Choosing Wisely to address doctor’s overorders
“Choosing Wisely” might be the motto for politicians mulling over their leadership. Or perhaps a how-to for visitors to RSVP.com. In fact, it’s the catchy title of a global campaign that is about to hit doctors’ surgeries and hospital wards in Australia.
Kicking off in the United States in 2012, the Choosing Wisely campaign has been adopted in almost a dozen nations, including England, Germany, Italy and Denmark. Essentially it’s a long list of diagnostic tests, treatments, pills and procedures that are being overused and overprescribed, and might be safer to avoid.
Some things on the list might be familiar to many readers – inappropriate antibiotics and vitamin D tests, for example – but other items might surprise even the most cynical medical sceptics. Australia’s Choosing Wisely list is scheduled to be published late next month, and it will be compulsory reading for anyone interested in avoiding unnecessary and potentially dangerous healthcare.
In the past decade Australian doctors have dramatically increased the number of tests they order, by 50 per cent, with almost 4 million more tests per year – and that’s just the tests ordered by general practitioners. The use and costs of pharmaceuticals continue to surge, with a doubling in the use of antidepressants in a decade, putting Australians among the top users within the OECD. The concern is that a proportion of the people taking such pills have mild problems for which the medications may deliver more harm than good.
Similarly, there is increasing use of knee procedures called arthroscopies, despite the fact that placebo tests have provided good evidence many operations are no more effective than pretend surgery.
An ageing demographic is often blamed for the blowout in the cost of healthcare, but a big driver is doctors doing things that don’t provide benefit or, worse, cause us harm.
In a sense, Choosing Wisely is the medical profession blowing a very large whistle on itself. These emerging lists of what not to do are an official acknowledgement that we’re being tested and treated much too often, causing untold harm and wasting scarce resources that could be better spent where they’re genuinely needed.
As has happened elsewhere, in the lead-up to the launch, medical specialties in Australia have been asked to nominate the top five interventions in their field for which there is evidence in support of winding back their use. When the representatives from the Royal Australian College of General Practitioners (RACGP) sat down to work out their top five, they quickly came up with a list of closer to 30.
The longer list includes recommendations for GPs not to use antipsychotic drugs for older people with sleeping problems or dementia, not to order ultrasounds for knee problems, not to prescribe antibiotics for children’s ear infections, and to wind back “pre-disease” diagnoses such as “pre-diabetes” or “pre-osteoporosis”.
The GPs’ official top five is still under wraps, but I’m guessing there will be recommendations to be much more cautious in prescribing a range of drugs, including the Valium family – known as benzodiazepines – as well as medications for high blood pressure, high cholesterol and acid reflux. It’s also likely there will be a call not to use so many diagnostic imaging tests for the heart among people at low risk of heart disease, including stress tests, ultrasounds, and CT scans that measure calcium scores.
In a sense it’s not so surprising to see GPs talking about what tests and treatments to avoid. Some big thinkers in medicine, such as the British GP Iona Heath, argue that one of the key roles of the general practitioner is to help protect their patients from the overmedicalisation and overtreatment that can come from medical specialists.
But Choosing Wisely has managed somehow to bring a lot of specialists on board too. In the US there are something like 60 medical specialties now creating their top five lists.
Choosing Wisely is being co-ordinated here by the publicly funded National Prescribing Service, now known officially as NPS MedicineWise, in collaboration with many doctor and consumer groups. But the lists of tests, treatments and procedures themselves are being developed by doctors’ groups alone – a feature seen as one of the major strengths of the campaign. The idea is that this will ensure buy-in from doctors who would otherwise reject directions developed by government, potentially regarding them as dangerous cost-cutting that could put patients at risk.
The Canberra-based peak body Consumers Health Forum told The Saturday Paper it was generally supportive of such programs. Noting the rare spectacle of doctors arguing for less medicine, a spokesperson for the consumer group observed that “public self-scrutiny from the medical profession is a refreshing development”.
Although widely lauded in the US, Choosing Wisely has not been entirely without its critics. Its chief strength – that the campaign is doctor-led – may also be its chief weakness, because many doctors will be unwilling to take a scalpel to their own incomes.
As pointed out in a recent New England Journal of Medicine analysis, “specialist societies generally named other specialties’ services” when developing their lists. The American Academy of Orthopaedic Surgeons listed the use of an over-the-counter supplement among its top five, but didn’t list any of the major procedures that are the key sources of its surgeons’ incomes, despite evidence that procedures such as knee replacement are performed unnecessarily.
The other key criticism of the campaign in the US is that too much energy has gone into publicising the lists, and too little time into making sure we actually wind back the use of harmful and wasteful tests and treatments.
Sydney University’s Associate Professor Adam Elshaug argues that much work will be needed to implement real change. A formal adviser to the campaign, Elshaug previously spent several years as a researcher in the US. He has become something of an international expert on unnecessary or “low value” healthcare and how to wind it back. But anyone who thinks too much medicine is only a problem in the wild market-driven system of the US should think again.
“We do have a problem here,” says Elshaug. “Pilot data suggests Australia is just as bad or worse in inappropriate overutilisation.” He points quickly to vitamin D testing, where he estimates a reduction to more appropriate levels could save Australia more than $100 million a year. Other examples where there’s evidence suggesting excess are arthroscopy for the knee, routine diagnostic scans for lower back pain, and the perennially overused antibiotics.
“We are not only overusing potentially unsafe tests, treatments and procedures,” says Elshaug, “we are wasting valuable healthcare resources.”
To genuinely tackle the excess, governments, professionals and the community will need to face up to our deeply embedded cultural belief that “more is better” in healthcare, in addition to confronting the powerful commercial, professional and technological drivers of oversupply of medicine.
Brisbane GP Justin Coleman acknowledges the limitations of Choosing Wisely and its simple lists, but he argues it will help bring a change in the culture that over time will produce new norms and break down resistance to positive reform.
Also an academic and blogger, Coleman is running the working group for the RACGP that is developing their top five list. He notes that not all of the things on the list will reduce costs. “As a general rule it takes a GP more time with a patient not to order a test, than to order one.”
Over the past year we’ve watched a government almost destroy itself trying to introduce a co-payment for GP visits. Critics argued this was an attack on Medicare; proponents responded it was a necessary cost-saver. For any government genuinely wanting to sustain Medicare, winding back ineffective and dangerous healthcare will not only save money but also improve the nation’s health. Working out how to confront the commercial, cultural and professional obstacles standing in the path of that reform is the obvious challenge. Choosing Wisely seems a small step in the right direction.
This article was first published in the print edition of The Saturday Paper on Mar 21, 2015 as "Doctor’s overorders". Subscribe here.