Choosing Wisely for Thyroid Conditions: Recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism
The overuse of low-value interventions is a global problem. A growing body of knowledge highlights that it leads to a waste of precious health care resources and poses patients at risk of harm . Choosing Wisely is a worldwide health care professional-led initiative that aims to advance the dialogue between physicians and patients about low-value health interventions, avoiding wasteful or unnecessary medical tests, treatments, and procedures . The Choosing Wisely initiative started in the United States in 2012 led by the American Board of Internal Medicine (ABIM) and is now present in many countries, involving more than one hundred medical associations/societies, hospitals, and universities. Given that thyroid conditions are widespread and that low-value interventions for these conditions are frequent in clinical practice, we aimed to develop a list of recommendations of measures not to be done when approaching patients with thyroid conditions. This article aims to summarize the top five recommendations in the list developed by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) for the Choosing Wisely project. 

In 2017 the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Choosing Wisely Brasil agreed to work towards the development of a list of Choosing Wisely recommendations for thyroid conditions. The Thyroid Department named a Chair (JMD) and a Co-chair (ALM) for the initiative. Additional members of SBEM, representing thyroid groups from 10 tertiary care, teaching-based Brazilian institutions, were invited to compose the Task Force. Of note, all members of the Task Force were clinical thyroid specialists, not surgeons. The Task Force work consisted of 3 phases: brainstorming and ideation was conducted electronically through a Delphi approach in which all Task Force members were invited to submit proposals of recommendations; all proposals of recommendations were reviewed, and duplicates removed; the Task Force graded each recommendation on a 0 (lowest agreement) to 10 (highest agreement) scale. The 10 recommendations that received the highest scores by the Task Force were submitted for voting by e-mail to all SBEM associates, who graded each recommendation on the 0 (lowest agreement) to 10 (highest agreement) scale. A final list of the 5 recommendations that received the highest scores by the SBEM associates composes the Choosing Wisely – Thyroid SBEM recommendations. 

The Task Force was composed of 14 thyroidologists from 10 different Brazilian institutions. The brainstorming and ideation phase resulted in 69 recommendations, thus each member of the Task Force contributed with a median of 3 (min.-max. 1-11) recommendations. After the removal of duplicates and recommendations that did not adhere to the scope of the initiative, 35 recommendations remained. Then the 14 members of the Task Force graded each recommendation. The mean grades for the 35 recommendations ranged from 9.4 ± 1.2 to 6.0 ± 2.3. The 10 recommendations that received the highest scores by the Task Force were then submitted to all SBEM associates by e-mail . A total of 683 associates graded each recommendation electronically, attributing a grade (0 to 10) for each recommendation. The grades for the 10 recommendations ranged from 9.8 ± 1.2 to 7.6 ± 2.7, and the 5 recommendations that received the highest scores by the SBEM associates compose our final list of recommendations . The Portuguese version of the 5 recommendations is available as . 

In this report, we described the development of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) Choosing Wisely initiative list. A set of recommendations to avoid unnecessary medical tests, treatments, or procedures for thyroid conditions is offered with a transparent methodology. This initiative aims to foster productive interactions between physicians and patients, stimulating shared decision-making and elevating the standards of care for thyroid conditions. 

