To the Editor—The COVID-19 pandemic has produced devastating effects worldwide, with the causative coronavirus SARS-CoV-2 infecting over 170 million patients and causing more than 3.5 million deaths as of 1 June 2021. The resultant fear and anxiety among the public and treating physicians has frequently resulted in rapid changes to clinical practices and hospital triage decisions, many of which are not evidence based and are often detrimental. There have been wide variations at global and regional levels on guidance related to mask usage, testing protocols, vaccination and patient triage (both hospital admission and escalation to an intensive care unit), as well as the use of various pharmaceutical interventions in treating patients with COVID-19. Many of these deviations from evidence-based healthcare result in substantial harm, as they divert efforts and resources from outcome-based, data-driven best practices toward those that are of doubtful efficacy and are even harmful. As many countries continue to experience repeated waves of COVID-19, it is important to identify practical approaches that are evidence based and implementable in the real world to optimize the use of resources and improve outcomes. Although these are important all over the world, they are crucial in low- and middle-income countries, where resources are scarce.
The Choosing Wisely initiative was begun to promote conversations between patients and physicians about avoiding unnecessary medical interventions. The mission of Choosing Wisely is to help patients and physicians choose care that is evidence based, not duplicative, free from harm, and truly necessary1. It works by creating lists of ‘things clinicians and patients should question’, something that is particularly appropriate to public-health responses and management decisions in the current pandemic. In response to the widespread use of non–evidence-based practices, we initiated Choosing Wisely for COVID-19 to identify ‘best buys’ for the general public, patients and physicians.
We created an 18-member Choosing Wisely for COVID-19 Task Force in April 2021 with multi-stakeholder involvement. Members were drawn from the fields of public health, epidemiology, general practice, primary care, infectious disease, virology, critical care, internal medicine, pulmonology, pediatrics, oncology, health economics, clinical research, implementation science, and health policy. We also had patient and civil-society representatives to ensure that their views and voices were given due importance. Advisors to the group included leaders of the World Health Organization and senior government officials. Task Force members contributed to an initial ‘long list’ of 47 recommendations based on available evidence, including 9 recommendations from a Choosing Wisely initiative undertaken in 2020 (ref. 2). The members undertook two rounds of a modified Delphi process (described elsewhere3) to assign scores to the recommendations, and voted for their inclusion using the following criteria: evidence to support the recommendation, extent to which it is practiced, cost associated (including opportunity cost), clarity of the recommendation, feasibility of measurement, and relevance to the current situation.
We provide here the ten recommendations with explanations (Table 1): the first five are directed toward the general public, whereas the remaining five are meant for physicians managing COVID-19. The final recommendations are related to the following (recommendation numbers from Table 1 in parentheses): precautionary practices to decrease the risk of being infected (1 and 2); measures to be taken if someone has symptoms or has been diagnosed with COVID-19 (3 and 4); vaccination (5); judicious use of drugs (6, 7 and 8) and investigations (9) in managing COVID-19; and health systems and policies (10). The first two recommendations are most relevant in regions of high community spread and low vaccine coverage, whereas the remaining eight are relevant regardless of the setting.
The Choosing Wisely recommendations for the prevention, care and control of COVID-19 include the best evidence available at present, and address practices that are common, inefficacious, of low value or harmful in the response to COVID-19 in several countries. All recommendations are based on robust evidence and can improve outcomes for pandemic control globally. These are especially relevant in low- and middle-income countries, where resources are scarce, government expenditure on public healthcare is low, and optimum utilization is crucial. We emphasize that these recommendations are not meant to replace treatment protocols; instead, they are intended to promote shared decision-making by patients and physicians, and to provide guidance to treating physicians and the general public.
Our consensus list of recommendations for COVID-19 control has several implications. First, it provides guidance to the general public on simple measures that could decrease their risk of contracting COVID-19—we emphasize the importance of appropriate mask usage, avoiding crowded places (including social mixing) and encouraging adequate ventilation indoors, on the basis of growing understanding of the transmission of SARS-CoV-2. Second, this consensus list provides practical guidance to patients on what to do when they develop symptoms of or test positive for COVID-19, including recognition of symptoms and signs that warrant medical attention. Guidance for patients is important, as healthcare systems should also adopt a hospital triage system in which patients with mild to moderate illness are not admitted to the hospital, so precious hospital beds are reserved for patients with more-severe disease. Third, the consensus list provides clear recommendations to the general public on vaccination, as vaccines provide the most important path to control of the pandemic. Fourth, the consensus list encourages physicians to make evidence-based, outcomes-driven treatment decisions that will optimize resources and avoid wastage. By disseminating these recommendations, we are also discouraging defensive medical practice by physicians who fear litigation or criticism if they did not treat patients with unproven therapies. Finally, we emphasize the importance of maintaining essential non-COVID-19 healthcare areas such as cancer, tuberculosis, renal and cardiac disease, mental health and reproductive health even during major pandemics, as the consequences of not doing so are dire. During subsequent waves of the pandemic, policy decisions should ensure that while care for COVID-19 is maintained, other essential healthcare delivery continues uninterrupted.
Our Choosing Wisely for COVID-19 initiative has some strengths and limitations. The Task Force and advisors comprised diverse experts and representatives from all possible stakeholders involved in the management of COVID-19, including patient representatives and policymakers. This ensures that all stakeholders’ viewpoints are considered and makes our list of recommendations generalizable, widely applicable and implementable. All the recommendations have high-quality evidence to support them. Nevertheless, data on COVID-19 are rapidly evolving, and it is possible that these recommendations may change as new evidence is available. We reiterate that these recommendations are context specific, and that some of them (mask usage and physical distancing) may be most relevant in settings of widespread community transmission and limited vaccine access. Globally, vaccine access is highly inequitable, and many parts of the world are unlikely to have adequate vaccines for their populations within the next 2 years. In summary, the Choosing Wisely for COVID-19 initiative has identified ten key recommendations for the control of COVID-19 through inputs and systematic development process from diverse stakeholders. Adopting and implementing this list will promote more evidence-based implementation of policy and practices in managing the COVID-19 pandemic in various parts of the world. Most importantly, this list emphasizes the critical role that evidence-based medicine should serve, even during a raging pandemic.
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We gratefully acknowledge the valuable contributions of the task force advisors: S. Swaminathan (Chief Scientist, World Health Organization) and K. Vijayraghavan (Principal Scientific Advisor, Government of India).
G.K. is vice-chair of the board for the Coalition for Epidemic Preparedness Innovations, director of MSD Wellcome Trust Hilleman Laboratories, director of the Ignite Life Science Foundation, a member of the scientific advisory board of Mynvax, a member of the scientific advisory board for mRNA vaccines at Cipla (all of which are honorary, except Hilleman Laboratories, where G.K. is a Wellcome Trust–nominated Director and receives an honorarium that is transferred to her institution). M. Pai receives funding from the Bill & Melinda Gates Foundation for tuberculosis research.
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Pramesh, C.S., Babu, G.R., Basu, J. et al. Choosing Wisely for COVID-19: ten evidence-based recommendations for patients and physicians. Nat Med 27, 1324–1327 (2021). https://doi.org/10.1038/s41591-021-01439-x
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