Tests, treatments, and procedures for healthcare providers and consumers to question
Australia's peak health professional colleges, societies and associations have developed lists of recommendations of the tests, treatments, and procedures that healthcare providers and consumers should question.
Each recommendation is based on the latest available evidence. Importantly, they are not prescriptive but are intended as guidance to start a conversation about what is appropriate and necessary.
As each situation is unique, healthcare providers and consumers should use the recommendations to collaboratively formulate an appropriate healthcare plan together.
The Society of Hospital Pharmacists of AustraliaVisit page
- Don’t recommend the regular use of oral non-steroidal anti-inflammatory medicines (NSAIDs) in older people.
- Don't recommend the use of medicines with sub-therapeutic doses of codeine (<30mg for adults) for mild to moderate pain.
- Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date.
- Don’t initiate and continue antipsychotic medicines for behavioural and psychological symptoms of dementia for more than 3 months.
- Don’t initiate and continue medicines for primary prevention in individuals who have a limited life expectancy.
A working party was formed and they sought suggestions from SHPA’s Committees of Specialty Practice, Reference Groups, State and Territory branches and Federal Council. More than 40 proposed statements were considered by the working party. A shortlist of 10 statements was identified for consideration by the SHPA’s membership through an online survey. All members were invited to comment on each proposed statement, specifically: whether it related to the practice of pharmacy, related to medicines that are frequently used, and if a significant cost. Members were also invited to rate the statements in order of preference. The survey results were used by the working party to identify the final six statements which were presented to SHPA’s Federal Council who ratified the choice of the five final statements.
The Royal College of Pathologists of AustralasiaVisit page
- Do not perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years.
- Restrict the use of serum tumour marker tests to the monitoring of a cancer known to produce these markers or where there is a strong known underlying predisposition or suspicion.
- Do not perform surveillance urine cultures or treat bacteriuria in elderly patients in the absence of symptoms or signs of infection.
A list of ten items was compiled after reviewing international literature associated with the Choosing Wisely campaign in Northern America. The College’s advisory committees were canvassed for further relevant evidence based literature and their expert opinions were sought.
The ten items were then adopted as a College Position Statement titled ‘Inappropriate Pathology Requesting’. This list was then sent to RCPA Fellows and Trainees based in Australia to rank the top five tests to include in the Australian Choosing Wisely initiative. The five items selected were approved by both the RCPA's Board of Professional Practice and Quality and the RCPA Board of Directors.
The Royal Australian College of General PractitionersVisit page
- Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- Don’t test thyroid function as population screening for asymptomatic patients.
- Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- 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.
- Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- 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.
- Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- Don’t routinely do a pelvic examination with a Pap smear.
- Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
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.
The Royal Australian and New Zealand College of RadiologistsVisit page
- Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-12 (October 2016)
Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement Committee and the Economics and Workforce Committee, with each being asked to rank the recommendations.
The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council.
Recommendations 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 is adapted from Choosing Wisely Canada’s Oncology list. Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely Australia campaign.
The Royal Australian and New Zealand College of OphthalmologistsVisit page
- AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
- Don't prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
RANZCO has undertaken a multi-stage consultation process to ensure that the entire spectrum of medical eye specialists in Australia and New Zealand can contribute to the process of identifying and refining the top five recommendations. The first stage included a survey of fellows to identify possible recommendations, which were then narrowed down and by a dedicated “Choosing Wisely” committee of RANZCO members. A second survey was then sent to all members to provide feedback on the list of five and received a high response rate. Based on the extensive feedback received via the survey, RANZCO’s “Choosing Wisely” committee crafted the final wording of the top five recommendations. Finally, the RANZCO board discussed and approved the recommendations.
The Endocrine Society of AustraliaVisit page
- Don’t prescribe testosterone therapy unless there is evidence of proven testosterone deficiency.
- Do not measure insulin concentration in the fasting state or during an oral glucose tolerance test to assess insulin sensitivity.
- Avoid multiple daily glucose self-monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycaemia.
- Don’t order a total or free T3 level when assessing thyroxine dose in hypothyroid patients.
- Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
The Medical Affairs sub-committee of the Endocrine Society of Australia (ESA) collaborated with the Royal Australasian College of Physicians (RACP) to compile a list of 44 possible low-value interventions using desktop research.
The list was examined and refined down to 8 interventions: comprising 6 that were deemed sufficiently common or important to warrant consideration and two additional practices identified by the committee. A review of the evidence for these 8 was completed and circulated to the whole ESA membership for feedback via an on-line survey. Based on the results of the survey, which attracted 146 respondents, a top 5 was identified.
The Australian Physiotherapy AssociationVisit page
- Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule
- Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the rules).
- Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder
- Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
The APA sought nominations from fellows and associates of the Australian College of Physiotherapy, directors of the Physiotherapy Evidence Database, clinical specialist APA members and academic physiotherapists to form an expert panel. The APA invited all members to submit evidence about interventions related to physiotherapy that should be questioned. From members’ submissions and the expert group’s research, the expert group formed a shortlist of 8 recommendations. The expert group then considered the shortlist in terms of the extent of the health problem, usage of the test or intervention, and the evidence that the test or intervention is inappropriate. From this analysis, the expert panel selected five recommendations to put to APA members. In a second round of consultation, the APA received nearly 2500 responses, and almost 900 comments. The expert panel then considered feedback and refined the recommendations. This resulted in the 6 recommendations put forward below, for which there was overwhelming majority support.
The Australasian Society of Clinical and Experimental Pharmacologists and ToxicologistsVisit page
- Avoid using a higher or lower dose than is necessary for the patient to optimise the ‘benefit-to-risk’ ratio and achieve the patient’s therapeutic goals.
- Stop medicines when no further benefit will be achieved or the potential harms outweigh the potential benefits for the individual patient.
- Reduce use of multiple concurrent therapeutics (hyper-polypharmacy).
- Reduce the use of medicines when there is a safer or more effective non-pharmacological management strategy.
- Recognise and stop the prescribing cascade.
A working party of members of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) was established to propose an initial list of recommendations. ASCEPT’s membership was then invited to participate in an online survey to comment on the appropriateness of the proposed recommendations and suggest additional items for consideration.
Based on the survey responses, six recommendations were shortlisted. Following an evidence review the top 5 list items were selected. The final list was signed off by the ASCEPT President in April 2016.
The Australasian College of DermatologistsVisit page
- Monotherapy for acne with either topical or systemic antibiotics should be avoided.
- Do not routinely prescribe antibiotics for inflamed epidermoid cysts (formerly called sebaceous cysts) of the skin.
Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
- Do not prescribe topical or systemic anti-fungal medication for patients with thickened, distorted toenails unless mycological confirmation of a dermatophyte infection has been obtained.
- Do not assume that bilateral redness and swelling of both lower legs is due to infection unless there is clinical evidence of sepsis such as malaise, fever and neutrophilia, plus an expanding area of redness or swelling over a period of hours to days.
A long-standing College Fellow, in consultation with the Honorary Secretary has prepared 5 recommendations. All ACD members were invited to choose three out of the five recommendations. Following an NPS Representatives meeting, it was noted that five recommendations are needed. Therefore the remaining two recommendations were selected.
Royal Australasian College of SurgeonsVisit page
RACS collaborated with General Surgeons Australia (GSA) and the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) respectively on the development of lists for Choosing Wisely Australia. Each organisation worked closely with key members including the Sustainability in Healthcare Committee and Professional Development and Standards Board (RACS), and the Boards of Directors (GSA and ASOHNS) to develop the lists of tests/treatments/procedures for general surgery, and head and neck surgery.
Gastroenterological Society of AustraliaVisit page
The Gastroenterological Society of Australia (GESA) initially engaged its members through its regular online communications, sharing the aims of the EVOLVE initiative, as well as background information on the US and Canadian versions of Choosing Wisely. Members were provided with a copy of the five recommendations made by the American Gastroenterology Association. GESA also consulted externally, with the EVOLVE Lead Fellow addressing the GUT club and the Inflammatory Bowel Disease Group on the initiative. All members of GESA were invited to submit proposed items for the Top 5 list. The GESA Council reviewed all items before reaching consensus on the recommended final list. A review of the evidence for the shortlisted items was then undertaken and the final list and its rationales were signed off by the GESA Council in May 2016.
Australasian Chapter of Sexual Health MedicineVisit page
- Do not order herpes serology tests unless there is a clear clinical indication.
- Do not prescribe testosterone therapy to older men except in confirmed cases of hypogonadism
- Do not treat recurrent or persistent symptoms of vulvovaginal candidiasis with topical and oral anti-fungal agents without further clinical and microbiological assessment.
With the assistance of the Royal Australasian College of Physicians as part of Evolve, the Australasian Chapter of Sexual Health Medicine (AChSHM) Council produced and distributed to its membership an online survey. The survey listed 5 examples of clinical practices in sexual health medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context.
Members were asked to comment on these examples and to suggest other low-value practices which may be a sizeable issue in the specialty. Based on the feedback, 8 items were identified for further investigation by AChSHM Council through an evidence review. This resulted in the final list of 5 recommendations which were endorsed by the Council on 15 December 2016.
In July 2018 the Australasian Chapter of Sexual Health Medicine undertook a review of their Top-5 recommendations. Due to changes in evidence, and physician support, recommendation 5 was replaced. The removed recommendation read: “Reconsider the use of nucleic acid amplification testing for gonorrhoea in low-prevalence (i.e. <1% prevalence) populations and people who do not belong to a higher risk group.”
Australian and New Zealand Society for Geriatric MedicineVisit page
- Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.
- Do not prescribe medication without conducting a drug regimen review.
- Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.
Members of the Australian & New Zealand Society for Geriatric Medicine completed an online survey asking them to choose the 5 most relevant ‘low value’ practices from a list of 11. Respondents were also asked to nominate any additional practices which they regarded as overused, inappropriate or of limited effectiveness in the specialty of geriatric medicine. A total of 196 responses were received.
The list of items were then subject to consideration by the Federal Council. Specifically, members of Federal Council were asked to rate each of these 16 items in terms of their strength in meeting 7 criteria: Is there a reasonable evidence base upon which to drive change? Are older people likely to benefit from work we might do to change practice? Is the problem sizeable? Are there opportunities and a willingness within geriatric medicine to lead practice change? Are there opportunities to collaborate with other organisations with a shared interest in the area? Will this promote a positive profile for ANZSGM? Is this an area of potential conflict with other Societies?
Based on the ratings they assigned to these items the ‘Top 5’ list items were chosen and reformulated as recommendations for clinicians.
Australasian Society for Infectious DiseasesVisit page
- Do not investigate or treat for faecal pathogens in the absence of diarrhoea or other gastro-intestinal symptoms.
- In a patient with fatigue, avoid performing multiple serological investigations, without a clinical indication or relevant epidemiology.
- Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection.
- Avoid prescribing antibiotics for upper respiratory tract infection.
- Do not use antibiotics in asymptomatic bacteriuria.
An initial list of 10 low value interventions was compiled by the Lead Fellow of the Australasian Society for Infectious Diseases (ASID) Inc following an online discussion in ASID's discussion forum, Ozbug. The Royal Australasian College of Physicians (RACP) then facilitated a consultation of all ASID members via a survey distributed through the society’s e-newsletter. In the survey, members were asked to rank the 10 suggested interventions and suggest additional items for consideration. A subsequent shortlist of items was created by selecting the top 7 interventions as ranked by the members from the initial list.
The shortlist was sent to ASID’s special interest groups and selected members who had agreed to assist, who were asked to recommend the items to comprise the ‘top 5’. This final list was endorsed by ASID Council on 31 July 2015. The Top 5 was then circulated again to the ASID members for final comments before being signed off by ASID’s Executive Committee.
Australian College of NursingVisit page
- Don’t restrict the ability of people with diabetes to self-manage blood glucose monitoring unless there is a clinical indication to do so.
- Don’t routinely administer antipyretics with the sole aim of reducing body temperature in un-distressed children.
- Don’t initiate plain X-ray for foot and ankle trauma unless criteria of the Ottawa Ankle Rules are met.
The Australian College of Nursing (ACN) as nursing lead, established a collaborative working party incorporating a diverse range of nursing expertise. Professional nursing bodies involved in initial collaboration included: Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM); CRANAplus; Australian Primary Health Care Nurses Association (APNA); Australian College of Mental Health Nurses (ACMHN).
ACN’s membership was consulted via publications, web site and ACN’s National Nursing Forum. This consultation provided a broad view from our members regarding planning and delivery of nursing care across Australia. An interactive session invited delegates to actively participate in identifying those nursing practices, interventions, or tests that evidence shows provide no benefit or may even lead to harm. This informative stimulating session examined a range of nursing practices and their effects on healthcare consumers.
At this point specialist nursing groups were approached for comment on our recommendations. This group included: Australasian College for Infection Prevention and Control (ACIPC); Australian Diabetes Educators Association (ADEA); Continence Nurses Society Australia (CNSA); Australian and New Zealand Urological Nurses Society (ANZUNS); Medical Imaging Nurses Association (MINA); and the Australian and New Zealand Orthopaedic Nurses Association (ANZONA). Final consultation with ACN Members and Fellows prior to submission ensured a collaborative result.
Australian and New Zealand Society of Palliative Medicine & the Australasian Chapter of Palliative MedicineVisit page
- Limit routine use of antipsychotic drugs to manage symptoms of delirium.
- Do not use oxygen therapy to treat non-hypoxic dyspnoea.
- Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice.
- To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review.
- Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.
Fellows from the Australian and New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine (ANZSPM/AChPM) convened a working group to produce an EVOLVE list for palliative medicine. The Royal Australasian College of Physicians (RACP) assisted this working group in compiling a list of 15 clinical practices in palliative medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas.
This list was then sent out to all ANZSPM and AChPM members, seeking feedback on whether the items fully captured the concerns of clinicians in an Australasian palliative medicine context and if not, whether any items should be omitted and/or new items added. 40 responses to this email were received. Based on these, 3 items were removed leaving a shortlist of 12. An online survey was then sent to all ANZSPM and AChPM members asking respondents to rate each item against three criteria from 1 (lowest) to 5 (highest), and to nominate any additional practices worthy of consideration.
The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question. Based on the 114 responses to this survey, the top 5 were selected.
Australasian College for Emergency MedicineVisit page
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.