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Choosing Wisely recommendations archive

The Choosing Wisely recommendations have not been updated or reviewed since 2019. This archive serves as an account of the work that the project did. The recommendations and guidance may in some cases no longer be relevant or have been superseded.

Since 2020 Choosing Wisely has promoted shared decision making between patients, carers and healthcare professionals.

  1. In hospital care settings the use of any antibiotic should be reviewed within 72 hours of being started.
  2. People should be advised on and signposted to alternative options by their pharmacist such as self-care, lifestyle changes and non-pharmacological interventions where appropriate.
  3. All medicines a person is being prescribed are appropriate for the individual and are optimised in line with personal goals in all care settings. This may involve discontinuing or deprescribing some medicines. This will improve access for people to medicines expertise and making medicines use as safe as possible.
  4. Stop the inappropriate use of antipsychotics to manage behaviour that challenges in people with learning disabilities, dementia and other mental health conditions

  1. Do use training of psychologically informed practice for clinicians treating patients with sub-acute and chronic low back pain. e.g. Back Skills Training (BeST) intervention
  2. Do use stratification tools to guide treatment for patients with back pain e.g. include STarT Back in Primary Care.
  3. Do offer a structured education and neuromuscular exercise programme for patients with osteoarthritis, to enable self-management and coping with arthritis e.g. ESCAPE- pain
  4. Do offer a three-month trail of supervised pelvic floor muscle training as a first line treatment to pregnant women and women experiencing stress or mixed urinary incontinence.
  5. Do offer a programme of supervised pelvic floor muscle training (PFMT), alongside lifestyle modifications and vaginal oestrogen, if appropriate, for a minimum of 16 weeks (continue if effective) to women with symptomatic prolapse, before surgery is considered
  6. Do offer a strength and balance exercise programme, with a minimum of 50 hours’ dosage, to older people living in the community who have experienced any of the following:
    • More than one fall in the last year
    • Problems with balance or walking
    • Fear of falling or reduced confidence when walking.

  1. Day surgery should be considered the default for many elective surgical procedures. Variation in the use of day surgery for these operations should be measured and this information should be available to patients.
  2. With the appropriate preoperative assessment and preparation elective surgical patients do not need to be admitted to hospital the day before their operation.
  3. Healthy patients having planned minor or intermediate surgery do not need routine preoperative tests. NICE guideline should be used (NG45) to help determine which tests are appropriate.
  4. Patients choosing surgery who are at a high risk of dying after an elective surgical procedure (predicted 30-day mortality of greater than 1%) should be identified by their age, type of surgery and coexisting medical conditions. They should have a shared decision-making consultation to discuss their individual chance of benefit or harm and to identify their personal preference.
  5. Patients should be helped to stop smoking, reduce alcohol consumption, improve fitness and nutrition and modify weight where possible. This should be in addition to active measures to optimise individual medical conditions before surgery.

  1. Not all patients with simple respiratory tract infection infections will need antibiotics.
  2. Review use of antibiotics for patients with bacteria in their urine who have no, minimal, non-specific, or long-standing urinary symptoms
  3. Consider stopping antibiotics after 4 days for patients with abdominal infection under control after operation or drain
  4. Discuss the use of antibiotics with patients who are close to the end of life
  5. Review the use of antibiotics for conditions that are not infections

  1. Connecting an intoxicated (alcohol) patient up to a drip and providing intravenous fluids will not help them feel better or allow discharge from hospital any quicker.
  2. Children with small fractures on one side of the wrist, ‘buckle fractures’ do not usually need a plaster cast. They can be treated with a removable splint and written information. There is usually no need to put a plaster cast on, or follow these children up in fracture clinic as they will get better just as quickly without this.
  3. Small fractures of the base of the fifth metatarsal, a bone on the outside of the foot, do not usually need to put into a plaster cast as they will heal just as quickly in a removable boot.
  4. Some injuries, such as hip and shoulder dislocations, can be treated with sedation in the emergency department rather than undergoing a general anaesthetic in the operating theatre.
  5. Tap water is just as effective for cleaning wounds as sterile saline.

  1. Consider restricting coagulation screens on patients presenting to emergency departments to only those taking anticoagulant drugs, massive haemorrhage or suspected of having a bleeding disorder.
  2. A clinician should discuss the need for a lumbar puncture for a patient suspected of having a sub-arachnoid haemorrhage if a CT is performed within 6 hours of the start of the headache.
  3. Review the routine use of urine toxicology tests in patients who are poisoned.
  4. People who have suffered a first seizure, who have fully recovered, have no headache and have a normal neurological examination do not usually need a CT scan while in the emergency department. They should be offered an MRI as an outpatient instead.
  5. Discuss the need for antibiotics for asymptomatic bacteriuria in older people

  1. When patients are particularly frail or in their last year of life, unless there is a clear preference otherwise by the patient or advocate, discuss with the patient and family/carers the option of decreasing the number of medicines to only those used for control of symptoms.
  2. Being alert to the possibility of dementia in patients at risk, with further assessment on an individual basis is good practice, but routinely screening for dementia using structured tools has not been recommended by the UK National Screening Council. It risks false positive diagnoses and has no proven benefit.
  3. When considering risk modifying treatment in primary prevention, for example treatment for blood pressure, cholesterol or bone density, share the option to have treatment or not before prescribing. Decision aids exist to support this process for doctors and patients.
  4. Treating Stage 1 (mild) hypertension in people without any other cardiovascular risk factors may have only small potential benefit for an individual. Consider total cardiovascular risk before initiating drug treatment.
  5. Ultrasound has very limited value in making a diagnosis of polycystic ovarian syndrome:
    Polycystic ovaries do not have to be present to make the diagnosis, and the finding of polycystic ovaries does not alone establish the diagnosis.
    Symptoms and a hormonal profile* will usually be enough to establish a diagnosis.
    *NICE recommends: Testosterone/SHBG/LH/FSH/Prolactin/TSH.
  6. Once a patient being treated with a statin has reached their target level of cholesterol, there is no need to keep measuring it.

  1. Life support for patients at high risk of death or severely impaired functional recovery should not be offered. A discussion with patients and their families should focus on the goals of comfort care.
  2. Tests and investigations should only be done in response to answering a specific question rather than routinely.
  3. Blood transfusions should only be given when the haemoglobin is less than 70 g/L. Blood transfusions may occur above this level where the patient is haemodynamically unstable or actively bleeding.
  4. Patients who are mechanically ventilated may not need to be deeply sedated, and where possible daily trials to lighten sedation should be done.

  1. Medicines like aspirin, heparin or progesterone should not be used in a bid to maintaining a pregnancy in a woman who has had unexplained and recurrent miscarriages.
  2. Aspirin is not recommended as a way of reducing the chances of pregnant women developing blood clots (thromboprophylaxis).
  3. Unless the mother has diabetes, ultrasound scans should not be used to check if a baby is bigger than normal for its gestational age (macrosomia).
  4. A simple ovarian cyst less than 5cm in diameter in a woman who has not gone through the menopause does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.
  5. Electronic monitoring of a baby’s heart should not be offered routinely during labour unless the mother is at a higher risk of complications than normal.

  1. Avoid use of antibiotics for group B Streptococcus carriage until labour starts.
  2. Endometrial hyperplasia can often be managed without surgery.
  3. Where possible an external cephalic version should be offered for breech presentation before a planned caesarean section is agreed.
  4. Parental karyotyping is not routinely indicated in recurrent miscarriage. Information should be given to the patient, any questions answered, and their individual circumstance and preferences discussed.
  5. Nausea and vomiting in pregnancy is very common and most women are able to manage this by eating and drinking frequently.

  1. Do not review uncomplicated cataract cases on day one post-op
  2. If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock.
  3. Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes.
  4. If conjunctivitis is thought to be viral, there is no need to send samples to the laboratory or to treat with antibiotics.
  5. The initial episode of unilateral anterior uveitis does not usually need further investigation

  1. Referral for cataract surgery should be made based on a shared decision-making process about how it may impact quality of life. It should not be restricted because of visual acuity alone.
  2. Patients and doctors should use shared decision making to decide when to initiate treatment and what treatment to use for wet active age related macular degeneration. This should take into consideration evidence for visual outcomes to make a fully informed choice of treatment.
  3. Doctors and patients should discuss the risks and benefits of having cataracts surgery on both eyes on the same day.
  4. Before referring a patient for chronic open angle glaucoma and related conditions and related conditions ensure you have considered the following tests available in the community including:
    • central visual field assessment using standard automated perimetry (full threshold or supra-threshold)
    • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
    • intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry
    • peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the patient prefers, the van Herick test or OCT.

    Patients should be referred for further investigation and diagnosis of COAG and related conditions, after considering repeat measures if:

    • there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or
    • there is a visual field defect consistent with glaucoma or
    • IOP is 24 mmHg or more using Goldmann-type applanation tonometry

    If these criteria are not met, people with IOP below 24 mmHg are advised to continue regular visits to their primary eye care provider.

  5. When considering whether a patient should have cataracts surgery, you should use a validated risk stratification algorithm.

  1. Helmet therapy is not effective in the treatment of positional plagiocephaly in children, other treatment options should be considered and discussed with your patient.
  2. Polyethylene Glycol should be used in preference to Lactulose in the treatment of chronic constipation in children.
  3. Buccal midazolam or lorazepam should be in the treatment of prolonged seizures in young people and children, as these are the most effective treatments, in preference to rectal and intravenous diazepam.
  4. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.

  1. Unless a patient is at increased risk of prostate cancer because of race or family history, PSA testing does not necessarily lead to a longer life.
  2. Calcium testing is used when there are symptoms of kidney stones, bone disease or nerve-related disorders; but it is not necessary to test less than three months after the previous test except in acute conditions, during major surgery or in critically ill patients when tests should not be made more often than every 48 hours.
  3. Only consider transfusing platelets for patients with chemotherapy-induced thrombocytopenia where the platelet count is < 10 x 109/L except when the patient has clinical significant bleeding or will be undergoing a procedure with a high risk of bleeding.
  4. Use restrictive thresholds for patients needing red cell transfusions and give only one unit at a time except when the patient has active bleeding.
  5. Only transfuse O Rh D negative red cells to O Rh D negative patients and in emergencies for females of childbearing potential with unknown blood group.

  1. Avoid unnecessary duplicate genetic testing for inherited variants.
  2. Don’t give a patient a blood transfusion without informing them about the risks and benefits (although do not delay emergency.
  3. Don’t transfuse red cells for iron deficiency anaemia without haemodynamic instability
  4. Use statins in appropriate patients.

  1. In the treatment of depression, if an antidepressant has been prescribed within the therapeutic range for two months with little or no response, it should be reviewed and changed or another medication added, which will work in parallel with the initial drug that was prescribed.
  2. When adults with schizophrenia are introduced to treatment with long-term anti-psychotic medication, the benefits and harm of taking oral medication compared to long-acting depot injections should be discussed with all relevant parties.
  3. Women who are planning a pregnancy or may be pregnant should not be prescribed valproate for mental disorders except where there is treatment resistance and/or very high risk clinical situations.
  4. When a diagnosis of psychosis is made, CT or MRI head scans should only be used for specific indications where there are signs or symptoms suggestive of neurological problems.

  1. Cognitive testing alone does not diagnose dementia.
  2. Aim to use non-drug treatments for the management of behavioural and psychological symptoms of dementia.
  3. Do not forget pain as a common cause of agitation in patients with dementia.
  4. Antipsychotics can cause serious side effects in patients with Lewy Body Dementia. They should only be used under expert guidance.
  5. Anticholinergic drugs can be detrimental to cognition in later life and have other serious side effects.
  6. Do not refuse patients access to a service, investigation or treatment solely on the basis of their age.
  7. Management of older adults with mental problems should be guided by Old Age specialists, who are able to manage the complex needs of this population.
  8. The care of frail older adults with complex needs who need an inpatient admission, is best managed in an older person’s specialist ward environment.
  9. Do not use physical restraints in older adults in hospital settings with delirium except as a last resort.
  10. If benzodiazepines or antipsychotics drugs have been initiated during an acute care hospital admission, make sure there is a clear plan to review their use, ideally tapering and discontinuing prior to discharge.

  1. Patients with suspected migraine mostly don’t need brain imaging.
  2. Patients with low back pain do not routinely need imaging.
  3. When managing patients with transient loss of consciousness (TLoC), investigations should be performed only after an appropriate neurological and cardiological assessment.
  4. Atraumatic lumbar puncture needles are preferred for lumbar puncture to reduce the risk of post LP headache.
  5. When managing patients with fleeting sensory symptoms, investigations should not be performed unless clinically indicated.
  6. When managing patients with suspected carpal tunnel syndrome (CTS) requiring surgery, a neurophysiological assessment should be performed.
  7. Do not use MRI head imaging in patients with suspected Parkinson’s disease.

  1. In advanced cancer, the use of chemotherapy that is unlikely to be beneficial and may cause harm should be minimised.
  2. In cases of a minor head injury, imaging is not likely to be useful.
  3. Back pain which is uncomplicated, that is not associated with ‘red flags’ or radicolupathy usually does not require imaging.
  4. Where there is suspicion of a pulmonary embolus, imaging should be guided by clinical scoring systems.
  5. After treatment for cancer, the use of routine scanning should only be used where this is beneficial to the patient.

  1. MRI Is indicated only in specific circumstances. Clinical features will often be sufficient to guide management without the need for imaging.
  2. Morton’s neuroma is essentially a clinical diagnosis and investigations are generally unnecessary.
  3. US is the investigation of choice in the assessment of rotator cuff and surrounding soft tissues.
  4. Imaging is not normally required for Parkinson’s disease (PD).
  5. Routine follow up imaging is not always appropriate. IREFER guidelines are available, which help you determine what is best for your patients.

  1. Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.
  2. Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay. Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests. A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis. Repeat testing is not normally indicated.
  3. Everyone should consider Vitamin D supplementation during winter.
  4. Bisphosphonate therapy should be reviewed with every patient after 3-5 years, and a treatment holiday considered. This should follow a shared-decision making conversation which includes the risks and benefits of continued treatment.
  5. The use of intra-articular and soft-tissue steroid injections for non-inflammatory musculoskeletal conditions should be preceded by consideration of non-invasive alternatives such as exercise and physical therapy.  Consent to any invasive procedure such as this must arise from a shared-decision making conversation with every patient, which includes assessment of the risks and benefits.
  6. C3, C4 and dsDNA are important tests to help in the diagnosis and assessment of disease activity in lupus. They should be reserved for specialist monitoring of disease activity and should be avoided as screening tests.

  1. If a woman has abnormal vaginal discharge that is likely to be caused by thrush (also known as candida) or Bacterial vaginosis (BV) and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.
  2. A woman who is thought to be having recurrent thrush should have an examination of the skin around her vagina to exclude other conditions such as lack of vaginal estrogen, allergies or other skin conditions rather than be given another course of thrush treatment.
  3. If a woman over the age of 45 years with typical symptoms of menopause, such as hot flushes and sweats and if her periods have become irregular, much lighter or have stopped, further bloods tests to check hormone levels are not usually necessary.
  4. Women who have a copper intrauterine device (IUD) or the hormonal intrauterine system (IUS) fitted only need to seek professional advice when they cannot feel the threads which hang from the device. Women should be taught how to feel for these threads.

  1. Women can have routine cervical smears taken if they are due at the time that they are attending for other sexual health issues.
  2. Women without medical problems can be routinely given a repeat 12-month prescription of oral contraception rather than 3 or 6-month supplies.
  3. Women requesting intrauterine contraception can attend for a one-stop consultation and insertion appointment provided they have access to high quality local guidance on the procedure and its risks and benefits e.g. online website resources including a check-list.