Recommendations

ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.

Recommendation 1-5
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.

Recommendation 6
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.Download ANZCA Recommendations

Recommendation 1-5
The Faculty of Pain Medicine (FPM), ANZCA established a working group to develop a preliminary list of pain medicine related practices that were identified, using current clinical evidence, as having possible limited benefit, no benefit or which may potentially cause harm to patients. An online survey tool was used to survey all FPM fellows and trainees inviting them to rank these recommendations and to provide any comment related to them. This engagement facilitated consensus and informed the Fellows and trainees about FPM’s involvement with the Choosing Wisely campaign.

FPM's final list of 5 Choosing Wisely recommendations reflects those that were the most broadly supported by the clinicians and which were considered to be the most relevant to community practice.

Recommendation 6
FPM Board directed that a poll of the fellowship be conducted to assess support for a sixth Choosing Wisely recommendation regarding the role of medicinal cannabis in chronic non-cancer pain treatment. The survey question was very similar to the final wording of the recommendation, and was supported by 79% of the fellows who responded (more than 25% of the active fellowship).

The final draft wording of the recommendation, explanation and list of key references was then approved by the Board and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the following Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.

Recommendation 7
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.

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In 2018 The Royal Australasian College of Physicians worked with a Lead Fellow nominated by The Thoracic Society of Australia and New Zealand (TSANZ) to review evidence for 12 paediatric thoracic recommendations on low-value care in paediatric thoracic medicine. These recommendations were the subject of email discussions and deliberation by members of the Paediatric Special Interest Group (SIG) of the TSANZ. They were further discussed at a workshop held at a meeting of the Asia Pacific Society of Respirology in 2017, which included TSANZ members. Based on the feedback provided at this workshop and through email discussions with members of the SIG, four were removed and two of the original 12 were considered for inclusion in the final recommendations with overwhelming support. Members of the Paediatric SIG were then invited to choose three out of the remaining six through an email based poll. This served as the basis for final recommendations, which were further refined and developed through successive drafts based on the input of the Lead Fellow, the results of consultation with other specialty groups and the views of the TSANZ Board.

In 2020 TSANZ worked with RACP’s Policy & Advocacy team as part of the Evolve program to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting under the guidance of the TSANZ Central Office and members of the TSANZ Board, the list was condensed to the top-5 recommendations for reducing low-value practices in adult thoracic medicine. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest in or professional engagement with thoracic medicine.

Per usual processes, the recommendations were then consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further work and refinements by Policy & Advocacy and TSANZ, which approved these top-5 recommendations. 

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The Australian and New Zealand Society of Nephrology (ANZSN) Clinical Policy and Advisory Committee worked with the RACP, as part of the Evolve Program, to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting, the list was condensed to the top-5 recommendations for reducing low-value practices in nephrology. Dr David Tunnicliffe has been the Lead Fellow on the project.

The list of recommendations was then subject to an extensive review process that involved key College societies with an interest or professional engagement with nephrology as well as health equity. It was then further consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further research and finetuning of the list, which was then finalised and approved by the ANZSN.

College’s Expert Advisory Committee, comprising seven longstanding Fellows considered four potential recommendations, together with supporting evidence, and agreed to proceed with three of them. The Committee then refined and finalised the recommendations. These were reviewed by the NPS Representatives Committee and finalised in response to the feedback received.

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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.

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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.

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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.

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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 7-10 (September 2021)

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 and Economics and Workforce Committees, 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.

This initial list has now been reviewed with recommendations 7, 8 & 10 remaining unchanged, recommendation 9 has been updated based on the advice of the Faculty of Radiation Oncology Quality Improvement Committee and Recommendation 11 has been replaced based on the feedback of the Quality Improvement Committee and the Policy and Advocacy team.

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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.

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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.

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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.

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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.

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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.

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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.

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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.”

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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.

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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.

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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.

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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.

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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.

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