Medical overuse and low-value care, defined as healthcare that is ineffective, harmful, or provides marginal benefit at disproportionately high cost, are widely recognized as global issues that strain healthcare systems. An early effort to address these problems was the Choosing Wisely campaign, which aimed to foster conversations between clinicians and patients about unnecessary tests, treatments, and procedures. A core principle of this campaign is that patients are “prepared to talk with their clinicians” about these matters, leading to the development of five specific questions for patients to ask their healthcare providers. These “Choosing Wisely questions” help guide discussions on necessity, risks, simpler/safer alternatives, consequences of inaction, and costs of treatments or procedures.
Despite the widespread promotion of the Choosing Wisely questions, there has been limited evidence evaluating their effect on patient outcomes, particularly among adults with varying levels of health literacy. Health literacy, assessed in this study using the Newest Vital Sign (NVS), categorizes individuals as having “limited” (NVS scores 0–3) or “adequate” (NVS scores 4–6) health literacy. It is known that individuals with lower health literacy typically experience shorter medical visits, ask fewer questions during consultations, and may find it challenging to understand shared decision-making (SDM) questions, including those from the Choosing Wisely campaign. These disparities contribute to poorer health outcomes, such as increased hospitalization and mortality. Given these challenges, tailored interventions have been proposed as a way to support more effective communication and potentially reduce health inequities for those with lower health literacy.
This study conducted a preplanned analysis of a randomized trial to investigate two main objectives: (a) whether the impact of the Choosing Wisely consumer questions on question-asking and SDM outcomes differed based on participants’ health literacy, and (b) to explore the relationship between health literacy, question-asking, and other decision-making outcomes within the context of low-value care. The research included 1439 Australian adults, stratified by their health literacy levels, and evaluated the Choosing Wisely questions, an SDM preparation video, both interventions combined, or a control group. A hypothetical low back pain scenario, chosen due to the prevalence of low-value care in this area, was used to engage participants.
The findings indicate that while the Choosing Wisely questions and the SDM video interventions generally did not have differential effects based on participants’ health literacy for most outcomes, adults with limited health literacy consistently scored lower on decision-making outcomes in the context of low-value care. Specifically, compared to individuals with adequate health literacy, those with limited health literacy demonstrated:
- Lower knowledge of SDM rights (82.1% vs 89.0%).
- Less positive attitudes towards SDM (48.3% vs 58.1%).
- A greater likelihood to follow low-value treatment plans without further questioning (mean score of 7.46/10 vs 6.94/10).
- Generated fewer questions aligned with Choosing Wisely topics (related to treatment risks, costs, and alternatives).
Notably, participants with limited health literacy were also more likely to indicate they would use the video interventions again compared to those with adequate health literacy (67.7% vs 55.7%). These results highlight the ongoing necessity for research and practical efforts to develop and test diverse intervention formats that effectively support individuals with lower health literacy in engaging in question-asking and shared decision-making, particularly as they may be more vulnerable to low-value care.
Reference for this article:
Muscat, D. M., Cvejic, E., Smith, J., Thompson, R., Chang, E., Tracy, M., Zadro, J., & McCaffery, K. (2024). Equity in Choosing Wisely and beyond: the effect of health literacy on healthcare decision-making and methods to support conversations about overuse. BMJ Quality & Safety. Advance online publication. https://doi.org/10.1136/bmjqs-2024-017411
