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

From: Highlighting the need for de-implementation – Choosing Wisely recommendations based on clinical practice guidelines

Category Number of recommendations* Guideline: Choosing Wisely recommendation Justification (level of evidence)
Unfavorable balance between benefits and harms 27 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 22 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 11 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 8 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 3 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 2 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)
  1. *A recommendation could be classified into several categories