Dr Matthew Anstey
MBBS MPH FACEM FCICM PGDipEcho DCH
Choosing Wisely Australia Advisory Board Member
Medical Advisor to Australian Commission on Safety and Quality in Health Care
Intensive Care Physician Sir Charles Gairdner Hospital
August 2015
CHOOSING WISELY AUSTRALIA
• Starting a national conversation about tests,
treatments and procedures that provide no
benefit and in some cases may cause harm
• Focused on high quality care, supporting
conversations between the consumer and
clinician
• Based on the best available evidence and what
care is truly needed
• Part of a global movement to assess low value
care
Do you agree?
• There is a problem with the use of
unnecessary tests, treatments and procedures
in medical practice.
– Strongly agree
– Agree
– Neutral
– Disagree
– Strongly disagree
• In your own practice, how often do patients
ask for a test, treatment or procedure that you
think is unnecessary?
• Every day
• Several times a week
• Once a week
• Less than once a week
• Less than once a month
Do you agree?
• Medical practitioners have a responsibility to
help decide on the appropriate use of tests,
treatments and procedures?
– Strongly agree
– Agree
– Neutral
– Disagree
– Strongly disagree
• How much influence do you have in reducing
the use of unnecessary tests, treatments and
procedures in your clinic or service?
– A high level of influence
– A moderate level of influence
– Some influence
– Limited influence
– No influence
THE ISSUES
• Not all tests add value
• Can expose the consumer to
undue risk of harm and cost
• Consumers are often
unaware
• Many tests have become
ingrained in the system
THE ISSUES
• Consumer expectations:
‘more is better’
• Pressure on clinicians to
cover all clinical possibilities
• 30% expenditure in the US
considered wasteful*
*reference available on request
Choosing Wisely – United States
• Began in 2009 from ABIM
• Physician charter for professionalism includes:
“commitment to a just distribution of finite resources”
• Top Five lists – speciality specific enumerations of five
achievable practice changes to improve patient health
through better treatment choices, reduced risks, and,
where possible, reduced costs.
• >50 speciality-specific lists and more than 10
consumer partners
• Preserves the pre-eminence of physician judgement,
patient choice and therapeutic relationship
9
CHOOSING WISELY AUSTRALIA
• Led by Australia’s
medical colleges
and societies
• Facilitated by NPS
MedicineWise
• Colleges and
societies develop
lists of
recommendations
CHOOSING WISELY LAUNCH
Five medical colleges
and societies released
their recommendations,
“5 Things to Question”
LIST DEVELOPMENT
• Lists and recommendations are developed and
owned by the colleges and societies
• List development criteria:
– Tests and treatments misused or over used
or carry significant cost
– Items within the speciality's purview and
control
– Evidence based
– Transparent process
Choosing Wisely Australia
• RACGP: long term PPI use, don’t
HT/lipids therapy without
assessing risk, don’t self monitor
type 2 DM oral, don’t screen low
risk CV patients, avoid BDZ with
history misuse/multiple agents.
• ACEM
• RCPA : urine cultures, PSA testing
& hyperlipidaemia < 7yrs of life,
Vitamin D, tumour markers
• RANZCR: imaging for ankles,
lower spine & cervical spine;
duplex ultrasound, PE
• Australasian Society Clinical
Immunology and Allergy
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Australasian College for Emergency
Medicine
• Avoid requesting CT KUB in otherwise healthy emergency
department patients, age <50, with known history of kidney
stones, presenting with symptoms and signs consistent with
uncomplicated renal colic.
• Avoid coagulation studies in emergency department patients
unless there is a clearly defined specific clinical indication, such
as for monitoring of anticoagulants, in patients with suspected
severe liver disease, coagulopathy or snakebite.
• Avoid blood cultures in patients who are not systemically septic,
have a clear source of infection and in whom a direct specimen
for culture is possible.
ACEM
• For emergency department patients approaching endof-life, ensure clinicians, patients and families have a
common understanding of the goals of care.
• Don’t request imaging of the cervical spine in trauma
patients, unless indicated by a validated clinical
decision rule, such as Canadian C Spine rule or Nexus
Low risk criteria.
• Don’t request CT head scans in patients with a head
injury, unless indicated by a validated clinical decision
rule,
REACHING CONSUMERS
• Supporting both
consumers and
clinicians to have
conversations about
appropriate care
• Consumer resources
for website
• Engaging with
consumer
organisations
MEDIA COVERAGE
• ‘Campaign urges patients,
doctors to cut unnecessary tests
and treatments’ ABC News Online
• ‘Less is the New More:
Choosing medical tests and
treatments wisely’ The Conversation
• ‘Unnecessary tests: Choosing
Wisely campaign targets brain
scans, food allergy tests’
Sydney Morning Herald
CRITICAL SUCCESS FACTORS
• Health profession-led, collaborative approach
• Consumers at the centre
• List development and ownership driven by
colleges
• Talking to patients : ‘Quality’, ‘reducing risk of
harm’ and ‘waste’ resonates
• Implementation and evaluation