Equity considerations for Choosing Wisely in New Zealand

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.  Given the marked inequities in health in New Zealand, important parallel campaign objectives should be to avoid making these inequities worse, and to help reduce health inequities.  We know that new health care interventions or campaigns have the tendency to widen inequities, as they are taken up first by those in society with the most resources and the least need.

So how can we ensure that Choosing Wisely does not fall into this trap?

Partnership with Māori in governance and design of the campaign is essential, as well as monitoring for equity in the evaluation of programme impacts. In addition, there are a number of specific considerations relevant to the Choosing Wisely campaign when it comes to ensuring health inequities are reduced and not worsened:

  1. Inadequate access to health care is a significant driver of health inequities. Even within health care services, there is evidence that for certain conditions Māori receive less tests, fewer prescriptions and less treatment.   The Choosing Wisely campaign needs to make sure that messages to health professionals to reduce unnecessary care and that “more is not necessarily better” do not further exacerbate inequitable under-treatment for Māori.
  2. Just because certain groups don’t get enough care for some things doesn’t mean they also don’t get too much of the wrong things – there is some overseas evidence that disadvantaged groups experience double burden of undertreatment and overtreatment[i]. We need New Zealand research to understand how the issue of low-value and inappropriate care affects different ethnic and social groups.
  3. Some Choosing Wisely recommendations designed for the majority population may exacerbate health inequities for certain groups. For example, a recommendation not to prescribe antibiotics for acute upper respiratory tract infections[ii], may sound reasonable given the majority of URTIs are viral and antimicrobial resistance is a rising concern.  However, for Māori and Pacific children in New Zealand, who experience high rates of rheumatic fever, sore throats should be swabbed and treated with antibiotics presumptively until swab results are available[iii].  Colleges in New Zealand need to take equity into account when developing lists of Choosing Wisely recommendations, and be very clear when communicating where recommendations should not be applied for all population groups.
  4. Choosing Wisely depends on shared decision making, which requires good communication and understanding between health professionals and patients. Health professionals need a high degree of cultural competence to ensure they are able to impart the right information and elicit a patient’s values and preferences.  Choosing Wisely patient resources need to be informed by the views and needs of Māori and other disadvantaged groups, and this needs to be supported by efforts to improve the cultural competence of health professionals in New Zealand.

[i] Schpero, W et al. “For Selected Services, Blacks And Hispanics More Likely To Receive Low-Value Care Than Whites.” Health affairs 36.6 (2017): 1065–1069. PMC. Web. 15 July 2018.

[ii] http://choosingwisely.org.nz/professional-resource/asid/

[iii] http://www.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/sore-throat-algorithm.pdf