The Royal Australian College of General Practitioners
Recommendations from the Royal Australian College of General Practitioners (RACGP) on treating hypertension or hyperlipidaemia, prescribing benzodiazepines, self-monitoring of blood glucose, proton pump inhibitor therapy and screening for vascular disease. The Royal Australian College of General Practitioners (RACGP) is Australia’s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 30,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia.
Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
There is no evidence that self-monitoring of blood glucose (SMBG) affects patient satisfaction, general well-being or general health-related quality of life. A 2012 Australian review found SMBG may possibly reduce HbA1c levels by 0.25-0.3%, considered clinically insignificant. SMBG actually increased hypoglycaemia risk, although causation was uncertain. This recommendation aligns with the 2015 draft NICE guidelines for self-monitoring of blood glucose, the Canadian Agency for Drugs and Technologies in Health (CADTH) recommendations and the Scottish Intercollegiate Guidelines Network. Therefore, use HbA1c levels to guide therapy, and promote lifestyle interventions regardless of diabetes control. Exceptions (i.e. not ‘routine’) may include: symptomatic hypoglycaemia; heavy machinery operators on a sulfonylurea; elderly people with renal failure; pregnancy; and possibly short-term education about diet influencing blood sugar. Australian government spending on test strips was $143 million in 2012. Diabetics not on insulin who used SMBG, averaged 300 test strips annually.
Recommendation released April 2015
- Malanda UL, Welschen LMC, Riphagen II, et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin, Cochrane Database Syst Rev. 2012 Jan 18: 1
- Farmer AJ, Perera R, Ward A et al. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ 2012;344:e486
- National Institute for Health and Care Excellence (NICE); Type 2 diabetes in adults. Clinical Guideline Update, 2015 draft
- Department of Health and Ageing and University of South Australia. Pharmaceutical Benefits Scheme products used in the treatment of diabetes. 2012
- CADTH Recommendations on Self-Monitoring of Blood Glucose Using Test Strips, Canada 2009
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.
- 1 Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- 2 Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- 3 Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 4 Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 6 Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- 7 Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- 8 Don’t routinely do a pelvic examination with a Pap smear.
- 9 Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- 10 Don’t test thyroid function as population screening for asymptomatic patients.