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 Thoracic Society of Australia and New ZealandVisit page
- Do not use oral beta2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
- For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
- Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.
- Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
- Do not prescribe antibiotics for exacerbation of asthma.
The Royal Australasian College of Physicians worked with a Lead Fellow nominated by 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.
The Royal Australian College of General PractitionersVisit page
Recommendations 1 - 5 (April 2015)
Recommendations 6-10 (March 2016)
The Royal Australian and New Zealand College of RadiologistsVisit page
Clinical radiology recommendations 1-6 (April 2015)
Radiation oncology recommendations 7-12 (October 2016)
The Australian Physiotherapy AssociationVisit page
The Australia and New Zealand Child Neurology SocietyVisit page
- Do not routinely perform electroencephalographs (EEGs) for children presenting with syncope (fainting).
- Do not routinely perform computed tomography (CT) scanning of children presenting with new onset seizures.
- Do not routinely undertake repeat blood level monitoring of antiepileptic drug (AED) treatments.
- Do not routinely undertake neuroimaging for new onset primary headache without first examining for neurological abnormality.
- Do not routinely perform electroencephalographs (EEGs) for children presenting with febrile seizures.
Following deliberations, the ANZCNS Board determined to investigate the evidence for nine priority recommendations regarding low-value clinical practices in paediatric neurology. An evidence review was developed for these recommendations and served as the basis for an online survey sent to all ANZCNS members asking respondents if they agreed, disagreed or were unsure if these recommendations were evidence based, undertaken in significant numbers, and important in terms of reducing patient harm and unnecessary healthcare expenditure. Based on survey responses, each of the nine was assigned a score and ranked accordingly. Based on this information and a final evidence review, these top 5 recommendations were chosen.
Royal Australasian College of SurgeonsVisit page
RACP Paediatrics & Child Health DivisionVisit page
The Paediatrics & Child Health Division (PCHD) formed a group of interested Fellows to comprise a General Paediatrics EVOLVE Working Group. A review of low-value practices relevant to general paediatrics was conducted drawing on lists published by Choosing Wisely US and Canada, contributions to Choosing Wisely Australia by other medical colleges and published EVOLVE lists developed by other specialties in order to identify low-value practices of relevance while avoiding duplicating the mention of practices already identified in other EVOLVE lists. Based on this review, the Working Group shortlisted 15 items for further consideration.
These 15 items were then reviewed and discussed by participants at a workshop held at the RACP Annual Congress 2016. Following these deliberations, the list was further narrowed down to 10 items. These 10 items were incorporated into an online survey which also summarised the recent evidence on each of these items. A link to the survey was distributed to all Fellows and advanced trainees of the RACP Paediatrics & Child Health Division.
Survey respondents were asked whether they agreed, disagreed or were unsure about whether each item was undertaken in a significant number of paediatric patients, whether there was good evidence that the item should be undertaken less often and whether reducing use of the item was important in terms of reducing harm and/or costs to the healthcare system. Each item was assigned a score based on respondents’ answers to these three questions on each item. There were 269 respondents representing a survey response rate of approximately 22 per cent. The five highest scoring items were selected to be on this ‘top-five’ list.
Australasian Society of Clinical Immunology and AllergyVisit page
The RACP Strategic Policy and Advocacy group assisted ASCIA in compiling the original list of 25 tests, treatments and services, that have been identified either in past work by ASCIA, other literature reviews or in evidence reviews performed by overseas specialist physician bodies or health agencies as being overused, inappropriate or of limited effectiveness.
Two electronic surveys were sent to ASCIA members who are Fellows of the RACP (256 members in total) in February 2015 and March 2015, to firstly rank a top 5 from the list of 25, and secondly to review the wording and rankings of the top 5 recommendations. The overall response rate for these surveys was 20%. All ASCIA members and relevant patient organisations were then invited to review the list.
Australasian Paediatric Endocrine GroupVisit page
- Do not rely solely on bone age measurement for assessing growth in young children with short stature under 2 years of age.
- Do not routinely measure insulin-like growth factor binding protein 3 (IGFBP-3) for workup and diagnosis of childhood short stature.
- Do not initiate gonadotropin-releasing hormone (GnRH) analogue treatment in children outside of central precocious puberty, for the target outcome of delaying puberty and improving final adult height.
- Do not routinely prescribe aromatase inhibitors to promote growth in children with short stature.
- Do not rely on random measures of circadian hormones for diagnostic purposes.
A working group of lead clinicians from APEG brainstormed an initial list of 11 low-value practices in paediatric endocrinology and a preliminary review of the evidence for each was undertaken. An online survey was developed based on these 11 recommendations along with a summary of the evidence for each, and circulated to APEG members for their feedback. For each recommendation, respondents were asked to assign a score from 1 to 5 (where 1 = strongly disagree and 5 = strongly agree) on two criteria: ‘The recommendation is evidence based’ and ‘The recommendation is relevant to paediatric endocrinology in Australasia’. Based on the recommendations which received the highest average total scores, and after a final in-depth review of the related evidence, the final top five were chosen and approved by APEG.