Focused on high quality care, Choosing Wisely Australia will enable health professionals, healthcare stakeholders and Australians to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases can lead to harm. At the upcoming April launch, the first recommendations developed by participating colleges and societies will be released.
The following medical colleges and societies will be represented at the April launch:
- Australasian College of Emergency Medicine
- Australasian Society of Clinical Immunology and Allergy
- The Royal Australian College of General Practitioners
- The Royal Australasian College of Physicians
- The Royal Australian and New Zealand College of Radiologists
- The Royal College of Pathologists of Australasia."
From a Health Report transcript: "We've spoken before on the Health Report about the Choosing Wisely campaign in the United States and now it's washing up on our shores...[Ass Prof Adam Elshaug, Uni of Sydney]: "In fact it's the first truly physician-led program anywhere in the world where medical groups have got together, doctors, to try and identify healthcare services, practices and tests, interventions, that they think have little or no benefit for their patients...I think some of the resistance to these sorts of campaigns in the past have been this notion that we are either saying something is high value or low value. That is, it should be done or it shouldn't be done...'Sometimes' is the answer. So it's actually about really trying to target those patient groups for whom the most benefit can be achieved, and in fact then the test should be avoided on patients who it could actually cause some harm...I did an analysis in the US Medicare system where we looked at just 26 low value healthcare practices and how prevalent they are in the US Medicare system, and we found that there's over $8 billion of waste just on those 26 services in the US. If we were to translate that directly to the Australian Medicare system, that would equate to almost $600 million annually in savings...we've suggested that anybody considering going down the Choosing Wisely path consider not only a top five list of clinical services but perhaps a top five list of administrative system process services as well."
Justin Coleman is chairing the RACGP working group for Choosing Wisely, and has published the working list of 28 suggestions and shortlist of 10. This will be whittled down to the top five and with be formally launched on 29/4/15. The criteria for making the list were:
- the intervention must be done often – indeed, too often!
- it must result in significant cost or harm, and
- the recommendation against the intervention must be backed by evidence.
"This list is not trivial. Even if you disagree with a few here or there, I believe that if most GPs followed these recommendations in most cases, it would substantially improve patient safety, reduce harms caused by overtesting, overdiagnosis and overtreatment and, as a bonus, free up tens of millions of dollars annually within our health system."
List of recommendations:
- Don’t commence medications for hypertension or hyperlipidaemia without first assessing CV risk, to guide the need for therapy.
- Don’t order screening lipid tests more often than 5-yearly in a person who is low-risk (i.e. absolute 5-yr CV risk < 10%).
- Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- Don’t use cardiovascular imaging (CT coronary calcium score, stress test, carotid u/s) to screen low-risk patients (i.e. absolute 5-yr CV risk < 10%, and asymptomatic).
- Don’t routinely use prostate specific antigen (PSA) as a screening tool. If ordering PSA, first inform the patient of the benefits and harms.
- Don’t order imaging for back pain (XR, CT, MRI) except to investigate fracture, tumour, infection or cauda equina syndrome.
- Individualise the HbA1c target in type 2 diabetes, and don’t aim too low in the elderly and those with a long duration of diabetes.
- Avoid, wherever possible, addictive medications (benzodiazepines, opioids) for chronic conditions, especially in those with a history of mental health conditions or substance abuse.
- Don’t use long-term anti-acid therapy without at least annual attempts to down-titrate or cease, unless Barrett’s oesophagus.
- Don’t use antipsychotics first-line in older patients for insomnia or dementia.
[n.b These are hitherto unpublished, so I may not have worded them quite as accurately, or included all caveats.]
- Don’t use shoulder imaging for straightforward shoulder pain.
- Don’t use antibiotics in asymptomatic bacteruria, except in pregnancy.
- Don’t order tumour markers as a general screening tool (e.g.CEA, PSA).
- Don’t order knee ultrasounds.
- Don’t order FBC, B12 or iron studies as a ‘routine annual screen’: order them if you have a reason to do so.
- Don’t use ultrasound guidance for shoulder joint injections.
- Don’t order upper abdominal ultrasound to investigate mildly abnormal LFTs.
- Don’t use antibiotics for otitis media (for age 2-12 years, non-Indigenous) where reassessment is a reasonable option.
- Don’t make ‘pre-disease’ diagnoses (e.g. pre-hypertension, pre-diabetes, osteopaenia) if doing so will tempt you to instigate medications.
- Don’t prescribe antibiotics for acute sinusitis (unless >7 days or worsening). Nor for pharyngitis or bronchitis.
- Avoid unnecessary ‘routine screening’ tests in pregnancy unless targeted reason. E.g. UEC, LFT, thalassaemia screen, full iron studies [ferritin alone is more useful], toxoplasma and listeria.
- Avoid early routine dating scans in pregnancy unless there is doubt about a woman’s dates.
- Don’t advocate screening mammography in women less than 50 years of age unless high risk, nor for women over 70 years of age.
- Don’t order ankle imaging unless the Ottawa ankle rules indicate it (ditto cervical spine imaging without applying Ottawa C-spine rules).
- Don’t treat osteoporosis without explaining risk-benefit to the patient in absolute terms, including a fracture risk calculation. Low BMD is not enough.
- Don’t order serological testing for herpes simplex.
- Don’t use anti-acid medication in unsettled infants.
- Don’t routinely do pelvic or breast examination before prescribing oral contraceptives.