What will help doctors play a more active role in tackling low value healthcare and ensuring healthcare is more sustainable?
This question was a recurring theme at the recent Choosing Wisely Australia National meeting, as Jennifer Doggett reports for the Croakey Conference News Service.
As Croakey has reported from other recent conferences – including the Green Health Forum and a summit on value-based care – the conversations that took place at #CWANM22 are also happening more widely.
Jennifer Doggett writes:
Medical practitioners have an important role in addressing low value healthcare, but there are many structural and other barriers to their contributions in this area.
Speakers in both the plenary and breakout sessions at the recent Choosing Wisely Australia National meeting identified the need for systemic efforts and reforms to better support doctors in tackling low value care.
Suggestions included introducing compulsory clinical epidemiology for all medical and specialist training, increasing the use of decision support tools, and removing Medicare Benefits Schedule (MBS) item numbers for low value care.
One key strategy identified was to target medical education and training in order to influence medical cultures and ensure doctors are aware of the need to reduce low value from the start of their professional lives.
Professor Wendy Levinson, Chair of Choosing Wisely Canada, provided an example of their successful grassroots medical education campaign, Choosing Wisely STARS (Students and Trainees Advocating for Resource Stewardship).
This program identifies medical students with an interest in this area and supports them to catalyse grassroots, student-led initiatives to advance a focus on high value healthcare in medical education.
Levinson reported that in Canada the STARS program had resulted in a number of changes to the curriculum from the ground up, such as embedding problem-based learning.
She encouraged Australia to also consider adopting this program.
“These are the leaders of the future and they care about sustainability,” she said.
Listening to consumers
The importance of doctors listening to and partnering with consumers to understand their needs and concerns was highlighted by Professor Anne Duggan, the Chief Medical Officer at the Australian Commission on Safety and Quality in Health Care (ACSQHC).
In her keynote address, Duggan focussed on her own journey as a clinician and described how listening to patients describe the psychological and social impact of Crohn’s Disease on their lives made her aware that consumers with chronic conditions need more than just treatment and medication.
Duggan described the structural barriers that can prevent doctors from spending the time to listen to patients’ experiences, particularly those with intermittent rather than ongoing conditions.
“The system doesn’t deal well with patients whose conditions flare up unexpectedly. We need to build patient input into reflective practices about how clinicians deliver care,” she said.
This includes embedding feedback on healthcare variation into clinical governance processes to ensure that clinicians use both data on their own clinical practices as well as feedback from consumers to reflect on how they can improve the quality of care they provide.
“So much clinical variation is because we are not listening to consumers,” she said, suggesting the need for a systemic approach so clinicians have the opportunity to learn from variations in their practice, taking into account consumer preferences which are one reason for healthcare variation.
She highlighted the role of the ACSQHC in addressing low value care and identified two of the National Safety and Quality Health Service standards as key: clinical governance and partnering with consumers.
“If we get these two right, all the others will happen,” she said.
Health worker engagement
The importance of working with doctors and other healthcare workers to improve both outcomes and efficiency was highlighted in a presentation by Dr Niharika Garud from the University of Melbourne.
Garud described research she had undertaken which combined and mapped three independent datasets including:
- Self-reported healthcare worker data
- Insurance-related outcomes
- Hospital outcomes.
By analysing and triangulating this data, Garud investigated whether healthcare worker engagement impacted outcomes such as acquired complications and readmissions. She also looked at the impact of engagement on spending and overall efficiency.
This research demonstrated that healthcare worker engagement has a positive outcome on patient outcomes, wellbeing and service efficiency.
In fact, the study found that for every one percent increase of employee engagement, there is a three percent reduction in hospital acquired infections.
Given that a reduction in hospital acquired complications delivers a significant reduction in costs, Garud argued that increasing healthcare worker engagement was an important sustainability strategy.
She also discussed the drop in their engagement during the COVID-19 pandemic, and stressed the need to do further investigation of this “great resignation” due to its significant implications for quality and safety.
She suggested that the likely causes go beyond simply work stress or job pressure and also include broader factors such as the impact of lack of job security, particularly for those on short term contracts.
“Healthcare workers are already operating under extreme pressures. When life stresses such as financial insecurity are added this gets worse. How can we expect higher levels of engagement from workers who don’t know if they have a secure job?”
Garud also stressed the need for a systemic approach to mental wellbeing, and said organisations that talk about and address this issue have much higher levels of engagement and retention than organisations that see mental wellbeing as an individual responsibility.
“Wellbeing is a ‘we’ problem not an ‘I’ problem,” she said.
Doctors driving over-treatment
In her keynote address, Professor Rachelle Buchbinder, a rheumatologist, epidemiologist and author (with orthopaedic surgeon Dr Ian Harris) of the recently published book Hippocrasy, identified a number of ways in which doctors contribute to over treatment, including relying on medical intervention over natural history and the over-estimation of medical effectiveness.
Buchbinder attributed this to a range of different causes, including doctors’ need to feel effective, which provides them with an incentive to think they can do more than they can.
She also identified poor science literacy among clinicians as a reason why many over-emphasise personal experience when making clinical decisions.
Buchbinder described how advances in medicine can result in low value care, such as when the development of new and more sensitive tests creates ‘diseases’ that aren’t a problem.
She gave as an example the widening diagnosis of diabetes in pregnant women, which she said has caused harm without improving outcomes for women or babies.
Buchbinder had a number of recommendations for participants wanting to take a more systematic approach to addressing low value care. These included:
- Compulsory clinical epidemiology for all medical and specialist training
- Educating doctors that advice and education is “not doing nothing” it is care to patient – often better than an active intervention.
- Increasing the use of decision support tools
- Introducing compulsory criteria for tests likely to be over-used.
- Including context and lay summaries in imaging reports
- Placing signs in waiting rooms stating that the health service is a Choosing Wisely practice which encourages patients to ask questions (she acknowledged that this idea came from consumer advocate Jan Donovan)
- Developing a “medical watch” program along the lines of “media watch” which dispels common health care myths
- Removing MBS item numbers where there is evidence for low value care (as recommended by the Medicare Benefits Review Taskforce).
She also highlighted the need for more regulation and assistance to help doctors reduce unwarranted variations in practice.
“Clinical care standards are helpful to understand what care we should deliver and what patients should expect – I would like to see clinicians actively embracing the standards among their peers as best practice,” she said.
While acknowledging the important role that consumers play in addressing low value care, Buchbinder also emphasised that doctors are an important influence over consumers’ attitude to care options.
“Patient expectations largely come from us, that’s why they think we can fix everything and more is better,” she said.
Other participants provided their perspectives on this issue in the interactive sessions.
Dr Robyn Lindner, a program manager at NPS Medicinewise, highlighted the important role of Choosing Wisely in helping clinicians implement changes in their practice and engage consumers. She said this differentiates it from top-down quality improvement processes.
Dr Lisa Rasmussen from Mercy Health argued that nurse practitioners should play a much bigger role in addressing low value care and also emphasised the importance of centralised data.
GP Dr Fiona van Leeuwen reminded participants that when talking with patients about Choosing Wisely, it’s important to remember that you can’t choose something that you don’t know exists.
“Patients have been a neglected but powerful component of potential change – we can’t ask them to make decisions about their treatment if they don’t know what options exist,” she said.
Nicholas Elmitt, policy manager from the Australian Medical Association, commented that it is important to be careful about assuming it is a problem when doctors deviate from best practice guidelines. He cited research showing that consumers have a broader definition of the health system than providers.
Finally, Professor Wendy Levinson reminded participants to acknowledge the progress that has been made, while also taking responsibility for building on this success in the future.
“We didn’t talk about this 10 years ago but culture change takes time and we need to be patient,” she said.
“Overuse is not sustainable – after COVID, every health system in the world will be under pressure. Clinicians need to step up to make healthcare more sustainable.”
On Twitter check out the discussions: #CWANM22
Also follow this Twitter list of participants.