[Choosing wisely recommendations in rheumatology : One year after their first publication]

[Characteristics of pharmacotherapy in older patients with rheumatism]

Due to medical advances and the availability of efficient immunosuppressive therapies, the life-expectancy of people suffering from inflammatory rheumatic diseases is continuously increasing. In Germany, geriatric patients (definition: age older than 70 years combined with geriatric multimorbidity) affected, e. g. by rheumatoid arthritis (RA) frequently receive corticosteroids and less often biologic disease-modifying antirheumatic drugs (bDMARDs) and conventional DMARDs (cDMARDs), which is justified by additionally existing comorbidities and polypharmacy. Using geriatric typical assessments as well as detailed medication regimens the treatment risk of bDMARD and cDMARD administration can be properly evaluated. Current data on biological therapy in older patients with rheumatism support this recommendation. Following the "choosing wisely" initiative of the German Association of Internal Medicine the authors listed 5 positive and 5 negative recommendations concerning the pharmacotherapy of older patients suffering from rheumatism (e. g. RA) as practical guidance towards safer bDMARD and cDMARD treatment for geriatric RA patients.

[Choosing Wisely: rationale, implementation, and evaluation]

"Klug entscheiden" (Choosing Wisely) is an initiative launched by the German Society for Internal Medicine (DGIM) to boost the quality of medical indication by identifying both medical/therapeutic over- and underuse. Twelve specialist societies for internal medicine and DGIM associated societies develop corresponding recommendations which are subsequently evaluated and rejected or approved in a structured procedure by a multidisciplinary commission. Since 2016, 115 positive and negative recommendations have been developed and released for print media, radio and television. Physicians can obtain the DGIM/BDI* certificate "Klug entscheiden". First steps have been undertaken to implement "Klug entscheiden" in medical education. The wide dissemination and intense discussions give a reason to hope that positive and negative recommendations will be put into practice and that the awareness towards the relevance of the quality of medical indication will grow. And finally, specific recommendations are to be developed the implementation of which can be evaluated prospectively. * Professional organization of German specialists for internal medicine.

["Deciding wisely together" - an initiative of the Association of the Scientific Medical Societies in Germany: Mission, methodology and application]

The question of how to improve healthcare quality and the need for patient empowerment and shared decision-making has been the subject of political and scientific debate for years. In addition to various quality initiatives, "top lists" summarizing selected recommendations to increase awareness of overuse, spread by means of public campaigns, has become popular on the international level - known as the "Choosing Wisely" initiative. However, the trustworthiness of "top lists", their impact on patient-relevant outcomes, their role in and integration into the context of the various pre-existing approaches to improve healthcare quality and the effects of neglecting under- and misuse are not clear. On the other hand, "top lists" may provide new opportunities to improve awareness and dissemination of carefully selected recommendations based on high-quality guidelines. Therefore, the Association of Scientific Medical Societies in Germany (AWMF) has established an ad hoc commission to design a system-specific initiative. The commission has the task to clarify goals, methods of development and concepts for implementation and evaluation, to address concerns and to build upon specific existing resources - e. g., the established quality management system for guidelines in Germany. The key goals defined by the commission include the systematization of the dialogue between healthcare practitioners and patients and the promotion of ethically founded decision-making as an answer to an increasing economic orientation of the healthcare system. To ensure the methodological quality of specific recommendations, the commission has developed a manual. To the best of our knowledge, this manual is the first detailed method paper aiming to guide developers of "Choosing Wisely" recommendations. More than 20 German medical scientific societies have already addressed the subject of "top lists".