More is not always better

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Choosing Wisely Australia - improving care by tackling unnecessary practices
By Dr Matthew Anstey Stand first: Choosing Wisely Australia^® is a new initiative aimed at sparking an important national conversation about the many unnecessary and sometimes harmful tests, treatments and procedures entrenched in the health system. It promises significant benefits for hospitals.

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The launch last month of Choosing Wisely Australia marks the beginnings of what is hoped will be a fundamental change in the way we approach medical practice and patient care.
Its aims are to improve care by addressing the many inappropriate, unnecessary and often obsolete interventions that remain in common use. They often lead to additional and often invasive investigations, exposing consumers to undue risk of harm, emotional stress and financial cost. Importantly, they are a diversion from high quality care.
Choosing Wisely Australia is drawing on the expertise of Australia’s peak professional bodies to develop lists of questionable practices. Five medical colleges and societies encompassing a large area of practice – have conferred with their members and released their recommendations: Five things clinicians and consumers should question. These are based on the best available evidence, expert opinions and research.
Out of this, material is being developed to equip health professionals and consumers with the sound science and evidence they need to make informed decisions and to engage in frank conversations about what care is truly needed. Under the slogan ‘more is not always better’, the aim is to show that not all tests, treatments and procedures are in the consumer’s best interest.
The initiative is being facilitated in Australia by NPS MedicineWise, an organisation that has established itself as respected and influential voice in quality use of medicines and medical tests. .
The issue of wasteful, obsolete, unsafe or evidence-lacking interventions is global and for the past decade, there has been growing recognition of the need to tackle them. Many studies have sought to identify the practices that most urgently need addressing but progress has been slow in translating this into changes to medical practice.
That is, until Choosing Wisely. The Choosing Wisely^® movement is proving successful in the United States where it was launched in 2012 by the ABIM Foundation. What started modestly with nine organisations is now a collaboration of more than 70 medical speciality societies, as well as consumer organisations that collectively represent almost a million members.
What makes Choosing Wisely unique is that it is physician-led and it pursues change from the bottom up, uniting with patients to act across all areas of healthcare. After three years, the US initiative can justifiably claim that the long-overdue cultural shift it set out to create is beginning to emerge.
Choosing Wisely Australia and hospital care
We are hearing more and more about optimising value in healthcare. The value equation is the balance between the cost and the outcome. Some countries are increasingly focusing on trying to eliminate waste in healthcare, as waste does not improve the outcome, but does increase the cost. Evidence from the US suggests that up to 30% of all medical spending is unnecessary and does not add value to care. The recommendations set out in the Choosing Wisely Australia lists will not remove all of those unnecessary treatments, but the overarching, and perhaps more important aim, is to encourage doctors and patients to start looking to identify those practices that should be questioned.
Those working in hospitals know that there are many investigations and medications ordered routinely for patients. For instance, many patients receive daily blood tests or chest X-rays. There is increasing evidence to show that these routine investigations do not improve the care of patients yet add to healthcare costs. In addition, any test or medication can cause unintentional harm to patients from adverse drug reactions, false positive results and cumulative radiation exposure. Furthermore, some procedures performed may be of limited benefit to patients and expose them to potential harm. The Choosing Wisely Australia campaign aims to focus the attention of clinicians and patients on these low value or unnecessary items.
Partner organisations and their recommendations
The first medical colleges and societies to participate in the Choosing Wisely Australia initiative are: the Australasian College of Emergency Medicine, the Australasian Society of Clinical Immunology and Allergy, the Royal Australian College of General Practitioners, the Royal Australian and New Zealand College of Radiologists and the Royal College of Pathologists of Australasia. Each of these has provided lists of recommendations. The Royal Australasian College of Physicians (as the coordinating body for RACP members and specialty societies) is supportive of Choosing Wisely Australia through the shared goals of its Evolve program.
Many other organisations will join Choosing Wisely Australia as part of Wave 2. As more specialist groups join the initiative, more lists will be created. These lists will provide an immediate opportunity for hospitals to review their practices and identify ways they can adopt some of the recommendations. They may also spark new ideas and new approaches to address other potential targets for reducing waste within the hospital system.
The first iteration of Choosing Wisely Australia includes items from the colleges representing emergency medicine, pathology and radiology – areas that directly relate to hospital care. While organisations have been asked to provide five recommendations, it is anticipated that more will be added over time. Two colleges, the Australasian College for Emergency Medicine and the Royal Australian and New Zealand College of Radiologists found they had overlapping recommendations and have presented them jointly in addition to their own lists.
How Choosing Wisely is making a difference in American hospitals
The Choosing Wisely campaign has provided an opportunity for some of the eminent US healthcare systems to take a leadership role in the responsible management and fair distribution of healthcare resources.
While undertaking a fellowship at Kaiser Permanente, one of the largest integrated health systems in the world, I was fortunate to see up-close how they thought about the Choosing Wisely campaign. Departmental heads were asked to systematically review the Choosing Wisely recommendations, and to focus on the recommendations that related to conditions seen frequently amongst patients in their system.
For example, Kaiser Permanente Colorado focused on reducing imaging overuse for low probability pulmonary embolism, low back pain, syncope and uncomplicated headaches. Their audits subsequently showed that up to 25 % of the imaging for uncomplicated headaches may have been unnecessary.
Other large health systems in the US have also introduced the recommendations to their practice. Fletcher Allen in Vermont reduced the utilization of daily chest X-rays in ICU patients by one-half, and the number of tests of kidney function in patients on permanent dialysis or admitted to hospital for another reason from more than 1,300 per 1,000 patient days to fewer than 200 per 1,000 days.
Cedars-Sinai Health system became the first system to incorporate many of the Choosing Wisely recommendations into its electronic medical records system. When a physician attempts to order a test or treatment referenced on the Choosing Wisely lists, an alert provides more information to the physician before they can proceed with it.
Principles to consider in a hospital or health system
The Choosing Wisely Australia lists of recommendations provide an initial guide for clinician leaders and hospital executives. From my experience in the US, I suggest selecting one or two items to focus on that are aligned with any current quality reforms underway in the hospital.
To select these items, it is important to understand which are important to the clinicians and patients within your system. One way to determine which elements are a priority is to characterise them according to three variables: volume, cost and risk. [Figure 1] An item may be high volume but low in cost and of minimal risk to patients, and therefore of less importance than a high cost, high risk, moderate volume one.
After prioritising the items, determine whether your organisation can measure the use of the item (or what would need to be put in place to do this). Finally, talk to the clinician groups about whether they believe that they can change their usage patterns for the each of the items. The use of audit and feedback, when combined with an institutional focus, is a powerful method of creating change.
NPS Medicinewise
Since its inception in 1998, NPS MedicineWise has been the leading body driving quality use of medicines and medical tests in Australia. It does this in an evidence-based and highly collaborative way.
Independent and not-for-profit, NPS MedicineWise works with member organisations, industry and professional organisations, consumers and government and seeks advice from a broad range of expert advisors to positively change attitudes and behaviours about medicines and medical tests so that consumers and health professionals are equipped to make the best decisions when it counts.
College and society list recommendations
Royal Australian College of General Practitioners

1. Don’t use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.


2. Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.


3. Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.


4. Don’t screen asymptomatic, low risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.


5. Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.

Dr Matthew Anstey
MBBS FACEM FCICM MPH
Dr Matthew Anstey is an Intensive Care and Emergency Medicine specialist physician who has practiced in a variety of settings across Australia, and in the US at Harvard Medical School and the Beth Israel Deaconess Medical Center.
He has a Masters of Public Health in health policy from Harvard School of Public Health and was awarded the prestigious Commonwealth Fund Harkness Fellowship in Health Policy in 2012-13.
The fellowship was based at Kaiser Permanente in California. During his time there, Dr Anstey sat as an observer on the hospital’s National Guideline committee and was able to see their efforts in implementing Choosing Wisely for their organisation.
Following the fellowship, he worked as a research consultant for Stanford University Clinical Excellence Research Center on a project to identify “high value” health-care organisations, and the potentially-transferable features of models of care. He now works as an intensivist at Sir Charles Gairdner Hospital and as a part-time senior medical advisor to the Australian Commission on Safety and Quality in Health Care. He is an advisory board member for Choosing Wisely Australia and a committee member of the WA Council on Safety and Quality in Health Care. His research interests lie at the intersection of quality improvement and behaviour change.
Royal College of Pathologists of Australasia

1. Don’t perform surveillance urine cultures or treat bacteruria in elderly patients in the absence of symptoms or signs of infection.


2. Don’t perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years.


3. Don’t perform population based screening for Vitamin D deficiency


4. Don’t perform serum tumour marker tests except for the monitoring of a cancer known to produce these markers.


5. Don’t routinely test and treat hyperlipidemia in those with a limited life expectancy.

Australasian College for Emergency Medicine

1. Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.


2. Avoid coagulation studies in Emergency Department patients, unless there is a clearly defined specific clinical indication, such as for monitoring or anticoagulants, or in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation (POCT devices are unreliable in this circumstance).


3. Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.


4. For emergency department patients approaching end-of life, ensure clinicians, patients and families have a common understanding of the goals of care.


5. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule. (jointly with RANZCR)


6. Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule. (jointly with RANZCR)

Royal Australian and New Zealand College of Radiologists

1. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight bear as defined in the Rules).


2. Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D-dimer assay is positive.


3. Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score or Charlotte Rule followed by PE Rule-out Criteria (in patients not pregnant or postpartum). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D-dimer, not imaging.


4. Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.


5. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule. (jointly with ACEM)


6. Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule. (jointly with ACEM)

Australasian Society of Clinical Immunology & Allergy

1. Don’t use antihistamines to treat anaphylaxis: prompt administration of adrenaline is the only treatment for anaphylaxis.


2. Alternative/unorthodox methods should not be used for allergy testing or treatment.


3. Allergen immunotherapy should not yet be used for routine treatment of food allergy: research in this area is ongoing.


4. Food specific IgE testing should not be performed without a clinical history suggestive of potential IgE-mediated food allergy.


5. Don’t delay introduction of solid complementary foods to infants: ASCIA Infant Feeding Advice recommends early introduction of solid foods to infants (from 4-6 months old).