Medical Observer - Article - Making wise choices

Goodwill underpins the Choosing Wisely campaign but it remains to be seen if grassroots GPs will act on it.

The Choosing Wisely campaign was launched last month in Australia, three years after its US counterpart instigated an initiative that is generating significant global momentum.

The timing, in retrospect, was a wise choice.

Despite the best intentions of the American Board of Internal Medicine’s goal to advance “a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures”, its campaign was not without criticism.

For instance, a commentary in The New England Journal of Medicine noted that services on the lists varied widely in potential impact on care and spending, with protectionism among some participating societies a thinly-veiled accusation.

Other commentators went further. “The definitive tone of denial repudiates the Hippocratic oath and replaces it with the spirit of The Hunger Games,” wrote one critic in The American Spectator.

Associate Professor Richard King, senior medical director at Monash Health and chair of the Choosing Wisely Australia (CWA) advisory group, is confident that lessons have been learned from the American experience.

Even the fiercest critics would be hard-pressed to accuse the five colleges of acting in self-interest. All items on the lists devised by the radiologists and pathologists, for instance, could be said to hit them in their own pockets.

And, even though it has been estimated that the translation of the US experience to Australia could produce annual savings of $500—$600 million, the focus has remained firmly on quality improvements rather than cost-cutting.

“There was no mention of money at the launch,” says Professor King. “Yes, there were implications that there may be cost savings, and if that comes about, then fantastic. But this isn’t a cost-saving thing, and the government knows that because they set up their own committee.”

Although the role of Choosing Wisely in the government’s reviews of the MBS and PBAC has been described as “the elephant in the room” by Dr Lynn Weekes (PhD), the CEO of the scheme’s facilitator NPS MedicineWise, criticism has largely been reserved for other aspects of the CWA campaign.

A somewhat dictatorial tone, compared to the Ten Commandments in some quarters, may be something that is addressed by the equivalent German initiative, which is considering a title of Choosing Positively to counter the ‘Thou shalt not…’ approach.

Another charge was a lack of transparency in arriving at the final 27 interventions — split between the colleges of GPs, pathologists, radiologists, emergency physicians and immunologists — which were targeted for a new approach.

Democracy, however, was undoubtedly a key element in the selection of the RACGP’s list.

An initial list of 28 items was first created by a working group comprising Drs Justin Coleman, Evan Ackermann, Jenny Doust, Simon Morgan and Rob Hosking. This was whittled down to a final 10 interventions on the basis of evidence for significant harm, cost or overuse, and these were then put to college members, who were asked to nominate their top five.

Two procedures, PSA testing and imaging for lower back pain, were included in the lists put forward by the Royal College of Pathologists of Australasia (RCPA) and the Royal Australian and New Zealand College of Radiologists.

The final five RACGP interventions can be viewed here. Of these, the most controversial was the directive not to advise routine self-monitoring of blood glucose (SMBG) for patients with type 2 diabetes on oral medication, set in context of an Australian government spend of $143 million on test strips in 2012. Patients not on insulin performing SMBG averaged 300 strips annually.

“There is no evidence that SMBG affects patient satisfaction, general wellbeing or general health-related quality of life,” the RACGP says. “A 2012 Australian review found that SMBG may possibly reduce HbA1c by 0.25—0.3%, considered clinically insignificant. SMBG actually increased hypoglycaemia risk, although causation was uncertain.”

However, for Renza Scibilia, of Diabetes Australia Victoria, SMBG is an important part of her arsenal and should be considered for each individual patient.

“It gives me a snapshot of what my BGL is doing at that very moment. This information is very valuable. But more than that, it helps me find patterns,” she blogged. “Am I always high or low at a particular time of day? Does certain food cause a really significant and rapid rise in my BGL? ... A discussion about self-monitoring should not simply involve a blanket statement that it is of no benefit.”

The Choosing Wisely guideline has already caused the RACGP’s Dr Hosking to question his own practices.

“This was one that I must admit to being not terribly aware of as a problem until the costs to the community were pointed out to me,” he says. “I have had some very enthusiastic patients who have been religiously monitoring their blood glucose. They have been achieving excellent targets but I have been trying to [dissuade] them from doing such monitoring... from an expense point of view.”

The other RACGP suggestions, he says, will help GPs to resist patient pressure. Overuse of PPIs was considered the number one priority by the college due to increased risk of adverse events such as GI infection, community-acquired pneumonia, osteoporotic fractures, interstitial nephritis and nutritional deficiencies.

“It’s a continual battle to try and get people who have become almost psychologically dependent on certain medications such as the PPIs for [GORD],” adds the Bacchus Marsh GP. “To have the Choosing Wisely authority and literature to present to patients is useful.”

Dr Coleman, RACGP working group chair, expects the three interventions not to have made the top five will feature strongly when the guidelines are revisited in a three-year cycle.

“Some imaging interventions didn’t make the top 10 because there was some equivocal evidence,” says the Brisbane GP. “For example, there is a problem with overuse of shoulder and knee ultrasound. A GP experienced in corticosteroid injections will get just as good outcomes as a radiologist under ultrasound guidance. It’s far simpler for the patient and far cheaper for taxpayers.”

The drivers for overdiagnosis and misdiagnosis are complex and will be featured in a five-part series in The Lancet, including contributions from the University of Sydney’s Associate Professor Adam Elshaug, a member of the CWA advisory group.

The recommendation not to perform population-based screening for vitamin D deficiency was the topic most commented on in the GP voting and was eventually included in the RCPA list. Over-testing, according to Professor Elshaug, is the unintended result of a previous campaign to increase testing.

“Just 10 years ago, $3 million was spent on vitamin D testing. Fast forward 10 years and it is $145 million. It was a case of the drive for testing being too successful,” he says. “Now it’s a question of getting back to what might be considered to be a clinically appropriate level somewhere in between.”

Professor Elshaug also believes there is scope to expand CWA to include administrative, policy and process waste, as well as clinical services. The success of such a move may be easier to quantify, with evidence for success of the US Choosing Wisely campaign still thin on the ground, despite the participation of more than 70 specialty society partners.

For Professor King, examination of Medicare data alone may not provide an accurate gauge of the impact of CWA.

“Reducing the numbers of the tests on Medicare data is fraught in itself, in that you don’t know why people are having that test,” he says. “For example, an x-ray for lower back pain with a past history of prostate cancer, and not just for a minor injury, still comes up on Medicare data as an x-ray of the lumbosacral spine.”

Measurement of public awareness, and also the perception of the campaign by that speciality involved in almost all of the recommendations, is equally important for Professor King.

“If a survey of GPs revealed Choosing Wisely had affected practice further down the line then we would all be happy,” he says.