The first ophthalmic Choosing Wisely recommendations in Finland for glaucoma and wet age‐related macular degeneration

Growth in healthcare production and resources is assumed to lead to continuous improvement of well-being and health. However, already decades ago it was recognized that more health care may also incur counterintuitive effects (Fisher & Welch 1999, Table 1). Several medical speciality societies have initiated calling for physician leadership and responsibility to advocate cost-effective and just distribution of finite healthcare resources by advising clinicians what to do and what not to do, especially with missing or low-quality evidence (Parke et al. 2013). In 2013, American Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus released their top five lists for interventions which ophthalmologists and patients should question (Parke et al. 2013). By 2019, the Finnish Society Duodecim has published 92 Choosing Wisely recommendations for 55 medical entities with the first five for ophthalmology in 2018, based on Finnish national clinical practice guidelines for glaucoma and AMD (Tuulonen et al. 2014; Tuuminen et al. 2017) presented in English below. Avoid diagnosing glaucoma only on the basis of automated imaging instruments. Justifications: There is no consistent or generally approved definition of the diagnostic tests for glaucoma and their criteria in the scientific literature – nor is there evidence for either the most clinically effective or the most cost-effective tests and technologies to be used for the diagnosis and detection of progression to prevent glaucoma-induced visual disability (Tuulonen et al. 2014). The Cochrane review of 106 studies concluded that the accuracy of automated imaging tests for detecting manifest glaucoma was variable across studies and accuracy may have been overestimated due to the case–control design, which is a serious limitation of the current evidence base (Michelessi et al. 2015). In the Health Technology Assessment of imaging devices in community practice, the specificity for severe glaucoma of the best device was only 71% (Azuara-Blanco et al. 2016). Avoid nontargeted population screening for glaucoma because of lacking evidence that screening could prevent glaucoma-induced visual disability. Justifications: There is lack of high-quality studies indicating that any particular screening test or strategy policy reduces glaucoma-induced visual disability or is cost-effective. Avoid routine monitoring of diurnal intraocular pressure during follow-up of glaucoma. Justifications: The significance of measuring diurnal variation during follow-up in assessing the risk for progression of glaucoma is unclear. The number of studies is limited with nonoptimal quality. Avoid using ranibizumab and aflibercept as first-line therapy for wet AMD due to high costs. Justifications: Studies on the treatment of wet AMD with VEGF inhibitors (bevacizumab, ranibizumab, aflibercept) have failed to demonstrate clinically significant differences in the efficacy (anatomical and functional response) or safety of different treatment regimens over a follow-up period of a few years. The Council for Choices in Health Care within Ministry of Social Affairs and Health in Finland have stated that treatment of wet AMD with intravitreal bevacizumab is included in the publicly funded health service range of Finland (https://palveluvalikoima.fi/en/recommendations). The cost of bevacizumab in Finland is about 30–35 € compared to 700 € for ranibizumab and aflibercept. The cost of aflibercept can be substantially reduced by dividing the drug into three syringes. If the response of first-line drug is considered insufficient, treatment with another anti-VEGF drug may be warranted. Avoid initiating anti-VEGF therapy unless i) improvement of visual acuity or well-being can be expected; and ii) the harms or risks of treatment are expected to outweigh expected benefits. Justifications: In patients with a best spectacle-corrected visual acuity in the treated eye of less than 0.0625 decimals (ETDRS <20), there is little evidence of the anticipated benefits of treatment for the patient's functional capacity and quality of life. It is crucial to constantly and consciously consider sufficiency of care: both undertesting, undersdiagnosing and undertreatment – similar to overtesting, overdiagnosing and overtreatment. The latter increase the number of false positives, decrease quality of life and make it more difficult for severe cases to get appropriate care.