Introduction by Croakey: Low-value healthcare is defined as that which “provides little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost”.
A cohort study using NSW public hospital admission records recently sought to quantify at least some of the harms associated with seven types of low-value care. Researchers examined 16 types of hospital-acquired complications associated with 9,330 episodes of care across 225 hospitals during the three years from mid 2014.
For most procedures, the most common such complication was a health care-associated infection, which accounted for 26 percent of all complications observed and was associated with an increased length of time in hospital.
“Use of these seven low-value procedures is harming patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate,” the researchers reported in JAMA Internal Medicine (25 February).
“The full burden of low-value care for patients and the health system is yet to be quantified.”
It is timely, then, to hear from Steve Morris, Chief Executive Officer of NPS MedicineWise, about the latest Choosing Wisely Australia report investigating some of the drivers of unnecessary healthcare – as well as detailing some of the work tackling this problem.
Steve Morris writes:
Drivers of unnecessary healthcare are complex, with a new report from NPS MedicineWise revealing some of the key reasons GPs, specialists and health services request unnecessary tests, treatments or procedures.
These reasons aren’t overly surprising, but are fundamental to understand in the national effort to reduce unnecessary healthcare practices through the Choosing Wisely Australia initiative.
The 2018 Choosing Wisely Australia Report: Conversations for change also offers perspectives from healthcare providers, consumer health organisations and researchers on how Choosing Wisely helps address the overuse of medical tests and overdiagnosis of health conditions in Australia.
For the first time, survey findings from individual health services implementing the initiative have been published. The drivers behind unnecessary healthcare are the same common reasons as reported by GPs and specialists.
One reason relates to the complexities in accessing patient information across healthcare sites – between GPs, specialists and hospital staff – as patients move throughout the health system.
Survey findings show 54 percent of GPs, 61 percent of specialists and 36 percent of health services last year cited difficulties accessing information from clinicians in other settings, including results, as a key reason for requesting unnecessary healthcare.
Beyond the quick fix
There is no doubt improving communication across different care settings and empowering consumers to be active partners in their healthcare can help overcome barriers to optimal care.
There is no one quick fix, but the introduction of digital health records, improving communications to clinicians at hospital discharge, and patients keeping their own histories of medications and test results, are measures aimed at addressing this challenge.
Other common factors driving unnecessary or low-value healthcare included perceptions of patient expectations, the potential for medical litigation and uncertainty of diagnosis.
However, there is an interesting disconnect in the narrative about patient expectations, with people reporting they had unnecessary tests after a recommendation from their GP. To bridge this divide, Choosing Wisely Australia works with its members and supporters to increase awareness of why unnecessary healthcare occurs so we can collectively overcome barriers to change.
The cornerstone of the Choosing Wisely movement, now operating in more than 20 countries, is improving conversations between health professionals and consumers about available and appropriate health management options.
Patients are encouraged to have better conversations with their healthcare professionals about the options available to them, but most importantly whether those options are necessary or appropriate. The aim is to highlight the risks and benefits of tests, treatments and procedures to patients by encouraging them to ask questions before agreeing on a recommended course of action.
Meanwhile, healthcare professional colleges, societies and associations are developing evidence-based recommendations on tests, treatments and procedures that should be questioned by clinicians and consumers, with a total of 189 recommendations released by Choosing Wisely since launch. Twenty-six of these were released in 2018 and included advice on complementary medicines, knee arthroscopies and antibiotics for asthma.
NPS MedicineWise is also embedding relevant Choosing Wisely recommendations into its national educational visiting programs for general practice.
Our ankle and knee program to promote best practice in diagnosis and treatment of acute ankle and knee injuries was the first visiting program to include Choosing Wisely Australia recommendations. More than 7000 GPs participated in the visits, with 26 percent reporting increased application of a Choosing Wisely recommendation following the visit.
A low back pain program released in October 2018 harnesses a range of advice from Choosing Wisely members such as The Royal Australian and New Zealand College of Radiologists and the Australian Physiotherapy Association. This type of national educational outreach enables Choosing Wisely recommendations to be embedded into general practice, with NPS MedicineWise conducting close to 30,000 face-to-face educational visits in 2017-18.
Growing momentum
The Choosing Wisely Australia initiative has moved well beyond its initial foundation of six medical colleges and two national consumer health organisations, to a network of 69 official members and supporters.
We have seen significant growth among health services, with 25 now championing Choosing Wisely in their hospitals—some are even embedding the initiative into operational frameworks.
In addition, Better Care Victoria has funded a Choosing Wisely Scaling Collaboration for 11 health services, based on the successful implementation model developed by Austin Health and in partnership with NPS MedicineWise. This project is the first to be funded by a State Government and has other states and territories watching with interest.
Researchers at the University of Technology Sydney are exploring the relationship between low-value care and medico-legal drivers.
With fear of litigation a real concern for healthcare professionals, the two-year project funded by the Avant Foundation will consider defensive medical practices and work towards an educational intervention to promote communication and decision-making strategies for high-value care.
So, this is truly a transformative time for Choosing Wisely Australia as we continue to work closely with the healthcare profession and wider community to address low-value and unnecessary healthcare.
We are embracing new opportunities, including in research, education and advocacy, to broaden the national conversation and ultimately improve the quality and safety of our healthcare system.
• Steve Morris is Chief Executive Officer of NPS MedicineWise. For further reading, see the Croakey Conference News Service report from the 2018 Choosing Wisely Australia National Meeting.
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