Eastern Mediterranean Health Journal | All issues | Volume 31 2025 | Volume 31, issue 3 | A national intervention to reduce harm by combating overuse of medical services in Saudi Arabia

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A national intervention to reduce harm by combating overuse of medical services in Saudi Arabia

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Policy and practice

Aeshah Alsagheir1, Muna H Hassanein2 and Rawan A Alshahri3

1Saudi Ministry of Health, Riyadh, Saudi Arabia. 2Riyadh Region General Directorate of Health Affairs, Riyadh, Saudi Arabia. 3Saudi Patient Safety Center, Riyadh, Saudi Arabia (Correspondence to R Alshahri: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Choosing Wisely Saudi Arabia, a programme led by the Ministry of Health and Saudi Patient Safety Center, aims to reduce overuse of health care services, emphasizing patient safety, efficiency and patient-centred care.

Aim: To highlight the achievements of Choosing Wisely Saudi Arabia and make recommendations for more effective implementation.

Methods: Saudi Arabia began implementing Choosing Wisely as a pilot project in one hospital in January 2019 and later scaled up to other hospitals. To oversee the programme, we established a multistakeholder governance structure at the national and regional levels, which included a steering committee, a programme management office with a programme lead, a scientific committee, and regional and hospital champions. The steering committee developed the implementation guidelines, the Saudi Patient Safety Center developed the educational materials for patients, and the medical societies proposed the recommendations. The regional and hospital champions implemented the programme in the regions and at hospitals, respectively. The Saudi Ministry of Health funded the programme.

Results: During the first 4 years of implementation, 16 of the 20 health regions in Saudi Arabia implemented at least one Choosing Wisely initiative, leading to a reduction in the overuse of targeted medications and pharmacological agents, as well as laboratory and radiological services.

Conclusion: Choosing Wisely has been very helpful in reducing overuse of low-value health care services in Saudi Arabia. To make the programme sustainable and more effective, there is a need to adopt a comprehensive approach to implementation and involve more stakeholders from within and outside the Ministry of Health.

Keywords: choosing wisely, medical service, patient safety, patient-centred care, Saudi Arabia

Citation: Alsagheir A, Hassanein MH, Alshahri RA. A national intervention to reduce harm by combating overuse of medical services in Saudi Arabia. East Mediterr Health J. 2025;31(3):182–190. https://doi.org/10.26719/2025.31.3.182.

Received: 28/02/2024; Accepted: 04/12/2024

Copyright © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Medical service overuse is gaining recognition globally. It is the delivery of service where the potential for harm outweighs the benefits (1). To reduce overuse of low-value care, the American Board of Internal Medicine Foundation, Consumer Reports and 9 prominent medical specialty societies launched the Choosing Wisely campaign (2). The immediate objective of the campaign was to improve interactions between physicians and patients regarding essential care and to challenge the belief that more treatment is better (3). It aims to align physicians' practice to global best practices by discouraging medical interventions that are not necessary, administered without supporting evidence and/or potentially harmful (4). To achieve this, medical societies were requested to recommend ways healthcare providers could determine the appropriateness of tests and procedures and avoid them when unnecessary (1,4).

Saudi Arabia has a comprehensive healthcare system operated by public and private providers. The Ministry of Health provides 60% of the total health care services in the country, while government entities like the Ministry of Interior, Ministry of Defence, National Guard, Ministry of Higher Education, the Red Crescent, and the private sector, play key roles in healthcare provision (5,6). The regulatory bodies, such as the Saudi Commission for Health Specialties, oversee and regulate healthcare practice, enforce standards and ensure quality of service.

Overuse of health services is one of the challenges facing the healthcare system in Saudi Arabia, leading to significant shortfalls in value and quality (7). Many studies have reported overuse of laboratory tests, with inappropriate patterns such as the use of expensive tests and unnecessarily repeating tests (8–10). Some features of the Saudi healthcare system make overuse by patients and healthcare providers possible. For example, the availability of free health care services at public health facilities and third-party payments for services, such as health insurance, at private health facilities have been key drivers of overuse. Studies have shown that these can encourage individuals to seek medical care even when it is not necessary (11,12). Also, the private health sector, which delivers ≈25% of health care services in the country, provides services for a fee, which sometimes makes them to offer more services than required and thereby promoting overuse (12,13). The Saudi Council of Health Insurance has reported that each year, ≈80 million claims worth nearly SAR 25 billion are processed within its system (14). Insurance payments rely solely on a fee-for-service model and not outcome or performance-based. Consequently, there is an elevated risk of supplier-induced demand, fraud, waste and abuse (14).

The Health Transformation Plan of the 2030 Vision addresses these challenges by prioritizing the quality and safety of clinical care through promoting adherence to standards and protocols and the use of clinical practice guidelines (7). The plan aims to provide safe, effective, patient-centred, timely and equitable care. It led to the launch of the Choosing Wisely Saudi Arabia programme under the auspices of the Ministry of Health. The programme began as a pilot project in one hospital in 2019 (15) and was scaled up and officially launched in 2021. It was jointly coordinated by the Saudi Patient Safety Center and Ada’a Health (a programme designed to monitor healthcare services within the Ministry of Health).

This paper describes the design, implementation and preliminary results of the Choosing Wisely Saudi Arabia programme.

Methods

Table 1 presents the timeline for the initiation, planning and implementation of Choosing Wisely Saudi Arabia.

Preparatory phase

Governance

A national and regional multistakeholder governance structure was established in the 20 health regions in Saudi Arabia, with defined roles, responsibilities and relationships, to guide design and implementation.

At the national level, the steering committee, formed on 29 March 2021, was made up of representatives of the Patient Safety Center, Ada’a Program, Therapeutic Medicine Agency, Public Health Agency, Electronic Health Agency, and Hospital Services Assistant Agency of the Ministry of Health. The committee defines the programme goals, establishes subcommittees, monitors progress and makes recommendations for effective leadership and support. The programme lead, affiliated with the Ministry of Health, oversees Choosing Wisely programme at the national level and manages programme development, implementation and decision-making. The programme management office provides supervision for the regional teams, sets project vision, strategy, processes and quality standards, and provides training (4). The scientific committee is a technical core team, under the steering committee, which provides technical support for programme recommendations and approves educational materials for providers and patients. Its members include representatives of the Patient Safety Center and the Therapeutic Medicine Agency.

At the regional level is the regional champion, usually based in a health cluster or the regional health directorate, who leads and manages Choosing Wisely at the regional level. The functions include overseeing implementation, supervising health facility teams, providing regular reports to the national teams, and leading change management (2). The Choosing Wisely hospital champion serves as the focal person at the facility level. Their responsibilities include managing and administering the programme and leading change management within the health facility.

The programme lead and champions work part-time for Choosing Wisely, in addition to their regular job responsibilities while the Ministry of Health funds the programme.

Needs assessment

The steering committee facilitated a survey among physicians to assess guidelines-discordant practices as well as awareness and overuse issues, based on international recommendations. The scientific committee managed the survey, including data collection, analysis and reporting. The results revealed low awareness about unnecessary medical care and negative attitude towards discussing it. Overuse of antibiotics for skin abscesses was common, as well as frequent intensive care unit laboratory tests and unnecessary imaging. Based on the findings, Choosing Wisely focused on overuse of pharmacy, laboratory and radiology services, and established administrative units in the Ministry of Health to develop relevant materials and provide feedback.

Stakeholder engagement

The steering committee identified key stakeholders outside the Ministry of Health, including the Saudi Commission for Health Specialties, which oversees medical societies responsible for clinical guidelines. These societies were requested to develop and endorse the Choosing Wisely recommendations. The Council of Health Insurance, a key regulator of the private sector, was also involved. On 11 November 2021, the Council introduced stakeholders to the Choosing Wisely concept and roadmap and established regular communication channels for collaboration during implementation.

Development of guidelines and education materials

Several manuals have been created, including the Choosing Wisely Implementation Guide, which provides an overview of the programme and its rationale, and guidelines for implementation, including the roles and responsibilities of the various stakeholders. The Saudi Patient Safety Center approved, published and distributed the implementation guide, with support from the Ministry of Health (https://choosingwisely.spsc.gov.sa/HowToImplement.html). A Choosing Wisely Recommendations Development Guide was developed to facilitate formulation, endorsement and documentation of the recommendations, and a guide was created for the regional and hospital champions to document and report their success stories. The Empowerment Department at the Patient Safety Center developed and reviewed the patient and public health education materials, ensuring clarity and appropriateness. These resources were developed to promote informed decision-making in health care, in alignment with the mission of Choosing Wisely. To ensure broad accessibility, the materials are distributed in print (at health care facilities) and in electronic format (through Choosing Wisely website).

Implementation phase

Development of recommendations

The medical societies developed evidence-based recommendations, using the criteria set by the scientific committee, including prioritization within the Saudi health system, suitability for local practices and the need for measurable implementation indicators. They then posted the recommendations on the Saudi Arabia website after endorsement by the scientific committee (Figure 1). Each recommendation includes a version for healthcare providers in English and a version for patients in Arabic. Nine medical societies, including Emergency Medicine, Blood Disorders, Maternal–Fetal, Clinical Pharmacy, Professional Psychology, Clinical Chemistry, Epidemiology, Epilepsy, Family Medicine, and Rheumatology, helped in creating the recommendations. The recommendations will be incorporated into the national clinical practice guidelines.

Selection of regional and hospital champions

The General Directorates of Health Affairs and the health clusters in each region were approached to nominate Choosing Wisely Champions for their regions, using the criteria outlined in Table 2. Subsequently, the regional champions selected hospital champions to oversee implementation at health facilities. Selection of hospital champions was guided by the predetermined criteria presented in Table 2.

Training and orientation

The scientific committee conducted workshops to train the selected regional champions on planning, implementation and monitoring of Choosing Wisely and conducted awareness activities across all levels of the healthcare system, including webinars targeting healthcare professionals. Educational materials were made available on the Choosing Wisely Saudi Arabia website and X account.

Implementation roadmap

Choosing Wisely implementation at the regional level involved a range of activities. The regional champions organized workshops to introduce the programme to key health officials, including general directors of the Regional Health Affairs, executive directors of the Health Clusters, regional directors of Hospital Services, and hospital directors. They identified and trained hospital champions to lead and supervise programme implementation in their hospitals and reported progress at the national level.

Implementation at the health facilities was the responsibility of the hospital champions. Hospital-based implementation consisted of 3 phases, which sometimes overlapped. Phase 1 included engagement and change management. As recommended in the implementation guide, the hospital champion followed Kotter’s 8-step process for leading change (16) at the level of the hospital (Table 3). Phase 2 included identification of low-value practices, guided by scientific evidence linked to Choosing Wisely recommendations and consultations with clinic staff. This process was strengthened by analysing hospital administrative and clinic data to understand the extent of the overuse problem. An analysis of the causes of overuse was conducted to guide intervention selection. Phase 3 included the interventions, which involved applying relevant Choosing Wisely recommendations to address overuse of low-value practices. This was complemented by other active interventions rooted in the identified causes of overuse. Some of the adopted interventions included the development or updating of clinic guidelines and protocols, educating clinic staff and providing education to patients and their families.

Monitoring and evaluation

The steering committee developed key performance indicators to monitor Choosing Wisely at all levels. The steering committee managed the programme phases at the national and regional levels, while the project management office managed implementation at the regional level, with regional champions overseeing hospitals within each region.

Results

During the first 4 years of implementation, 16 of the 20 health regions in Saudi Arabia participated in the Choosing Wisely programme by implementing at least one aspect of the programme. In total, 74 regional and hospital champions led 67 initiatives nationwide, and 9 scientific societies collectively generated 91 recommendations.

Table 4 presents a description of some of the initiatives, including the type of intervention, target population, duration and outcomes. Five of the evaluated initiatives addressed overuse of pharmacological agents, including antibiotics, intravenous fluids, human albumin and proton pump inhibitors. There was a reduction in overuse of the targeted medications following implementation of Choosing Wisely. Three initiatives focused on reducing overuse of laboratory services, specifically vitamin D, troponin and creatine kinase–myocardial band testing, resulting in reductions in the targeted tests. Five initiatives addressed overuse of radiological services, such as brain computed tomography and magnetic resonance imaging, resulting in reduced use of these investigations.

Discussion

Reducing overuse of low-value health services is crucial for ensuring patient safety and satisfaction, cost reduction and development of a sustainable healthcare system (17). Choosing Wisely was initiated in 2012 to minimize unnecessary use of tests and procedures (18). Saudi Arabia is the first Arab country to implement the programme at the national level. It was supervised by the Ministry of Health and involved relevant stakeholders, exemplifying political commitment, leadership support and accountability, which are key drivers of successful implementation (11,19). This approach allowed the government to exercise authority over implementation and integrate the programme with national healthcare policies and standards, thus producing more extensive and long-lasting impact. It fostered a system-wide approach, promoting coordination among relevant stakeholders, which is a key factor in successfully addressing service overuse (11).

The Ministry of Health did not exclusively depend on passive dissemination of Choosing Wisely recommendations; instead, it used a combination of active interventions to further decrease the use of low-value services. Several studies have shown that relying solely on passive dissemination of Choosing Wisely guidelines is ineffective in reducing the use of low-value health care services (18–20). In Saudi Arabia, several interventions were adopted for implementing Choosing Wisely in hospitals, and these multicomponent interventions led to significantly higher success rates in addressing the use of low-value services than single component interventions (18,20).

Recruitment of clinicians as Choosing Wisely champions to advocate for interventions has been very helpful in reducing overuse of low-value care (18,19), just as educational interventions targeting health care providers, especially interactive education alone or in combination with other components, have (18–20). Engaging patients is crucial to securing support and involvement, as programmes to address overuse ultimately impact the types and quality of care patients receive (11,21). Interventions that directly involved patients, such as the use of patient-focused educational materials, have been found to help decrease the use of low-value health care services (19,21). Preliminary evaluation has revealed that the multiple Choosing Wisely initiatives have successfully reduced targeted low-value services in Saud Arabia (15,22,23), potentially leading to enhanced service quality and improved patient safety. It is challenging to compare the outcomes of the different initiatives and across the different fields of pharmacy, laboratory services and radiology because of variations in the targeted services and adopted interventions. Individual studies of the specific interventions would enable comparison with similar interventions in other countries.

Despite the encouraging outcomes, there were challenges in implementing Choosing Wisely Saudi Arabia. These included the deep-rooted culture of overuse, resource constraints, limited understanding of Choosing Wisely methodology by stakeholders, and the lack of awareness about its objectives. Frequent staff turnover and reassignments created additional hurdles, alongside the potential medicolegal actions and public complaints to the Ministry of Health. Implementation at the regional level depended on the availability of sufficient and relevant human resources, which made it challenging to implement across all Saudi Arabia regions. Despite the successes in reducing overuse of laboratory, pharmacy and radiology services, Choosing Wisely champions have identified challenges that have hindered progress from the different regions, mostly related to patient engagement, physician resistance and concerns about the medicolegal implications. Securing early support from leadership and raising awareness among patients, healthcare providers and the community are key factors for achieving success in Choosing Wisely interventions.

Sustainability began with the crafting of a clear vision, mission and goals, and implementing effective strategies, for Choosing Wisely Saudi Arabia. The programme seeks to use a multifaceted, multistakeholder partnership approach with diverse funding sources, as well as regular monitoring and evaluation with key performance indicators to measure success and identify areas for improvement in the long-term.

A limitation of this study was that it did not provide details about implementation of Choosing Wisely and did not discuss outcomes at the hospital and regional levels. We recommend separate documentation of these experiences to guide other entities interested in implementing a similar programme and offer insights into methodologies, best practices and effective interventions.

Conclusion

Choosing Wisely programme has been very helpful in reducing overuse of low-value health care services in Saudi Arabia. To overcome certain challenges and make implementation more effective and more sustainable, there is a need to adopt a more comprehensive approach to implementation that will involve more stakeholders from within and beyond the Ministry of Health.

Funding: None.

Conflict of interest: None declared.

Intervention nationale visant à réduire les dommages en luttant contre le recours excessif aux services médicaux en Arabie saoudite

Résumé

Contexte : Le Programme « Choosing Wisely Saudi Arabia », mené par le ministère de la Santé et le Centre saoudien pour la sécurité des patients, vise à réduire le recours excessif aux services de soins de santé, en mettant l’accent sur la sécurité des patients, l’efficacité et les soins centrés sur le patient.

Objectifs : Mettre en évidence les réalisations accomplies dans le cadre du Programme « Choosing Wisely Saudi Arabia » et formuler des recommandations en vue d’une mise en œuvre plus efficace.

Méthodes : L’Arabie saoudite a commencé à mettre en œuvre ce Programme en tant que projet pilote dans un hôpital en janvier 2019, et l'a ensuite déployé dans d'autres hôpitaux. Afin d’assurer son suivi, nous avons mis en place une structure de gouvernance multipartite aux niveaux national et régional, qui comprenait un comité d’orientation, un bureau de gestion des programmes avec un responsable, un comité scientifique et des porte-drapeaux régionaux et hospitaliers, respectivement. Le comité d’orientation a élaboré les lignes directrices relatives à la mise en œuvre, le Centre saoudien pour la sécurité des patients a mis au point les matériels éducatifs destinés aux patients et les sociétés médicales ont formulé les recommandations. Les porte-drapeaux régionaux et hospitaliers ont déployé le Programme au niveau régional et dans les hôpitaux. Son financement a été pris en charge par le ministère saoudien de la Santé.

Résultats : Au cours des quatre premières années de mise en œuvre, 16 des 20 régions sanitaires de l'Arabie saoudite ont adopté au moins une initiative du Programme « Choosing Wisely », ce qui a entraîné une réduction de la consommation excessive de médicaments et d’agents pharmacologiques ciblés, ainsi qu'une diminution de la surutilisation de services de laboratoire et de radiologie.

Conclusion : Le Programme « Choosing Wisely » s’est avéré très utile pour réduire le recours excessif aux services de soins de santé qui présentent un intérêt limité pour les patients en Arabie saoudite. Pour pérenniser et accroître l'efficacité de ce Programme, il convient d'adopter une approche globale de mise en œuvre et d'impliquer davantage de parties prenantes au sein et en dehors du ministère de la Santé.

تَدخُّل وطني للحد من الأضرار من خلال مكافحة الإفراط في استخدام الخدمات الطبية في المملكة العربية السعودية

عائشة إبراهيم الصغير، منى حسن حسنين، روان أحمد الشهري

الخلاصة

الخلفية: يهدف برنامج "الاختيار بحكمة" بالمملكة العربية السعودية، الذي تقوده وزارة الصحة والمركز السعودي لسلامة المرضى، إلى الحد من الإفراط في استخدام خدمات الرعاية الصحية، مع التأكيد على سلامة المرضى، والكفاءة، والرعاية التي تتركز على المرضى.

الأهداف: هدفت هذه الدراسة الى تسليط الضوء على إنجازات برنامج "الاختيار بحكمة" بالمملكة العربية السعودية وتقديم التوصيات التي تستهدف الارتقاء بمستوى الكفاءة في التنفيذ.

طرق البحث: شرعت المملكة العربية السعودية في تنفيذ برنامج "الاختيار بحكمة" في بادئ الأمر على هيئة مشروع تجريبي في أحد المستشفيات في يناير/ كانون الثاني 2019، وتوسعت فيه لاحقًا ليشمل مستشفيات أخرى. وللإشراف على البرنامج، أقمنا هيكلًا للحوكمة مكونًا من مجموعة من أصحاب المصلحة المتعددين على المستويين الوطني والإقليمي، واشتمل ذلك الهيكل على لجنة توجيهية، ومكتب لإدارة البرنامج يضم قائدًا للبرنامج، ولجنة علمية، ومناصرين من الجهات الإقليمية والمستشفيات. ووضعت اللجنة التوجيهية المبادئ التوجيهية المعنية بالتنفيذ، وأعد أيضًا "المركز السعودي لسلامة المرضى" المواد التثقيفية للمرضى، وقدمت الجمعيات الطبية توصياتها المقترحة. ونفَّذ المناصرون من الجهات الإقليمية والمستشفيات البرنامج على مستوى الأقاليم وفي المستشفيات، كما موَّلت وزارة الصحة السعودية البرنامج.

النتائج: نفَّذت 16 منطقة صحية من أصل 20 منطقة في المملكة العربية السعودية مبادرة واحدة على الأقل من مبادرات برنامج "الاختيار بحكمة"خلال السنوات الأربع الأولى من التنفيذ، وهو ما أثمر عن الحد من الاستخدام المفرط للأدوية والعوامل الدوائية المستهدفة، فضلًا عن تقليل اللجوء للخدمات المختبرية والإشعاعية.

الاستنتاجات: كان لبرنامج "الاختيار بحكمة" أثر إيجابي كبير في الحد من الاستخدام المفرط لخدمات الرعاية الصحية المنخفضة النفع في المملكة العربية السعودية . ولضمان استمرار البرنامج وزيادة مستوى فعاليته، تستدعي الحاجةُ اعتمادَ نهج شامل للتنفيذ وإشراك مزيد من أصحاب المصلحة من داخل وزارة الصحة وخارجها.

References

  1. Brownlee S, Chalkidou K, Doust J, Elshaug A, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. Lancet 2017;390(10090):156–168. PMID:28077232 https://doi.org/10.1016/S0140-6736(16)32585-5.
  2. American Board of Internal Medicine. Choosing wisely. Philadeplphia: ABIM, 2023. http://www.choosingwisely.org/about-us/.
  3. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89(7):990–995. PMID:24979166 https://doi.org/10.1097/ACM.0000000000000270.
  4. Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M, et al. Choosing Wisely in the UK: The Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ. 2015;350:h2308. PMID:25985331 https://doi.org/10.1136/bmj.h2308.
  5. Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: an overview. East Mediterr Health J. 2011;17(10):784–93. PMID:22256414 https://doi.org/10.26719/2011.17.10.784.
  6. Al-Hanawi MK, Almubark S, Qattan AMN, Cenkier A, Kosycarz EA. Barriers to the implementation of public-private partnerships in the healthcare sector in the Kingdom of Saudi Arabia. PLoS One 2020;15(6):1–15. PMID:32555648 https://doi.org/10.1371/journal.pone.0233802.
  7. Ministry of Health, Saudi Arabia. Health sector transformation programme, delivery plan. Riyadh: Ministry of Health, 2021. https://www.vision2030.gov.sa/media/0wop2tds/hstp_eng.pdf.
  8. Khalifa M, Zabani I, Khalid P. Exploring lab tests over utilization patterns using health analytics methods. Stud Health Technol Inform. 2016;226:190–193. PMID:27350501.
  9. Alkhalifah AM, Yahya A, Albattal S, Kofi M. Appropriateness of the lab utilization in PHCs, Riyadh, Saudi Arabia. Fam Med Prim Care Open Access 2022;6(2):8. https://doi.org/10.29011/2688-7460.100072.
  10. Khalifa M, Khalid P. Reducing unnecessary laboratory testing using health informatics applications: a case study on a tertiary care hospital. Procedia Comput Sci. 2014;37:253–260. https://doi.org/10.1016/j.procs.2014.08.038.
  11. Ellen ME, Wilson MG, Vélez M, Shach R, Lavis JN, Grimshaw JM, et al. Addressing overuse of health services in health systems: a critical interpretive synthesis. Heal Res Policy Syst. 2018;16(1):1–14. PMID:29907158 https://doi.org/10.1186/s12961-018-0325-x.
  12. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA 2008;299(23):2789–2791. PMID:18560006 https://doi.org/10.1001/jama.299.23.2789.
  13. Rahman R. The privatization of health care system in Saudi Arabia. Health Services Insights 2020;13. https://doi.org/10.1177/1178632920934497.
  14. Reka H. Value-based health care in Saudi health insurance market. White paper on value-based payment. Riyadh: Council of Health Insurance, 2022. https://vbhc.chi.gov.sa/assets/pdf/VBHC%20White%20Paper%20Version%20Final.pdf.
  15. Alsagheir A, Hassanein MH, Helail AS, Arafat M. Reducing unnecessary overuse of medical services in King Khalid General Hospital in Hafr Albatin Province: the effect of Choosing Wisely Campaign 2020. Saudi J Heal Syst Res. 2022;2(4):139–145. https://doi.org/10.1159/000526705.
  16. Kotter JP. Leading change. Why transformation efforts fail. Harvard Bus Rev. 2007. https://irp-cdn.multiscreensite.com/6e5efd05/files/uploaded/Leading%20Change.pdf.
  17. Parker G, Rappon T, Berta W. Active change interventions to de-implement low-value healthcare practices: A scoping review protocol. BMJ Open 2019;9(3):e027370. PMID:30904878 https://doi.org/10.1136/bmjopen-2018-027370.
  18. Cliff BQ, Avanceña ALV, Hirth RA, Lee SYD. The impact of Choosing Wisely interventions on low-value medical services: a systematic review. Milbank Q. 2021 Dec;99(4):1024–1058. PMID:34402553 https://doi.org/10.1111/1468-0009.12531.
  19. Rubagumya F, Sengar M, Ka S, Hammad N, Booth CM, Karim S. Choosing Wisely–barriers and solutions to implementation in low and middle-income countries. Curr Oncol. 2022;29(7):5091–5096. PMID:35877263 https://doi.org/10.3390/curroncol29070403.
  20. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies - a synthesis of systematic review findings. J Eval Clin Pract. 2008;14(5):888–897. PMID:19018923 https://doi.org/10.1111/j.1365-2753.2008.01014.x.
  21. Sypes EE, De Grood C, Whalen-Browne L, Clement FM, Parsons Leigh J, Niven DJ, et al. Engaging patients in de-implementation interventions to reduce low-value clinical care: A systematic review and meta-analysis. BMC Med. 2020;18(1):1–15. PMID:32381001 https://doi.org/10.1186/s12916-020-01567-0.
  22. Awashi HA, Daghriri MH, KhanLA. Diagnostic imaging overuse and the choosing wisely initiative. Gen Surg Open Access. 2022;5(3):12–13. https://www.pulsus.com/scholarly-articles/diagnostic-imaging-overuse-and-the-choosing-wisely-initiative-10611.html.
  23. Awashi HA, Darbashi HA, Khan LA. The Choosing Wisely initiative and esomeprazole over-prescription. EAS J Pharmacy Pharmacol. 2022;4(2):33–34. https://doi.org/10.36349/easjpp.2022.v04i02.002.