Article Text

Download PDFPDF

Choosing Wisely: assessment of current US top five list recommendations’ trustworthiness using a pragmatic approach
  1. Karl Horvath1,2,
  2. Thomas Semlitsch1,
  3. Klaus Jeitler1,3,
  4. Muna E Abuzahra1,
  5. Nicole Posch1,
  6. Andreas Domke1,
  7. Andrea Siebenhofer1,4
  1. 1Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Graz, Austria
  2. 2Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
  3. 3Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
  4. 4Institute of General Practice, Goethe University Frankfurt am Main, Frankfurt, Germany
  1. Correspondence to Dr Karl Horvath; karl.horvath{at}


Objectives Identification of sufficiently trustworthy top 5 list recommendations from the US Choosing Wisely campaign.

Setting Not applicable.

Participants All top 5 list recommendations available from the American Board of Internal Medicine Foundation website.

Main outcome measures/interventions Compilation of US top 5 lists and search for current German highly trustworthy (S3) guidelines. Extraction of guideline recommendations, including grade of recommendation (GoR), for suggestions comparable to top 5 list recommendations. For recommendations without guideline equivalents, the methodological quality of the top 5 list development process was assessed using criteria similar to that used to judge guidelines, and relevant meta-literature was identified in cited references. Judgement of sufficient trustworthiness of top 5 list recommendations was based either on an ‘A’ GoR of guideline equivalents or on high methodological quality and citation of relevant meta-literature.

Results 412 top 5 list recommendations were identified. For 75 (18%), equivalents were found in current German S3 guidelines. 44 of these recommendations were associated with an ‘A’ GoR, or a strong recommendation based on strong evidence, and 26 had a ‘B’ or a ‘C’ GoR. No GoR was provided for 5 recommendations. 337 recommendations had no equivalent in the German S3 guidelines. The methodological quality of the development process was high and relevant meta-literature was cited for 87 top 5 list recommendations. For a further 36, either the methodological quality was high without any meta-literature citations or meta-literature citations existed but the methodological quality was lacking. For the remaining 214 recommendations, either the methodological quality was lacking and no literature was cited or the methodological quality was generally unsatisfactory.

Conclusions 131 of current US top 5 list recommendations were found to be sufficiently trustworthy. For a substantial number of current US top 5 list recommendations, their trustworthiness remains unclear. Methodological requirements for developing top 5 lists are recommended.

  • Choosing Wisely
  • top five lists
  • trustworthiness
  • guidelines

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from


  • Contributors KH, TS, KJ and AS designed the study. KH, TS, KJ, AS, MEA, NP and AD were involved in the conduct of the study, data analysis and interpretation. KH drafted the manuscript and TS, KJ, AS, MEA, NP and AD critically revised it for important intellectual content. KH is the guarantor.

  • Funding This study was supported by the Techniker Krankenkasse, a German health insurance provider.

  • Disclaimer The sponsor had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication.

  • Competing interests KH, TS, MEA, NP, AD, KJ and AS have support from the Techniker Krankenkasse, a German health insurance provider, for the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.