Choose Wisely Research Articles

ASO Visual Abstract: Nodal Surgery for Patients ≥70 Undergoing Mastectomy for DCIS? Choose Wisely.

ASO Visual Abstract: Nodal Surgery for Patients ≥70 Undergoing Mastectomy for DCIS? Choose Wisely.

Nodal Surgery for Patients ≥ 70 Undergoing Mastectomy for DCIS? Choose Wisely.

Routine sentinel lymphadenectomy (SLNB) for early-stage HR+/HER2- breast cancer in women ≥70 is discouraged by Choosing Wisely, but whether SLNB can be routinely omitted in women ≥70 with DCIS undergoing mastectomy is unclear. This study aims to evaluate rates of axillary surgery and nodal positivity (pN+) in this population to determine the impact of axillary surgery on treatment decisions. Females ≥70 with DCIS undergoing mastectomy were identified from the National Cancer Database (2012-2020). The rate of upstaging to invasive cancer (≥pT1) or pN+ was assessed. Subset analyses were conducted for ER+ patients. Adjuvant therapies were evaluated among ≥pT1 patients after stratifying by nodal status. Of 9,030 patients, 1,896 (21%) upstaged to ≥pT1. Axillary surgery was performed in 86% of patients, predominantly sentinel lymphadenectomy (SLNB, 65%). Post hoc application of Choosing Wisely criteria demonstrated that 93% of the entire cohort and 97% of ER+ DCIS patients could have avoided axillary surgery. Nodal positivity was 0.3% among those who didn't upstage, and 12% among those upstaging to ≥pT1, with <2% having pN2-3 disease, irrespective of receptor subtype. Node-positive patients had higher adjuvant therapy usage, but there was no recommendation for adjuvant chemotherapy or radiation for 71% and 66% of pN+ patients, respectively. Axillary surgery can be omitted for most patients ≥70 undergoing mastectomy for ER+ DCIS, aligning with recommendations for invasive cancer, and omission can be considered in those with ER- disease. Future guidelines incorporating preoperative imaging, as in the SOUND trial, may aid in identifying patients benefiting from axillary surgery.

Choose Wisely! – Considering the Perceived Threat in the Selection of Trauma Film Clips May Improve the Ecological Validity of the Trauma Film Paradigm

Abstract Background The trauma film paradigm (TFP) is the gold standard experimental psychopathology model of psychological trauma. However, different film clips with distinct effects on trauma-analogue symptoms are used across TFP studies, raising questions about the generalizability of study-specific results and the ecological validity of the TFP. Little is known about differences among film clips commonly used in the TFP regarding key features of psychological trauma (i.e., threat and anxiety) and their veridicality. Methods Thirty healthy participants watched eight trauma film clips in randomized order and subsequently rated each in view of perceived threat, anxiety, and realism. In addition to descriptive statistics, variance analyses and pairwise comparisons were performed to test for differences on these outcomes. Results The results indicated significant differences among the trauma film clips in terms of perceived threat and realism. However, nearly all trauma film clips evoked moderate anxiety levels. Conclusions This study stressed the importance of perceived threat as a key feature in selecting film clips for the TFP, as highly threatening film clips were also perceived as more realistic. When replicated using delayed outcomes (e.g., intrusive memories), choosing trauma film clips in view of their perceived threat might improve the ecological validity of the TFP.

Choose Wisely: An Extensive Evaluation of Model Selection for Anomaly Detection in Time Series

Anomaly detection is a fundamental task for time-series analytics with important implications for the downstream performance of many applications. Despite increasing academic interest and the large number of methods proposed in the literature, recent benchmark and evaluation studies demonstrated that no overall best anomaly detection methods exist when applied to very heterogeneous time series datasets. Therefore, the only scalable and viable solution to solve anomaly detection over very different time series collected from diverse domains is to propose a model selection method that will select, based on time series characteristics, the best anomaly detection method to run. Existing AutoML solutions are, unfortunately, not directly applicable to time series anomaly detection, and no evaluation of time series-based approaches for model selection exists. Towards that direction, this paper studies the performance of time series classification methods used as model selection for anomaly detection. Overall, we compare 17 different classifiers over 1800 time series, and we propose the first extensive experimental evaluation of time series classification as model selection for anomaly detection. Our results demonstrate that model selection methods outperform every single anomaly detection method while being in the same order of magnitude regarding execution time. This evaluation is the first step to demonstrate the accuracy and efficiency of time series classification algorithms for anomaly detection, and represents a strong baseline that can then be used to guide the model selection step in general AutoML pipelines.

How Tasmanian Emergency Departments 'Choose Wisely' When Investigating Suspected Pulmonary Embolism.

Overuse of computed tomography pulmonary angiograms (CTPAs) for diagnosis of pulmonary embolism (PE) has been recognised as an issue for over ten years, with Choosing Wisely Australia recommending that CTPAs only be ordered if indicated by a clinical practice guideline (CPG). This study aimed to explore the use of evidence-based practice within regional Tasmanian emergency departments in relation to CTPA orders by determining whether CTPAs were ordered in accordance with validated CPGs. We conducted a retrospective medical record review of all patients who underwent CTPA across all public emergency departments in Tasmania between 1 August 2018 and 31 December 2019 inclusive. Data from 2758 CTPAs across four emergency departments were included. PE was reported in 343 (12.4%) of CTPAs conducted, with yield ranging from 8.2% to 16.1% between the four sites. Overall, 52.1% of participants had neither a CPG documented, nor a D-dimer conducted before their scan. A CPG was documented before 11.8% of scans, while D-dimer was conducted before 43% of CTPAs. The findings presented in this study indicate that Tasmanian emergency departments are not consistently 'Choosing Wisely' when investigating PE. Further research is required to identify explanations for these findings.

Choose Wisely: Surgical Selection of Candidates for Outpatient Anterior Cervical Surgery Based on Early Complications Among Inpatients.

Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are attractive targets for transition to the outpatient setting. We assessed the prevalence of rapid responses and major complications in the inpatient setting following 1 or 2-level ACDFs and CDAs. We evaluated factors that may place patients at greater risk for a rapid response or a postoperative complication. This was an institutional review board-approved, retrospective cohort study of adults undergoing 1 or 2-level ACDF or CDA at 1 hospital over a 2-year period (2018 and 2019). Data on patient demographic characteristics, surgical procedures, and comorbidities were collected. Rapid response events were identified by hospital floor staff and involved acute changes in a patient's clinical condition. Complications were events that were life-threatening, required an intervention, or led to delayed hospital discharge. In this study, 1,040 patients were included: 888 underwent ACDF and 152 underwent CDA. Thirty-six patients (3.5%) experienced a rapid response event; 22% occurred >24 hours after extubation. Patients having a rapid response event had a significantly higher risk of developing a complication (risk ratio, 10; p < 0.01) and had a significantly longer hospital stay. Twenty-four patients (2.3%) experienced acute complications; 71% occurred >6 hours after extubation. Patients with a complication were older and more likely to be current or former smokers, have chronic obstructive pulmonary disease, have asthma, and have an American Society of Anesthesiologists (ASA) score of >2. The length of the surgical procedure was significantly longer in patients who developed a complication. All patients who developed dysphagia had a surgical procedure involving C4-C5 or more cephalad. Patients with a rapid response event or complication were more commonly undergoing revision surgical procedures. Rapid response and complications are uncommon following 1 or 2-level ACDFs or CDAs but portend a longer hospital stay and increased morbidity. Revision surgical procedures place patients at higher risk for rapid responses and complications. Additionally, older patients, patients with chronic obstructive pulmonary disease or asthma, patients who are current or former smokers, and patients who have an ASA score of ≥3 are at increased risk for postoperative complications. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Choosing Wisely-Barriers and Solutions to Implementation in Low and Middle-Income Countries.

Globally, there is increasing emphasis on value-based cancer care. Rising healthcare costs and reduced health care spending and budgets, especially in low- and middle-income countries (LMICs), call for patients, providers, and healthcare systems to apply the Choose Wisely (CW) approach. This approach seeks to advance a dialogue on avoiding unnecessary medical tests, treatments, and procedures. Several factors have been described as barriers and facilitators to the implementation of the Choosing Wisely recommendations in high-income countries but none for LMICs. In this review, we attempt to classify potential barriers to the Choose Wisely implementation relative to the sources of behavior and potential intervention functions that can be implemented in order to reduce these barriers.

Teaching medical students to choose wisely through simulation.

The Choosing Wisely (CW) campaign aims to encourage dialog among physicians and patients about the costs and benefits of medical care. The purpose of the present study was to describe the implementation of the CW campaign among medical students in the pediatrics clerkship using different teaching strategies and to evaluate the students' perception and performance. A prospective, interventionist, open study with a control group was conducted. All sixth-year undergraduate medical students that were on their pediatric clerkship at the Emergency Department during the study period were invited to participate. The study consisted of two strategies: a remote video class about the CW initiative and in situ simulation training. By the end of the rotation, all participants were evaluated through an Objective Structured Clinical Examination (OSCE). A total of 50 students were included, of which 24 watched only the online video (control group) and 26 were exposed to both the online video and the simulation scenarios (intervention group). Students in the intervention group had a significantly higher total score in the OSCE compared to students in the control group (median 90 vs 90; range 78-100 vs 50-100; p: 0.047). Median scores of behavioral items of the OSCE grouped together were significantly higher in the intervention group compared to the control group (median 60 vs 50; range 40-60 vs 20-60; p: 0.002).Conclusion: Simulation training about principles of the CW campaign had a greater impact on behavioral aspects of undergraduate students. This learning strategy was well accepted by participants. What is Known: • The Choosing Wisely (CW) campaign aims to encourage dialog among physicians and patients about the costs and benefits of medical care. • Teaching high-value and cost-conscious care to medical students is highly desired.. What is New: • Simulation training about principles of the CW campaign had a greater impact on behavioral aspects of undergraduate students.

Annual Breast Cancer Screening Beginning at Age 40: Why Should Portugal Choose Wisely?

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Choose Wisely! Interactive Fiction Video Games in the English Classroom

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Pulse Oximetry.

Pulse Oximetry.

Choose Wisely: Adapt the Classification Characteristic for Migraine Trigger Points.

Choose Wisely: Adapt the Classification Characteristic for Migraine Trigger Points.

The normal range: it is not normal and it is not a range

The NHS ‘Choose Wisely’ campaign places greater emphasis on the clinician-patient dialogue. Patients are often in receipt of their laboratory data and want to know whether they are normal. But...

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients.

ObjectivesThe Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients.MethodsData was retrospectively collected from patients, ages 18–50 and Canadian Triage and Acuity Scale (CTAS) codes 2–5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging.ResultsData from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues.ConclusionConsiderable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.

Should UK based Physiotherapists Choose Wisely?

In 2012 the Choose Wisely campaign was launched in the United States in order to address concerns regarding medicalisation, over diagnosis and medical consumerism. The campaign has now spread internationally and includes a number of countries including Canada, Australia, New Zealand and Germany. The primary aim of the campaign is to facilitate healthcare professionals and patients to question the overall utility of medical interventions. Professionals through their professional organisations identify at least five commonly used interventions or tests, within their areas of speciality, which they feel provided no or little benefit to patients.This paper provides the background to the Choose Wisely campaign. The paper reviews the concepts of medicalisation, over diagnosis and medical consumerism, before considering the utility of the campaign in the UK alongside other forms of governance such as NICE. The paper goes on to consider distributive justice as the principal ethical issue related to the campaign. The paper concludes by asking if UK based Physiotherapists should Choose Wisely.

Your Metric Matters! Choose Wisely to Assess User Performance With Tourniquets in Simulated First Aid.

Readiness to perform lifesaving interventions during emergencies is based on a person's preparation to proficiently execute the skills required. Graphically plotting the performance of a tourniquet user in simulation has previously aided us in developing our understanding of how the user actually behaves. The purpose of this study was to explore performance assessment and learning curves to better understand how to develop best teaching practices. These were retrospective analyses of a convenience sample of data from a prior manikin study of 200 tourniquet uses among 10 users. We sought to generate hypotheses about performance assessments relevant to developing best teaching practices. The focus was on different metrics of user performance. When one metric was chosen over another, failure counts summed cumulatively over 200 uses differed as much as 12-fold. That difference also indicated that the degree of challenge posed to user performance differed by the metric chosen. When we ranked user performance with one metric and then with another, most (90%; nine of 10) users changed rank: five rose and four fell. Substantial differences in performance outcomes resulted from the difference in metric chosen, which, in turn, changed how the outcome was portrayed and thus interpreted. Hypotheses generated included the following: The usefulness of a specific metric may vary by the user's level of skill from novice to expert; demonstration of the step order in skill performance may suffice for initial training of novices; a mechanical metric of effectiveness, like pulse stoppage, may aid in later training of novices; and training users how to practice on their own and self-assess performance may aid their self-development. The outcome of the performance assessments varied depending on the choice of metric in this study of simulated use of tourniquets.

Can Knowledge About Heterogeneity in Treatment Effects Help Us Choose Wisely?

Randomized clinical trials help identify the potential health benefits and harms of an intervention. But patients vary widely in their responses, and such heterogeneity makes it difficult for physi...

Whole-brain radiation therapy for brain metastases: detrimental or beneficial?

Stereotactic radiosurgery is frequently used, either alone or together with whole-brain radiation therapy to treat brain metastases from solid tumors. Certain experts and radiation oncology groups have proposed replacing whole-brain radiation therapy with stereotactic radiosurgery alone for the management of brain metastases. Although randomized trials have favored adding whole-brain radiation therapy to stereotactic radiosurgery for most end points, a recent meta-analysis demonstrated a survival disadvantage for patients treated with whole-brain radiation therapy and stereotactic radiosurgery compared with patients treated with stereotactic radiosurgery alone. However the apparent detrimental effect of adding whole-brain radiation therapy to stereotactic radiosurgery reported in this meta-analysis may be the result of inhomogeneous distribution of the patients with respect to tumor histologies, molecular histologic subtypes, and extracranial tumor stages between the groups rather than a real effect. Unfortunately, soon after this meta-analysis was published, even as an abstract, use of whole-brain radiation therapy in managing brain metastases has become controversial among radiation oncologists. The American Society of Radiation Oncology recently recommended, in their “Choose Wisely” campaign, against routinely adding whole-brain radiation therapy to stereotactic radiosurgery to treat brain metastases. However, this situation creates conflict for radiation oncologists who believe that there are enough high level of evidence for the effectiveness of whole-brain radiation therapy in the treatment of brain metastases.

Choose Wisely: Auction or Negotiation?

We examine the method by which firms are sold, auctions or one-on-one negotiations. We define and describe a subset of transactions that result from auction failure (i.e., target-attempted auctions that secure only one bidder). Controlling for endogeneity, firm, and transaction specific characteristics, we show that failed auctions are associated with lower final premiums and higher acquirer returns compared with both successful auctions and pure negotiations (negotiations with only one bidder from the outset to the conclusion of the transaction). We find that several target, acquirer, and deal-specific characteristics affect the likelihood of auction failure. The loss of latent (perceived) competition that results from a failed auction partially shifts the wealth created by a merger or acquisition from targets’ to acquirers’ shareholders. To maximize shareholders’ wealth, targets should carefully consider the likelihood of auction failure ex ante.

Less Is More “Choose Wisely”

Less Is More “Choose Wisely”