Table 3 Justification categories for Choosing Wisely recommendations with examples. The categories are modified from Choosing Wisely principles and the GRADE criteria

Unfavorable balance between benefits and harms

Urinary tract infection: Do not treat asymptomatic bacteriuria in the elderly, because it does not decrease incontinence, urinary tract infections or mortality.

Eradication of bacteriuria does not decrease incontinence, urinary tract infections or mortality. Antibiotics have side effects and increase antimicrobial resistance. (A)

Ineffective treatment or insensitive diagnostic test

Tendon disorders of the shoulder: Do not use ultrasound to treat tendon disorders of the shoulder.

Ultrasound therapy is not more effective than placebo (pain, function). (A)

Unnecessary intervention

Stable Coronary Artery Disease: Do not do an exercise test for a patient with chest pain and low probability of coronary artery disease.

In this patient group the likelihood of a false positive result is high. (no evidence summary) [22, 23]

Alternative treatment options more effective

Acute otitis media: Do not routinely treat tympanostomy tube otorrhea with oral antibiotics.

Topical antibiotics are more effective than oral antibiotics in the treatment of tympanostomy tube otorrhea. Oral antibiotics have more side effects and increase antimicrobial resistance. (B)

Unfavorable balance between benefits and costs

Age-related macular degeneration: Avoid ranibizumab and aflibercept as first line treatments for age related macular degeneration due to high costs.

Comparable effectiveness but higher costs than other treatment options. (B)

No evidence for effectiveness

Glaucoma: Do not routinely measure diurnal fluctuations in intraocular pressure following monitoring progression of glaucoma.

The benefit is uncertain. There is little research and its quality is low. (D)