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Changing conversations, cultures and systems: the movement to tackle overuse in healthcare

The recent 2018 Choosing Wisely Australia National Meeting in Canberra was an opportunity for wide-ranging conversations that shared some of the experiences, success stories and challenges facing the movement to tackle overuse in healthcare.

Jennifer Doggett reports on the discussions below – featuring speakers from the United States, New Zealand and across Australia – for the Croakey Conference News Service.


Jennifer Doggett writes:

The Welcome to Country from Ngunawal elder Wally Bell set the tone for the day by stressing the importance of family, community and environment for health, reminding participants that “we all need country to survive”.

This holistic approach was echoed by the CEO of NPS MedicineWise, Dr Lynn Weekes, who invited delegates to reflect on Indigenous people’s understanding of medicine as a broad concept, involving family, spirit and country.

She challenged everyone attending to “probe deeply and have meaningful conversations” during the day, emphasising the role of Choosing Wisely in supporting meaningful relationships between health care providers and consumers.

She also highlighted the need for more action in “bringing consumers with us into the conversation”, a theme that was taken up later in many of the sessions.

Views from the United States

Daniel Wolfson, Executive Vice-President and Chief Operating Officer of the ABIM Foundation, gave an overview of the genesis of the Choosing Wisely campaign in the USA.

As previously reported, Wolfson has been instrumental in leading Choosing Wisely in the USA. He described how the campaign arose from concerns among physicians about the overuse of health care.

He outlined how the key messages of the campaign were developed in an environment in which talking about overuse of health care resources was “toxic” as it implied the rationing of resources.

Wolfson explained how the language of Choosing Wisely was carefully selected, given this environment, so that it focuses on the positive aspects of making evidence-based decisions about health care, rather than the implications these decisions have for reducing the overuse of resources.

He identified one of the major achievements of Choosing Wisely (USA) as the “major cultural change” involved in normalising discussions about health resource use among physicians and in the media.

Examples that reflected this change were a shift in the debate on health care “from an emphasis on thoroughness to one on appropriateness”, and a change from asking: “Why DIDN’T we order that test?”, to asking: “Why DID we order that test?”

Creating a culture

A number of stories presented at the event highlighted the diverse ways in which Choosing Wisely Australia has been successful in improving quality care and resource use in different areas of the Australian health system.

Dr David Rosengren, Deputy Executive Director Operations at Metro North Hospital and Health Services in Brisbane (pictured), described how he and his team had worked to embed the Choosing Wisely message and principles in all aspects of their operations.

Rather than focus on specific interventions, Rosengren described their “value-based employment program”, which fosters a culture where staff at all levels are encouraged to suggest ideas to reduce waste and improve the value of resource use.

Rosengren gave the example of a suggestion made by a theatre nurse to reduce bags of unused blood being wasted in operating theatres. He told how the nurse had suggested putting an alarm clock on the esky containing the blood, to enable operating theatre staff to monitor when it needed to be returned to the refrigerator, if not required. As a result of this simple and low-cost action, Rosengren reported that the service had not wasted a single bag of blood in the past eighteen months.

Choosing Wisely principles also had been applied at Metro North Hospital and Health Services in the way patients were instructed to fast prior to surgery.

Rosengren described how previously patients scheduled for surgery were all instructed to fast in line with the time-frame for their scheduled surgery.

However, due to constantly changing schedules and priorities within the busy public hospital, many of these patients ended up not undergoing surgery at the scheduled time. This meant that many patients would fast unnecessarily, leading to poor patient experience and potentially adding to their health problems.

As a result of the application of Choosing Wisely principles, patients now are only told to fast when they are called to theatre. Rosengren highlighted the benefits to both patients and the hospital of this simple change, which doesn’t cost any money but which significantly increases patient satisfaction.

Scaling and embedding

A number of speakers raised the importance of sharing and disseminating learnings from the many different approaches to Choosing Wisely.

Daniel Wolfson described some of the challenges that this posed in the USA with a privatised and very fragmented health system. In fact, he reported that to date only five US states had expressed interest in being involved in the Choosing Wisely campaign.

He praised the role of NPS MedicineWise as a national body able to work across the country in sharing information and influencing health care policies and programs.

Camilla Radia-George, Manager of Innovation Projects at Safer Care Victoria, presented a project focused on scaling and embedding Choosing Wisely strategies throughout the Victorian health system.

She explained how Better Care Victoria, in partnership with NPS MedicineWise and Austin Health, is scaling up the Champion Health Services program implemented by Austin Health to ten additional sites across Victoria.

The aim of this project is to reduce low value care and improve outcomes for patients, clinicians and the health care system overall. It involves funding for 11 services to work together and problem solve a range of issues using a Choosing Wisely approach.

Radia-George explained how this project will provide valuable lessons on how successful projects can in future be scaled up to have a broader application across the health system.

Clinician ownership

The importance of Choosing Wisely as a clinician-owned and grass-roots program (rather than a ‘top down’ approach to change management) was emphasised by several speakers and participants.

Dr Paul Buntine, an emergency physician from Box Hill Hospital, presented one example of how peer-education applying Choosing Wisely principles can successfully improve quality care and resource management in hospital settings.

He described the ‘No Unnecessary Tests’ (or NUTS) program developed at Box Hill Hospital, which has resulted in some major reductions in unnecessary and low value care; for example, a reduction in unnecessary imaging for pulmonary embolism and a 50 percent reduction in venous gas testing in the Emergency Department.

The key to the success of this project, as described by Buntine, was the peer-to-peer approach, which engaged younger doctors in presenting the evidence on the appropriate use of these tests to their peers.

Allied health matters

The application of Choosing Wisely to allied health was also covered in a presentation by Dr Joshua Zadro, a physiotherapist and post-doctoral research fellow from the University of Sydney.

He presented the results of a project aiming to increase the evidence-based use of X-rays for ankle trauma and discussed some of the challenges in implementing Choosing Wisely principles in this area.

Zadro said one of the main barriers to the successful implementation of projects such as this is that “physios don’t like guidelines and think that their patients get good results from low value care”.

He referenced some additional research he is undertaking on physiotherapists’ attitudes and the barriers/facilitators to improving care through evidence-based strategies as a useful tool for the future implementation of Choosing Wisely strategies in physiotherapy.

He also noted that measuring changes in care in allied health is more difficult than in medical practices as there are no allied health MBS item numbers.

Pathology results

The scale of potential savings that can result from the Choosing Wisely approach to reducing unnecessary and low value care was highlighted by the presentation by Malcolm Stringer, CEO of Pathology Queensland (the largest supplier of pathology in the public sector in Queensland).

Stringer reported estimates that between $4 million and $22 million per year is available in potential savings in Queensland alone through improving pathology use. He emphasised this should not be seen as a cost cutting goal as these resources could then be re-invested into the health system to achieve greater benefits elsewhere.

He described a successful Choosing Wisely project: the introduction of ‘Re-test rules’ that prohibit the duplication of pathology tests on patients, within a defined time window. This was based on data showing that different areas of the hospital would sometimes order duplicate tests, rather than checking to see if these tests had already been ordered.

Stringer stated that in 2017 this project had saved $781,000. He added that while this was impressive, Pathology Queensland had identified further improvements could be made as the project involved identifying duplicate tests only at the laboratory – meaning that the patient had already undergone the collection of a testing sample, thus exposing them to unnecessary and sometimes invasive procedures.

A further improvement to this project is planned, which will involve the roll out of integrated medical record and electronic ordering to reduce the initial ordering of unnecessary pathology tests.

Challenges

The meeting also highlighted some of the challenges facing the further implementation of Choosing Wisely principles and projects across the Australian health system.

A number of speakers and participants identified the current time-based, fee-for-service funding system as a significant barrier to the further application of Choosing Wisely principles.

GP Dr Walid Jammal noted that:

Choosing Wisely is an opportunity to support GPs’ intrinsic desire to do a good job. However, the current system works against us – it rewards transactions and does not support high value care.

We need to move from a transactional fee-for-service model that drives everything through the doctor towards a system that supports teamwork and quality care where each person in the practice is used to the best of their ability.”

This was supported by Consumers Health Forum of Australia CEO, Leanne Wells, who stated that:

We have an outdated fee-for-service funding model that does not support quality care.

We need to look at how primary health care and general practice can organise to be more flexible and agile in order to respond to patient needs.”

Jammal identified two current opportunities on the health reform agenda to support Choosing Wisely: the MBS Review; and the Health Care Homes trial.

He suggested that the MBS Review could consider instilling ‘appropriateness’ into item number descriptions in order to reduce low value care and that the Health Care Homes trial needs to focus on changing financial structures to enable nurses and other primary health care providers to work alongside doctors.

He argued for a systemic approach to embedding Choosing Wisely principles into the workflow of health professionals, stating: “Don’t make Choosing Wisely more work – make it easy to do the right thing.”

Negotiating medical hierarchies and cultures

During a “Champion Health Services” panel discussion, speakers raised resistance from senior doctors to Choosing Wisely initiatives and the importance of encouraging junior doctors to become innovators and quality improvers.

They emphasised the important role of Choosing Wisely advocates in teaching young doctors about quality improvement, resource management and other issues they don’t get taught at medicine school.

This was echoed by comments from participants, although one delegate made the point that there are many older doctors who are committed to Choosing Wisely and that an open mind and willingness to change established practices was more important than age.

The challenge of changing entrenched medical cultures and practices was also raised throughout the day.

Daniel Wolfson stressed how difficult it is for many health professionals to “unlearn some basic things they learned in training”. He also emphasised the importance of adopting multiple strategies for influencing behaviour change as patterns of behaviour are so ingrained and it is often very difficult to shift established practices.

Co-design and consumers

Consumer issues were a major focus of the meeting, and the need for a continued focus on consumer partnerships was stressed by Leanne Wells and a number of consumer advocate participants.

In her presentation and a subsequent interview, Wells discussed the significant efforts still required to ensure that the promising progress being made by Choosing Wisely Australia is sustained over the long term.

Along with some of the other presenters and participants, Wells highlighted the need to address systemic barriers to improving the interactions between health care providers and consumers.

She flagged the need for “big discussions on where we take primary health care reform and how payment systems sit around patient-centred models of care”, and said:

There is still a culture in the health system that it’s not OK for consumers to question providers, either because of a belief about their respective roles or just the pressure created by time and financial drivers.

We shouldn’t be naïve in thinking that Choosing Wisely Australia can overcome the systemic barriers that exist in our health system to the provision of quality, consumer-centred care, and it is likely that progress of Choosing Wisely will plateau unless some of those broader system reforms are taken seriously.”

Wells also argued against the use of the term “engaging consumers”, which she said was often used to mask tokenistic or superficial consumer input into a health policy or program.

She argued for a more meaningful approach to collaboration between consumers and health professionals, which includes co-design at all levels of the system. “There is no design without co-design,” she said.

Wells cited Choosing Wisely Australia as a good example of co-design and welcomed the “solid intent” of NPS MedicineWise to make the concept of a consumer partnership real.

However, she also acknowledged that collaborative practice between consumers and health care providers is a journey in which there is still a long way to travel and that significant learning needs to occur before this can become “business as usual”.

Building trust

The issue of trust between consumers and healthcare providers was discussed extensively at the National Meeting as an essential criterion for the successful implementation of Choosing Wisely principles and projects.

Daniel Wolfson asked participants to consider how to build trust in healthcare, highlighting the challenges involved in building the trust necessary to make informed and evidence-based decisions within the context of a relationship in which neither party might know the other well.

He argued that the context for effective individual consumer-provider relationships has to be a broad community trust in institutions and health professionals.

One example he provided of a breakdown in trust in this area is the anti-vaccination movement, which does not respect institutions or health professionals.

One challenge to consumers’ trust in health care providers was raised by a participant, who asked why the community should trust health professionals to self-regulate when this system had led to so much low value and harmful care being provided.

Legal concerns

Associate Professor Nola Ries from the University of Technology, Sydney, outlined some of the medico-legal drivers of low value care, debunking the common assumption that this is primarily driven by fear of litigation.

She outlined her research demonstrating that doctors often overestimate their risk of being sued and that their perceptions of legal requirements are a greater determinant of their practices than the reality.

Margaret Faux, a lawyer and medical billing expert attending the session, questioned how to reconcile the concept of medical necessity with the lower threshold of “appropriateness” promoted by Choosing Wisely advocates, to ensure doctors are not open to legal action from consumers or insurance funds.

Ries explained that doctors who have a more accurate and positive view of law provide less unnecessary care and that therefore it was important to educate health professionals so they have a more nuanced understanding of their legal obligations.

She called for a shift from defensive practices (which prevent trust) to preventive practices (which promote trust), acknowledging that this would need a change of cultures and attitudes to achieve.

Focus on FACTS

The key learnings from the day were neatly summed up by NPS MedicineWise Client Relations Manager Dr Robyn Lindner who used the acronym ‘FACTS’ to identify the main take-home messages as follows:

Focus: don’t try to take on everything, stay focused on what can be achieved even if it seems like a small step.

Accountability: don’t lose sight of the need for accountability in improving quality of care and the use of health care resources.

Conversations, communication, common language: these are crucial and need to occur at all levels, including between health providers from different sectors of the health system as well as between health providers and consumers.

Trust: trust is the foundation of the relationship between consumers and health care providers. Without trust nothing can be achieved.

Silos: get rid of silos in the health system, both between clinical specialties as well as between consumers and professionals. Silos create barriers to change and obstruct trust and communication.


Tweet reports

Welcome to country

Dr Robyn Lindner, NPS MedicineWise

Daniel Wolfson, ABIM Foundation

Champion health services panel
Dr Matthew Anstey,  Intensivist Sir Charles Gairdner Hospital, Chair Choosing Wisely Advisory Group
Therese Kelly  Project Manager, Choosing Wisely Gold Coast Health
Asmara Jammali-Blasi  Project Lead, Choosing Wisely State Collaborative (Victoria) Austin Hospital
Dr Paul Buntine  Emergency Physician Box Hill Hospital

Dr Derek Sherwood,  Ophthalmologist, Nelson Eye Specialists, Chair Council of Medical Colleges in New Zealand: ‘Working with students and educators to include Choosing Wisely in medical culture’

Spreading the Choosing Wisely message to engage the healthcare community

Gary Power, Deputy Chair, Consumer Advisory Group Royal Brisbane and Women’s Hospital

Dr Paresh Dawda, GP, Prestantia Health

Other reports

Posters

See the CHF poster.


See the Commission poster.

Feedback from participants

Selfies and snaps

Further reading – medical republic

Read the medical Republic article

Read the Croakey coverage of last year’s meeting.


Thanks to all tweeps

Below are the Twitter analytics, via Symplur, for the period of Croakey’s coverage (25 May-3 June). The Twitter transcript is here.


This link compiles the Croakey coverage of #OKtoAsk2018.

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