The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review

Original Scholarship
Health Care Practice / Quality

Policy Points:

  • Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low-value health services.
  • Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low-value services.
  • Multicomponent interventions targeting clinicians are currently the most effective types of interventions.

Context: Choosing Wisely aims to reduce the use of unnecessary, low-value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low-value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective.

Methods: We searched peer-reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi-squared tests or Wald tests to compare across interventions.

Findings: We reviewed 131 articles. Eighty-eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician-based interventions were more effective than consumer-based, though there is a dearth of studies on consumer based interventions. Only 17% of studies included a control arm.

Conclusions: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low-value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high-quality studies that include active controls.

Keywords: delivery of health care, health services/standards, health services/economics, Choosing Wisely guidelines, health care quality.



Cliff BQ, Avanceña AL, Hirth RA, Lee SYD. The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systemic Review. Milbank Q2021;99(4):1024-1058.