Opinion: 13 October 2015.

Harkness Fellow Dr Matthew Anstey looks at some of the key considerations for a new Australian campaign aimed at eliminating unnecessary and potentially harmful tests, procedures and treatments.

Harkness Fellow Dr Matthew Anstey

Harkness Fellow Dr Matthew Anstey

We all know that most doctors want to practise appropriate medicine, but there are many pressures influencing their prescribing and ordering habits, ranging from patient expectations to the doctor’s own knowledge, time pressures and availability of resources. As a result, there is significant variation in the appropriateness of treatments patients receive.1,2

In 2002, the American College of Physicians Foundation, the American Board of Internal Medicine Foundation and the European Federation of Internal Medicine co-authored a physician charter that included a commitment to a “just distribution of finite resources”.3 It went on to say that a doctor had a professional responsibility for the “appropriate allocation of resources” and “avoidance of superfluous tests and procedures”.

In response to this charter, an aspirational challenge arose to identify examples of unnecessary treatments (tests and procedures) and became the Choosing Wisely campaign in the United States.4Specialist medical societies created their evidence-based lists of five “low value” or “unnecessary” treatments which range from the routine use of postoperative antibiotics to routine PSA-based screening for prostate cancer. This campaign has since spread to many different countries, and Choosing Wisely Australia launched earlier this year.5

The concept of low-value care and the recommendations chosen have been discussed elsewhere. It is interesting though, to look at the evidence base for the campaign itself. In order to do that it is necessary to clearly define the desired outcome of the Choosing Wisely project.

The US campaign aimed to promote conversations and influence patient and physician attitudes, a conscious “bottom-up” approach. A cynic might question whether this actually leads to a meaningful outcome i.e. a reduction in unnecessary treatments. However this strategy has blossomed into some important projects and “lessons from the field”, where organisations such as the non-profit managed care consortium Kaiser Permanente have identified recommendations from the lists that are important to their patients, and have subsequently reduced the overuse of these tests and treatments.

There are several features of the Choosing Wisely Australia campaign worth mentioning. First, NPS MedicineWise, which is leading the campaign, has a strong history of changing attitudes and behaviours around the use of medicines and, more recently, medical tests. It conducts educational outreach to a large number of Australian GPs every year, which has been shown to result in changes in prescribing habits. NPS conducts rigorous evaluations of its programs each year.

Second, as has happened in the US, each specialist group that signs onto Choosing Wisely convenes a working party ‒ a group of expert “opinion leaders” to craft a short list of recommendations. This is supported by a Cochrane review paper that showed the use of opinion leaders can successfully promote evidence-based practice.6

The groups then either survey their members to refine the lists or use a structured process to reach a consensus opinion within the working group. So far, five Australian medical colleges have formulated lists of recommendations of the tests, treatments and procedures that clinicians and consumers should question, with another six professional medical bodies set to do so early next year. While there does not seem to be any high-quality evidence to support using consensus approaches to change behavior, this method of using opinion leaders is a clever approach.7

Many times during my Harkness Fellowship in the US, I heard that when doctors were asked to change their practice, their initial response was to argue about the details or say that their own personal practice was different. Many executives felt that providing doctors with data about their own performance overcame that barrier nd was often a more powerful motivator than financial incentives in changing practice.

By asking doctors (via specialist colleges) to create their own lists based on current evidence ‒ as is happening in both the US and Australia ‒ it makes it hard for them to argue about the items chosen. In addition, surveying members to determine the lists, can lead to greater exposure for the campaign and engagement of doctors whose behaviour you are trying to influence.

Another key aspect of the campaign is linking with consumer groups in attempt to spark conversations between patients and doctors about the utility and risks of treatments. Surveys have repeatedly shown that doctors feel that some of their practice habits result from patient expectations. Whether this is a true reflection of patient expectations or just the doctor’s perception still needs to be studied, but in any case, finding ways to change these expectations and discussions is essential. Interestingly, it appears that the provision of information to consumers (such as handouts) by itself is insufficient to lead to improved adherence, knowledge or clinical outcomes. However there is evidence for decision aids improving these factors.

There will be an evaluation of the impact of Choosing Wisely Australia, loosely based around a paper recently published by the Choosing Wisely International Group.8

Work being done by the Australian Commission on Safety and Quality in Health Care to establish an Atlas of Variation, will help promote further discussions about unnecessary and low-value treatments and tests.  As a recent Grattan report suggests, a combination of approaches to promote disinvestment from outdated practices is likely to be more successful than any singular approach, and will help strengthen the case for better data collection  to track the use of unnecessary treatment in Australia.9

Finally, language is important. We need to avoid referring to medical treatments as “care”. “Care” can never be inappropriate or unnecessary. It is the amount, the type, the invasiveness or duration of treatments (be they investigations, procedures or medications) that can be inappropriate. Caring is the gift those working in medicine can provide to those in their time of need.

The Harkness Fellowship

Dr Anstey was the 2012-13 Commonwealth Fund Harkness Fellow in Health Policy. He spent his fellowship year based at Kaiser Permanente in California, which has nine million members across nine states and a fully integrated computerised medical record. During his fellowship year he completed a multi-centre study looking at provider perceptions of the appropriateness of care in Californian Intensive Care Units, mentored by Elizabeth McGlynn and Murray Ross. 10,11

Reference list

  1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med. 2003;348(26):2635–45.
  2. Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust [Internet]. 2012 [cited 2013 Oct 25];197(2). Available from: https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia
  3. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243–6.
  4. Cassel CK GJ. Choosing wisely: Helping physicians and patients make smart decisions about their care. JAMA. 2012 May 2;307(17):1801–2.
  5. MedicineWise NPS. Choosing Wisely Australia [Internet]. Choosing Wisely Australia. [cited 2015 Jun 18]. Available from: http://choosingwisely.org.au/
  6. Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2011;8(8).
  7. Local consensus processes | CADTH.ca [Internet]. [cited 2015 Aug 19]. Available from: https://www.cadth.ca/resources/rx-for-change/database/intervention?id=5
  8. Bhatia RS, Levinson W, Shortt S, Pendrith C, Fric-Shamji E, Kallewaard M, et al. Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care. BMJ Qual Saf. 2015 Aug;24(8):523–31.
  9. Duckett S, Breadon P, Romanes D, Fennessy P, Nolan P. Questionable care: Stopping ineffective treatments. [Internet]. Grattan Institute; 2015 [cited 2015 Aug 19]. Available from: http://grattan.edu.au/wp-content/uploads/2015/08/828-Questionable-Care3.pdf
  10. Anstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care. 2015;19(1):51.
  11. Anstey M. Working to Make ICU Care “Just Right” – CHCF.org [Internet]. [cited 2015 Aug 19]. Available from: http://www.chcf.org/articles/2015/07/working-make-icu-just-right

Author bio

Dr Matthew Anstey MBBS FACEM FCICM MPH is an Intensive Care and Emergency Medicine specialist physician who has practised in a variety of settings across Australia. He has also practised in the US at the Harvard Medical School and the Beth Israel Deaconess Medical Centre. 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. He is an advisory board member for Choosing Wisely Australia.

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