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Table 1 Fourteen operational definitions adapted from 18 Choosing Wisely recommendations to hospital claims data

From: Developing indicators for measuring low-value care: mapping Choosing Wisely recommendations to hospital data

Recommendation (source) Narrower definition Broader definition
Avoid performing a colonoscopy for constipation in those under the age of 50 years without family history of colon cancer or alarm features (CWC) Colonoscopy with diagnosis of constipation, and no diagnoses of anaemia, weight loss, family or personal history of cancer of digestive system, or personal history of other diseases of the digestive system in previous 12 months. Minimum age: 18. Maximum age: 49. Sex: both Colonoscopy with diagnosis of constipation and no anaemia, weight loss, or family or personal history of cancer of the digestive system recorded in the admission. Minimum age: 18. Maximum age: 49. Sex: both
Don’t perform carotid endarterectomies or stenting in most asymptomatic high-risk patients with limited life expectancy (CWC) Carotid endarterectomy with no stroke or focal neurological symptoms recorded, and ASA code 4–5 or age 75 + with ASA 3. Exclude emergency admissions and admissions from the emergency department. Minimum age: 18. Sex: both [16, 26] Carotid endarterectomy with no stroke or focal neurological symptoms recorded, and ASA code 4–5 or age 75 +. Minimum age: 18. Sex: both [16, 26]
Don’t perform endovascular repair of abdominal aortic aneurysms in most asymptomatic high-risk patients with limited life expectancy (CWC) Endovascular repair of aneurysm, with diagnosis of abdominal aortic aneurysm without mention of rupture in the admission, and ASA code 4–5 or age 75 + with ASA 3. Exclude emergency admissions and admissions from the emergency department. Minimum age: 18. Sex: both Endovascular repair of aneurysm, with diagnosis of abdominal aortic aneurysm without mention of rupture in the admission, and ASA code 4–5 or age 75 + . Minimum age: 18. Sex: both
Avoid performing an endoscopy for dyspepsia without alarm symptoms for patients under the age of 55 years (CWC) Endoscopy with diagnosis of dyspepsia, and no diagnoses of dysphagia, iron deficiency anaemia, other nutritional anaemia, abnormal weight loss, personal or family history of cancer of digestive system, or personal history of peptic ulcer disease in the previous 12 months. Minimum age: 18. Maximum age: 54. Sex: both Endoscopy with diagnosis of dyspepsia and no diagnoses dysphagia, iron deficiency anaemia, other nutritional anaemia, abnormal weight loss, personal or family history of cancer of digestive system, or personal history of peptic ulcer disease in the admission. Minimum age: 18. Maximum age: 54. Sex: both
Don’t perform fusion surgery to treat patients with mechanical axial low back pain from multilevel spine degeneration in the absence of: … (CWC) Spinal fusion with diagnosis of low back pain with no mention of sciatica, spondylolisthesis, spinal deformities, or pain in legs in previous 12 months. Minimum age: 18. Sex: both Spinal fusion with diagnosis of low back pain or spinal stenosis with no mention of sciatica, spondylolisthesis, spinal deformities, or pain in legs in admission. Minimum age: 18. Sex: both
Avoid recommending knee arthroscopy as initial/management for patients with degenerative meniscal tears and no mechanical symptoms (CWUS) Knee arthroscopy in patients with knee osteoarthritis and no diagnosis of ligament strain or damage and no diagnosis of pyogenic arthritis. Minimum age: 55. Sex: both [27, 28] Knee arthroscopy in patients with knee osteoarthritis or meniscal derangements and no diagnosis of ligament strain or damage and no diagnosis of pyogenic arthritis. Minimum age: 18. Sex: both [27, 28]
Don’t use epidural steroid injections (ESI) for patients with axial low back pain who do not have leg dominant symptoms originating in the nerve roots (CWC, CWA) ESI with diagnosis of low back pain with no mention of leg pain or radiculopathy in previous 12 months. Minimum age: 18. Sex: both ESI with diagnosis of low back pain with no mention of leg pain or radiculopathy in admission. Minimum age: 18. Sex: both
Avoid an open approach for primary bariatric surgical procedures [as opposed to a laparoscopic approach] (CWUS) Bariatric procedure (including sleeve gastrectomy, gastric bypass, gastroplasty, gastric banding, biliopancreatic diversion, gastric reduction) and no previous bariatric procedure recorded within 12 months. No codes indicating revision or reversal procedure. No laparoscopic procedure codes in admission. Minimum age: 18. Sex: both  
Don’t routinely remove the gallbladder [during bariatric surgery] unless clinically indicated (CWUS) Bariatric procedure with cholecystectomy in admission. No gallbladder disease in previous 12 months. Minimum age: 18. Sex: both  
Don’t use IVC filters as primary prevention of pulmonary emboli in the absence of an extremity clot or prior pulmonary embolus (CWUS)
Don’t use inferior vena cava (IVC) filters routinely in patients with acute VTE (CWUS)
IVC insertion with no current or past pulmonary embolism (PE) diagnosis or deep vein thrombosis (DVT) in previous 12 months, or current acute venous thromboembolism. Minimum age: 18. Sex: both All IVC insertions [16]
In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit (CWA)
Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes (CWUK)
Retinal laser or cryotherapy procedure and lattice degeneration diagnosis, with no procedure code indicating repair of retinal detachment, or history of diagnosis of retinal detachment in previous 12 months. Minimum age: 18. Sex: both Retinal laser or cryotherapy procedure and lattice degeneration diagnosis, with no procedure code indicating repair of retinal detachment, or history of diagnosis of retinal detachment. Minimum age: 18. Sex: both
If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock. (CWUK) Lacrimal duct probing procedure on patient under 12 months, with diagnosis of stenosis of lacrimal duct in claim. Sex: both Lacrimal duct probing procedure on patient under 12 months. Sex: both
Don’t perform endometrial biopsy in the routine evaluation of infertility (CWUS) Endometrial biopsy, not related to suspicion of malignancy, with infertility diagnosis given as primary diagnosis. Minimum age: 18. Sex: female Endometrial biopsy, not related to suspicion of malignancy, with infertility diagnosis. Minimum age: 18. Sex: female
Intravitreal injections may be safely performed on an outpatient basis. Don’t perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication (CWA) Intravenous injection, not associated with other intraocular surgery or for a patient requiring anaesthetic services. Minimum age: 18. Sex: both  
Day surgery should be considered the default for most surgical procedures (except complex procedures). Variation in the use of day surgery for specific operations should be measured and this information should be available to patients (CW UK)   
  1. ASA American Society of Anesthesiologists Physical Status Classification [29], CWA Choosing Wisely Australia, CWC Choosing Wisely Canada, CWUK Choosing Wisely United Kingdom, CWUS Choosing Wisely United States, IVC inferior vena cava, VTE venous thromboembolism