appropriateness [Saskatchewan, Canada]
- The provincial Appropriateness of Care Program was established in 2015 to lead provincial initiatives and provide support to regional improvement efforts
- They have provincial projects, a regional network, and education/training resources for those in Saskatchewan
- Follow @HQSask on twitter
- Multiple resources to help health care providers and patients combat polypharmacy, including guidelines for stopping medications
Ten Therapeutic Commandments [Canada]
- Ten Commandments for Patient-Centred Treatment, based on this BJGP article
NPS MedicineWise [Australia]
- Being medicinewise will help patients ask questions about medicines and medical tests, and know where to get trusted information; having the right information will help patients make better health decisions
- This Independent, not-for-profit, evidence-based resource for patients encourages them to choose medicines wisely, make healthy lifestyle choices, and learn more about potential safety issues with complimentary medicines
- They have a campaign devoted to fighting Antibiotic Resistance, including resources for health care providers
*NEW* Wiser Healthcare [Australia]
- A research collaboration involving The University of Sydney, Bond University, Monash University and international colleagues. It is funded by the Australian National Health and Medical Research Council, through both its Centres for Research Excellence scheme and its Program Grant scheme. It aims to conduct research that will reduce overdiagnosis and overtreatment in Australia and around the world
- @wiserhealthcare on Twitter
- The British Medical Journal (BMJ)'s collection of articles and commentaries that relate to overdiagnosis
Prudent Healthcare [Wales, UK]
- An initiative from Wales that has four main principles: 1) Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production; 2) Care for those with the greatest health need first, making the most effective use of all skills and resources; 3) Do only what is needed, no more, no less; and do no harm. and 4) Reduce inappropriate variation using evidence based practices consistently and transparently.
- Key points taken from The National Institute for Health and Care Excellence (NICE) and associated guidelines
- NB: Many guidelines currently being updated and website structure broken [inaccessible March 2014]
RCGP Standing Group on Over-Diagnosis [UK]
- Chaired by Margaret McCartneySee their report to council
Realistic Medicine [Scotland]
- Annual Report of the Chief Medical Officer, NHS Scotland, in which Dr Calderwood wants to "engage in a conversation with clinicians on the following questions:
- How can we further reduce the burden and harm that patients experience from over-investigation and overtreatment?
- How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients?
- How can we ensure value for public money and prevent waste?
- How can people (as patients) and professionals combine their expertise to share clinical decisions that focus on outcomes that matter to individuals?
- and more . . .
DIAnA Salud (DIAnA Health) [Spain]
- Dissemination of Initiatives to Analyse Appropriateness (DIAnA) in Healthcare is a Spanish project
- Essencial: Afegint valor a la pràctica clínica (Essential: Adding Value to Clinical Practice) is the cornerstone project which includes recommendations to reduce unnecessary test and treatments, a great infographic (in Catalan) explaining the culture and recommendations, and a patient information section
Slow Medicine [Italy]
- Slow Medicine is a movement started around 2002 that aims to create a return to medicine that is Sober (avoiding excess), Respectful, and Fair. Modelled after the Slow Food movement, a slower paced approach to care would have patients experiencing a gentler, less burdensome approach to achieving health and good living.
Slow Medicine [The Netherlands]
- This initiative emphasisizes 10 basics of care: Time, Personal Focus, Autonomy and Self Management, Positive Health, Prevention with good lifestyle, Quality of life, Integrative medicine including evidence-based alternative medicine, Safety first: do no harm, Passion and Compassion, and Human focused technology
Smarter Medicine [Switzerland, in French/German]
- This Swiss initiative appeals to patients, GPs, and specialists to help them avoid unnecessary interventions
- The cornerstone of this campaign is a list of diagnostic tests and treatments in general internal medicine that offer no measurable benefit to patients, and present more risks than benefits; they want to inspire with the idea that in medicine, "less can be more."
Quaternary Prevention/Prévention quaternaire [Belgium]
- Dr. Marc Jamoulle (@jamoulle) is a Belgian GP who wrote about overdiagnosis at least as early as 1986. His article "Information and computerization in general practice" starts the discussion around quaternary prevention, focusing on the way information technology can dehumanize healthcare.
- Read a brief summary of Quaternary Prevention to learn more about this approach
The Catalan Agency for Health Information, Assessment and Quality (CAHIAQ) / Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) [Catalonia]
- Based in Barcelona, Spain, they hosted the Preventing Overdiagnosis 2016 conference; their strategy and projects are described in a 6-page PDF (in English)
- "AQuAS has now the mission of generating relevant knowledge to contribute to the improvement of the quality, safety and sustainability of the Catalan Health Care System and thus easing the decision-making process for citizens and health care managers and professionals."
- Essencial is a cornerstone of their work, developing recommendations to reduce low-value interventions and working with primary care to change clinical practices
Commitment to Quality Scientific Societies in Spain / Compromiso por la Calidad de las Sociedades Científicas en España [Spain]
The " Commitment to Quality Scientific Societies in Spain " is a partnership between the Ministry of Health and 48+ specialty societies. It started in April 2013 with the main objective to reduce the use of unnecessary medical interventions, with unnecessary meaning those which have not proven effective, have limited or doubtful effectiveness , are not cost-effective or are not high priority. Secondary objectives are:
- Avoid iatrogenic harm from performing unnecessary interventions
- Reduce variability in clinical practice
- Help share this message among health professionals committed to quality and efficiency of care
- Help disseminate the message about the appropriate use of health resources to the general public
- Among the societies is The Spanish Society of Family Medicine and Community (semFYC). They have prepared two lists of "don't do" items; their second list of recommendations of things clinicians should not do is HERE
- La Sociedad Española de Radiología Médica (SERAM) have a list HERE
Show More Spine [Finland]
- We love a stiff backbone, those who are not afraid to stand tall against excessive and unnecessary medical interventions imposed on healthy people. We love to see action and debate and we want to see these controversies discussed openly and fully with all concerned.
- We believe that everyone needs to #ShowMoreSpine -- and be empowered to call out situations whenever excessive medicine is working to capture more people in its web. We believe that squidgy guidelines don’t have the patient’ best interests at heart, and overly wide disease definitions need to be challenged, confronted, debated and changed.
- We are committed to building a movement of like-minded people, people willing to #ShowMoreSpine and commit to sharing ideas and strategies that can counter the squidgieness that we know is threatening to hurt us all.
The Coalition of Doctors to Prevent Over-diagnosis of Thyroid Cancer [Korea]
- Korea suffers from a glut of cheap and accessible preventative testing; unfortunately the availability of this has only correlated with increased diagnosis (and treatment) of disease, such as thyroid cancer, but no overall impact on mortality
- Read their story here
- An article in NEJM about how they are Turning the Tide Against Overdiagnosis
To combat the ordering of too many tests and procedures, Dr Balram Bhargava founded this movement; hoping to start in the area of cardiology, his speciality, and expand to other fields, Dr Bhargava says this movement will help guide Indian doctors away from "American style care" and towards guidelines similar to those used by the NHS in the UK
Slow Medicine [Brazil]
- "Slow Medicine" emphasizes the primacy of time in medicine and in the art of caring. There must be time to listen, time to reflect, and time to build strong and lasting relationships among physicians, patients, families and community.
- Slow Medicine has a history in Italy, the USA, and it is growing and reaching other countries
están cambiando los tiempos [Uruguay]
- A cooperative blog and movement founded by E. Miguel Báez Pizzanelli, in Spanish
The group's main interest is people - oriented, families and community and comprehensive approach to health. "Our commitment is with the person and human values. This leads us to make every effort to combat inequities and take on leadership for real reform of the health system that begins changing personal and professional attitudes. We believe that without this personal commitment no possible collective change. The information provided in this site aims to be a support to the clinical and scientific work we do."
Overdiagnosis of Malaria
- No formal projects or initiatives but there are many articles on the subject and a Policy Brief from The Malaria Knowledge Programme of the Liverpool School of Tropical Medicine
Broader Focus on EVIDENCE-BASED MEDICINE (EBM Champions)
- This fantastic YouTube Channel with videos by Dr Aaron Carroll covers the gamut; evidence-packed videos talk about physician conflicts of interest, why frequent lab testing isn't very useful, the fact that trying to control blood pressure isn't always the right move for the elderly, and many more related topics
- The Centre, part of Bond University, undertakes research about the processes and implementation of Evidence-Based Medicine, in order to more intelligently and efficiently close the gaps between best available evidence and current clinical practice
- The blog highlights research at the Centre and related studies, events, and news
- It is another one of the major organizers for the annual Preventing Overdiagnosis conference
- "The main goal of the Therapeutics Education Collaboration (TEC) is to provide . . . health professionals and the public with current, evidence-based, practical and relevant information on rational drug therapy . . . Maybe the best way to describe us is as the "Mythbusters" of drug therapy."
- Home of the Best Science (BS) Medicine Podcast (hilarious and sharp, recent episodes free, archives require Premium Membership) 🍁
- A project of the University of British Columbia (UBC), the TI "assesses the clinical evidence presented in published articles, meta-analyses by the Cochrane Collaboration, and scientific material presented by the pharmaceutical industry." Their critical appraisals of drug therapy specifically are shared in the Therapeutics Letter. 🍁
Lead by Dr Mike Allan and sponsored by the Alberta College of Family Practice (ACFP), Tools for Practice creates biweekly articles that summarize medical evidence on a clinical question with a focus on information that can modify day to day practice. Articles are reviewed for current evidence and updated every 2-3 years, and are free from industry bias. Many of the reviews discuss gaps in evidence or faulty assumptions and persuade readers to unlearn practices that are not safe or effective. 🍁
- Tools section containing practical resources for Canadian patients and providers
- "a federally-incorporated, not-for-profit organization enabling appropriate care in primary care through the development and implementation of relevant, evidence-based programs and tools." 🍁
- A website "promoting better research for better healthcare" and in recognition that not all research is created equal
- The Patients/Public section provides resources to help understand the design, process, critical appraisal, and dissemination of research
The Help for Students & Teachers section emphasizes the use of 'fair tests' to help us recognize harmful or useless treatments, and helps teach how to recognize the difference between trustworthy (and untrustworthy) claims about the effects of treatments
- Is it true? Does taking massive doses of vitamins really reduce the size of a cancerous tumour? Are pharmaceutical companies poisoning us with chemicals and is “natural” where it’s at? Should we all be gluten free? or fat free? or carb free? Can the signs of ageing be reversed with a 300$ tube of beauty cream? The Internet allows fantasies to thrive, but your health (and wallet) should not be the target of nonsense. There is a body of evidence out there, and Dr. Christopher Labos and Jonathan Jarry are staring it right in the face.
- Through a podcast, a shared blog, and videos (and even appearances on the radio and in person), they explore what reproducible evidence has to say on important medical topics, and how scientific thinking shouldn’t be the sole purview of researchers. The bickering is just the cherry on top 🍁
Not much content and no recent updates:
- An Evidence-Based Resource for Patients and Clinicians; simple fact-based layout with links to lots of videos, essays, and books on the subject. Focus on Number Needed to Treat (NNT) and Screening programs.