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 treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
Avoid the routine use of antibiotics in acute otitis media (middle ear infection), except in a child with acute systemic features such as high fever, vomiting or lethargy. Clinical review at 24-48 hours is good practice, if available. Regardless of whether one or both eardrums are red or bulging, antibiotics do not reduce pain at 24 hours, and up to 20 children must be treated to prevent pain in one child at 2 to 7 days. Routine antibiotic use slightly reduces tympanic membrane perforation (NNT = 33) but has no effect on tympanic membrane findings at 3 months, nor on severe complications.
One in 14 children will develop antibiotic side effects, particularly rash, diarrhoea, or vomiting. Antibiotic use promotes bacterial resistance, both in the individual and community. Aboriginal and Torres Strait Islander children are at higher risk of complications and should be treated early. Guidelines vary about the value of antibiotic treatment in children aged 6-23 months, but support antibiotics for infants under 6 months.
Recommendation released March 2016
- Venekamp R, Sanders S, Glasziou P, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015;1:CD000219. Avail from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000219.pub4/abstract
- Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.
- Indigenous and Rural Health division, Department of Health. Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. Avail from: http://webarchive.nla.gov.au/gov/20150623204209/http://www.mbsonline.gov.au/internet/publications/publishing.nsf/Content/oatsih-otitis-media-toc
- Rovers M, Glasziou P, Appelman C, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006;368:1429-35. Avail from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17055944
- Hoberman A, Paradise J, Rockette H, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011 Jan 13;364(2):105-15 Avail from: http://www.ncbi.nlm.nih.gov/pubmed/21226576
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.