The recent Choosing Wisely Australia National Meeting in Melbourne heard from clinicians and others at the forefront of efforts to reduce low value care.
Marie McInerney writes:
“Why do we do the things we do?”
This question was recently put to a high level group of clinicians, researchers and facilitators from Queensland Health at a meeting seeking to develop an action plan for reducing low value care in Queensland’s public hospitals.
“(It’s) the way we do things” was one of the responses selected by nearly 40 percent of respondents.
This was by far and away the most common reason given, with ‘funding and incentives’ nominated by nine percent, and ‘patient expectations/understanding’ by just six percent.
For Associate Professor Ian Scott, who asked the question and presented these results at the recent Choosing Wisely meeting in Melbourne, this revelation prompted the need for a new combined social and cognitive approach to changing clinician behaviour to reduce unnecessary and sometimes harmful tests and treatments.
Scott, who is Director of Internal Medicine and Clinical Epidemiology at the Princess Alexandra Hospital in Brisbane, said there was a need to move beyond sole reliance on traditional knowledge translation strategies like clinical guidelines, education outreach, and audits, which represent “pretty small beer” in terms of practice change.
Instead, he suggested looking at interventions like “cognitive huddles” (getting together in clinical teams to tease out assumptions and “unlearn” low value care habits) and the “normalisation of deviance” (being prepared to question cognitive biases and challenge the status quo).
Scott’s approach is leading to the introduction of a modular critical thinking skills course in the Princess Alexandra’s medical undergraduate studies to acquaint student doctors with “the psychology of how we think and (about) biases that can affect our thinking simply because we’re humans and we’re as fallible as anyone else”, he said.
It may prove to be another spoke in the wheel for the Choosing Wisely initiative, which – having captured the imagination and effort of many medical colleges, health services and hospitals across Australia – is now looking to gain system-wide traction.
After four years, Choosing Wisely is setting its sights on how to shift from a range of single projects and interventions at a local level into being an ethos and a movement – embedded in systems, powered by champions, and self-sustaining (or at least internally funded, as a key Victorian central health agency chair made clear).
A key part of that mission involves bringing together many of those champions at a national conference each year, to showcase success and dismantle or at least dissect hurdles.
The recent third annual meeting did that again, showcasing the first state-wide scale-up of Choosing Wisely in Victoria, launching a new toolkit to fire up consumers, and raising questions about climate change and why GPs and the broader primary care system have been slower than hospitals (and GPs in the UK) to get on board.
Professor Trish Greenhalgh, an international expert in complex systems change who was keynote speaker at the meeting, was particularly impressed by Scott’s presentation.
“There’s so much wisdom in this, this is really great stuff,” she said, urging him to publish.
Drivers of low value care
Scott told the meeting he had observed two main drivers of low value care.
One is where ingrained practices from medical school training or early years as a junior doctor are perpetuated as a belief, habit or “ritual”, despite having been found to be outmoded, ineffective or even harmful.
The other is decisions that, in one context can be adaptive, but “become maladaptive” in other contexts, like:
- commission bias – a tendency to do something or seen to do something even if it’s not supported by robust evidence and may do harm
- impact bias – that over-estimates benefits and underestimates harms of intervention
- extrapolation bias – that assumes effects seen in one group of patients will be automatically replicated among a wider spectrum of patients and
- pro-innovation bias – a tendency to see “bright new shiny” tests and treatments as automatically better than old ones.
The meeting also was told of findings from St Vincent’s Hospital in Melbourne of three key drivers for unnecessary testing: a culture of having always done things that way in the unit, a fear of missing clinical deterioration, and no standard or decision making support tool to guide clinical decision making.
Scott’s proposal is for a process that brings together clinicians who operate at the frontline – the hospital unit, medical department, or general practice “microsystem” – and engages all the key stakeholders, not only doctors, but also pharmacists, allied health, nurses and patients.
The process then looks to have a “credible messenger” raise a low value care problem, encourage everyone to dissect their own decision-making “rationales” when confronted with powerful patient stories and data about waste and outcomes, and then for “ownership of the problem and how to address it to pass to the whole group, not just the messenger”.
“In our department we have ‘clinical conundrum sessions’ where we talk about these questions in a non-judgmental fashion and develop departmental policy around things we will no longer do,” Scott told the meeting.
“(It’s) to try to get people to think and reflect about their own thinking, what drives them to do the things they do and to see ‘okay, perhaps I need to understand that what I once believed is no longer valid’,” he said.
An issue of concern often raised is that Choosing Wisely is unable to pull systemic levers, such as fee-for-service funding that can drive clinician behaviour.
Systemic issues were raised also by conference MC Craig Reucassel, from the ABC’s hit series War on Waste, who said the shift in plastic shopping bag consumption and culture in Australia had come, not through greater awareness, but due to a price signal of having to pay for a bag.
Scott said there is no doubt that health system levers influence behaviour, through financial incentives, guidelines and performance standards, but he thinks we “tend to overrate” their influence on individual decision making, which is more about “belief systems”.
Watch this interview with Associate Professor Ian Scott.
Tackling opioid prescribing
The power of “unlearning” was another strong theme at the conference, including from Associate Professor Matthew Anstey, an intensive care specialist at Sir Charles Gairdner Hospital in Perth and a Choosing Wisely champion, who talked about the need to change patterns of prescribing opioids on discharge from hospital.
Anstey still has a vivid memory from intensive care training in Melbourne of an 18-year-old patient who fractured his ankle while playing basketball. The orthopaedic surgeon put a screw in his ankle, and the young man was discharged the next day with oxycodone.
“As an 18-year-old might do, he went out to a party, had a misadventure with that box of oxycodone and some alcohol, and had a respiratory arrest,” Anstey remembered.
“He basically left the ICU a month later in a persistent coma, which is probably the worst outcome he could have thought to have.”
Anstey and his team recently researched opioid prescribing patterns, and investigated practices at Sir Charles Gairdner with a survey of nearly 100 patients from the orthopaedics, general surgery and medical wards.
While they found some appropriate patterns and protocols, including specialist input from the hospital’s pain service and prescriptions of simple analgesics, there were some problems.
The main concerns were that almost half of the patients were discharged with opioids even though they hadn’t been given any on the day before leaving, only 16 per cent got a tailored volume – the rest just got the standard PBS boxes of 20 oxycodone tablets or 56 pregabalin tablets – and fewer than one in four had a “weaning plan”.
It’s a big worry, Anstey said, given that opioid medicine deaths in Australia exceed heroin deaths by a significant margin.
The hospital is changing its practices. Doctors are now required to develop a weaning plan, and to give an expected timeline for recovery, and the team is surveying patients to find out how many tablets they took after discharge to try to come up with recommended baseline volumes.
Anstey said there have already been quick unexpected benefits. His team reported back to one medical department that their prescribing patterns did not fit with standard analgesia guidelines. At a follow up audit, there was a significant reduction in the prescription of opioids on discharge.
Anstey said: “An amazing amount of information can be fed back that changes people’s behaviour because people want to change, they don’t want to do the wrong thing.”
Choosing lower greenhouse gas emissions?
Climate change is not explicitly on the agenda for Choosing Wisely, despite research showing that healthcare contributes to seven percent of Australia’s greenhouse gas emissions, with most caused by hospitals and pharmaceuticals, whose production, packaging and distribution are carbon intensive.
However, that may shift with Victoria’s Health and Human Services Department funding work to look at the environmental sustainability of Choosing Wisely initiatives at the Austin Hospital in Melbourne.
Dr Simon Judkins, who is based at the Austin Hospital and is president of the Australasian College for Emergency Medicine (ACEM), said the work is looking at how reductions in tests affect the hospital’s carbon footprint.
“We know every time you order a urine sample, it goes up in a plastic container, goes up in a plastic bag,” he said. “If we can reduce the inappropriate tests and only do the ones that are necessary, we’re going to see a significant impact on our carbon footprint.”
Judkins also pointed to work being done at Western Health, another Choosing Wisely partner, led by anaesthetist Dr Forbes McGain that is looking to save 140 tonnes of carbon dioxide emissions per year – the equivalent to taking 40 Australian cars off the road – after switching the types of gas they use during procedures.
These sorts of measures to reduce low value care and the impact on the environment are another way of engaging a broader scope of clinicians in the Choosing Wisely initiative, he said.
“I think (climate change) does need to be on the agenda of Choosing Wisely…I think it has to be on the agenda of all health organisations,” he said.
Watch these interviews
Dr Simon Judkins and Safer Care Victoria manager Camilla Radia-George :
Judkins and ACEM president elect Dr John Bonning from New Zealand about Choosing Wisely opportunities and barriers (including pharmaceuticals and tribalism) in both countries:
The Austin Hospital’s early involvement in Choosing Wisely may soon lead to a nationwide scale-up of the initiative based on insights from a year-long Safer Care Victoria scaling collaboration of the initiative in 11 health services across the state.
Associate Professor Steve Morris, CEO of NPS MedicineWise, which facilitates Choosing Wisely, told the meeting that Victoria was the first state to fund the expansion of Choosing Wisely Australia across its hospital network and others were watching with interest.
The Victorian roll out is being independently evaluated, with full results expected by September 2019. In the interim, it has released a new toolkit showcasing case studies and resources.
Watch the interview below, where NPS MedicineWise CEO Steve Morris speaks about the day’s highlights and what is on Choosing Wisely’s agenda to come.
Better Care Victoria
Leading a presentation of the collaboration’s work at the Choosing Wisely meeting, Better Care Victoria Chair Dr Doug Travis warned that change is hard and labour intensive.
“It’s not about a manual, a memo or edict, it’s about conversations, facts, evidence, hard work, forgiveness and repetition,” he said.
From Better Care Victoria’s point of view as a centralised agency, it was also about a new way of doing business, not just about “awarding grants and posting out a cheque”.
Instead, it’s taken a very proactive response to the collaboration, sending project officers out to the sites with multifaceted behaviour change strategies, toolkits and workshops, education and guidelines and, where applicable, changes to electronic ordering systems.
This was, Travis said, a message to government that “change costs money”.
But he also had a warning to the “senior people in the room” that sustained action has to come from within, and that the first round of funding for the Victorian collaboration “was to demonstrate to you that it works”.
It’s good for the patients, your staff love doing it, it’s a no brainer, so do the hard yards.
The only way to sustain this process is to embed a low value care evaluation process within a funded, encouraged and supported framework within your institutions.”
In a number of presentations, collaboration members talked about trying to address some of the risks of “erosion over time” of Choosing Wisely initiatives, particularly of how to sustain momentum if there is no longer a dedicated project officer.
For Western Health, a successful strategy was getting the service’s communications team involved, and putting out some effective messages like these below:
For St Vincent’s Melbourne, it was a combination of executive support, senior medical engagement, and strong results to date.
There was much more detailed advice on opportunities and challenges, including some insights from a high profile panel discussion.
- Executive buy-in and the support and engagement of the Board is critical (Dr Paul Eleftheriou, Chief Medical Officer, Western Health), particularly when dealing with groups that might be seen as “resistant” – “seeing me there flying the flag is critical, the staff needs to know we are putting our money where our mouth is”.
- However, talking about “overcoming resistance” may not be useful with those who are not yet converts to the cause, because it can imply they are “stubborn and stupid”, when they are being asked to stop doing something that they currently believe is excellent care (Professor Trish Greenhalgh).
- Greenhalgh also advised that she didn’t think the failure of a Chief Executive to engage has to be a show stopper as long as they are not actively sabotaging. “If you can stay under the radar you can get a lot done without a CE’s backing.”
MC Craig Reucassel raised a big question about why consumers or patients should be expected to have to ask Choosing Wisely’s 5 Questions to challenge health professionals on whether tests or treatments are necessary.
“You’re the ones with the degrees and genius, what have we got to do with it?” he asked.
Greenhalgh agreed, saying there was an important power dynamic involved, and that health professionals had a responsibility also to be their patients’ advocates, particularly when they were very unwell.
“When you’re very sick, you want to hand over your care to the doctor or nurse,” she said.
But she said there is no doubt from the evidence that involvement of patients in the health system, to the extent that they are able and wish, improves outcomes.
Jan Donovan, from the Consumers Health Forum of Australia, which partnered with Choosing Wisely to release this Conversation Starter Kit at the meeting, agreed about the importance of shared decision making which had been well documented in the UK.
“It found that people’s expectations about their treatment is much more realistic, the options they choose fit their values, it reduces unnecessary tests and treatments, and also reduces GP visits and hospital admissions. This is the key to transforming our system.”
And finally, here is news about award winning research by PhD student Dr Jonathan Kaufman that has produced a simple, gentle way of collecting infant urine samples. It won best student abstract submission at the meeting.
Ian Scott’s presentationOther presentations
Posters and selfies
For the period of our coverage of the conference (29 May – 9 June), 323 Twitter accounts sent 1,029 tweets using the conference hashtag, creating 6.8 million Twitter impressions, according to Symplur analytics.
Read the Twitter transcript here.
See a playlist of six video interviews with speakers and participants; three of these were broadcast live via the Periscope app, where they had a total of 911 views.
Marie McInerney covered #OkToAsk2019 for the Croakey Conference News Service. Bookmark this link for her stories.