Recommendations

The Royal Australian College of General Practitioners

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

The benefit gained from treating elevated blood pressure or lipids is proportional to a patient's baseline risk of a cardiovascular event. Patients with multiple risk factors who are at high risk of an event will gain the most benefit from treatment. Patients with elevated blood pressure or lipids but who are ‘low risk’ (< 10% 5-year risk according to the current National Vascular Disease Prevention Alliance (NVDPA) absolute CVD risk guidelines) do not require medication. The NVDPA guidelines also recommend treatment of blood pressure persistently greater than 160/100 mmHg regardless of baseline risk, and for other patients with conditions considered high risk, or with existing cardiovascular disease (see guidelines).

Ideally, patients should share in the decision to commence medication, with an understanding of the potential benefits and harms. Lipid-modifying drugs cost the PBS $1.1 billion in 2013-14, more than any other class of medication.

Recommendation released April 2015

Supporting evidence
  • Cholesterol Treatment Trialists' (CTT) Collaborators, Mihaylova B, Emberson J, Blackwell L, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012 Aug 11;380(9841):581-90. doi: 10.1016/S0140-6736(12)60367-5. Epub 2012 May 17.
  • Blood Pressure Lowering Treatment Trialists' Collaboration, Sundström J, Arima H, Woodward M, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014 Aug 16;384(9943):591-8.
  • NVDPA Absolute cardiovascular risk guidelines.
How this list was made How this list was made

Recommendations 1 - 5 (April 2015)

All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.

Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.

Recommendations 6-10 (March 2016)

The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.