CHOOSING WISELY AUSTRALIA

ConPharm June 2019

Anne-Marie Martin

NPS MEDICINEWISE

20 YEARS EXPERIENCEHELPING AUSTRALIANS MAKE BETTER HEALTH DECISIONS

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LEARNING OBJECTIVES

Demonstrate an understanding of Choosing Wisely and its principles.

List and implement Choosing Wisely recommendations.

Describe how patients can be empowered to ask questions about their health and healthcare.

RESOURCE STEWARDSHIP

“Wise management of health care resources is a core tenet of medical professionalism”

Wolfson et al Academic Medicine 89 (7) 2014

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CHOOSING WISELY

A global campaign to start a conversation about unnecessary tests, treatments and procedures

Encouraging conversations with patients about risks and alternative options

20 countries and growing

CLIMATE FOR CHANGE1

Significant waste in the health system

- Unwarranted variations in practice

- About 50% antimicrobial use in humans is inappropriate, but may be as high as 90% in general practice

Patients not receiving right care

- Low value care, service duplication, avoidable adverse events

Gap between aspiration vs actual behaviour

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AUSTRALIAN RESPONSES

GPs & specialists cite “patient expectations” as a major driver of unnecessary tests and treatments

Only 16% of surveyed Australians said they ask for tests

REASONS FOR UNNECESSARY TESTS

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CHOOSING WISELY AUSTRALIAChoosing Wisely Australia® is an initiative of NPS MedicineWise in partnership with Australia's health professional colleges, societies and associations. The campaign is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit, or in some cases, lead to harm.

From Choosing Wisely report (2018)

STARTING A CONVERSATION

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CHOOSING WISELY PRINCIPLES

1. Clinician-led

2. Emphasise quality of care and harm prevention

3. Consumer/Patient - focused

4. Evidence-based

5. Multi-professional

6. Transparent

RECOMMENDATIONS

Lists of “5 things to question”

Evidence based

Transparent

Quality of care focus

Starts a conversation

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RECOMMENDATIONS2

The Royal Australian College of General Practitioners (RACGP)

- Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.

- Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.

- Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.

- Don’t treat otitis media 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.

RECOMMENDATIONS2

The Royal College of Pathologists of Australasia (RCPA)

- Do not perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years.

- Do not perform population based screening for Vitamin D deficiency.

- Do not routinely test and treat hyperlipidemia in those with a limited life expectancy.

- 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 perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.

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RECOMMENDATIONS2

Australian and New Zealand Society for Geriatric Medicine

- Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia

- Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium

- 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

RECOMMENDATIONS2

The Society of Hospital Pharmacists of Australia (SHPA)

- Don’t initiate and continue medicines for primary prevention, in individuals who have a limited life expectancy.

- 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 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.

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RECOMMENDATIONS2

Pharmaceutical Society of Australia (PSA)

- Do not initiate medications to treat symptoms, adverse events, or side effects (unless in an emergency) without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a medication, or another treatment is warranted

- Do not promote or provide homeopathic products as there is no reliable evidence of efficacy. Where patients choose to access homeopathic treatments, health professionals should discuss the lack of benefit with patients.

- Do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness.

- Do not prescribe medications for patients on five or more medications, or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements should or can be reduced or discontinued.

- Do not recommend complementary medicines or therapies unless there is credible evidence of efficacy and the benefit of use outweighs the risk.

Positive messages

Creating supportive environments

Local health service pilots

Co-designing with consumers

CONSUMER ENGAGEMENT

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KE

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Available in 10 languages

5Q wallet cards

Empowerment through

asking the right questions

Non-specific low back pain is a diagnosis of exclusion

Only refer for imaging when necessary

Use a risk stratification approach to identify patients at risk of developing chronic disabling pain

Patient education, reassurance and activity are first line for all patients with non-specific low back pain

GP 

EDUCATION

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PATIEN

T INFO

RMATION 

MedicineWise AppComplete medicines list

Health management

Adherence to medicines

Information on medicines

Collection and reporting ofpatient-reported experiences

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FEATURES OF MEDICINEWISE APP

Build, edit & share medicine list

Set dose & appointment alerts

Track tests & results

Record important health information

Carer mode – create and manage multiple profiles

View relevant medicines info & rich media

Secure login & syncing

NEW

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Push notification and targeted messaging

FEEDBACK FROM GPs

Hypomagnesaemia & PPIs3

- Lack of evidence for routine screening of hypomagnesaemia in patients without risk factors on PPI therapy or before initiating long-term PPI use.

- Consider monitoring if chronic renal insufficiency or concomitant diuretic use

- Recommended in those suspected to have symptoms potentially due to hypomagnesaemia, such as cramps, paresthesias and cardiac arrhythmias.

Vitamin B123

- Serum vit B12 biannually if on long term PPIs (>2years), especially if high dose and have dietary restrictions (e.g. vegan)

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FEEDBACK FROM GPs

Lipid testing4

- Adults should have their blood lipids assessed every five years starting at 45 years of age (35 years for Aboriginal and Torres Strait Islander adults)

- Low absolute CV risk (<10%) repeat lipids every 5 years

- Moderate absolute CV risk (10-15%) repeat every 2 years

- High absolute CV risk (>15%) every 12 months

GET INVOLVED

Subscribe to the newsletter at choosingwisely.org.au

Engage on social media

- @ChooseWiselyAU

- Facebook/choosingwisely

Encourage patients

- 5Q wallet cards

- Videos

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REFERENCES

1. Oecd.org. (2019). Tackling Wasteful Spending on Health - en - OECD. [online] Available at: http://www.oecd.org/health/tackling-wasteful-spending-on-health-9789264266414-en.htm [Accessed 23 May 2019].

2. Choosing Wisely Australia. (2019). Choosing Wisely Australia: eliminating unnecessary tests, treatments & procedures. [online] Available at: http://www.choosingwisely.org.au/home [Accessed 23 May 2019].

3. Malfertheiner, P., Kandulski, A. and Venerito, M. (2017). Proton-pump inhibitors: understanding the complications and risks. Nature Reviews Gastroenterology & Hepatology, 14(12), pp.697-710.

4. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn, updated. East Melbourne, Vic: RACGP, 2018.

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