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 for Māori and other disadvantaged groups, and to help reduce health inequities.
Choosing Wisely is a global initiative that has been implemented in a number of countries, including USA, Canada, the UK, Australia and some of Europe.
The campaign aims to promote a culture where low value and inappropriate clinical interventions are avoided, and patients and health professionals have well-informed conversations around their treatment options, leading to better decisions and outcomes.
The Council of Medical Colleges (CMC) is facilitating this initiative in New Zealand as part of our commitment to improving the quality of care for all patients.
Choosing Wisely involves a number of professions including doctors, nurses, midwives, pharmacists and other professional groups. It also has strong consumer involvement, with two members of the Health Quality & Safety Commission’s consumer panel on its steering group.
The Health Quality Safety Commission and Consumer NZ are partners in the campaign and there is wide sector support from the New Zealand Medical Association, the Medical Council of New Zealand, Association of Salaried Medical Specialists, New Zealand Medical Students’ Association, Cochrane New Zealand, New Zealand College of Midwives and Pharmaceutical Society of New Zealand, Ko Awatea, Pharmac and Health Navigator Charitable Trust.
Many Medical Colleges and Specialty Societies in New Zealand have identified tests, treatments or procedures that may be unnecessary based on discussion with their members and based on the evidence.
Driving this culture change is a long-term programme of work involving multiple stakeholders, funders and sponsors. Current funders and sponsors of the Choosing Wisely campaign include Health Quality Safety Commission, Ministry of Health, PHARMAC, Pacific Radiology and the Council of Medical Colleges.
Choosing Wisely is not about saving money, although this may happen as a result of the campaign. It is about making sure New Zealanders receive the best and most appropriate care – based on evidence – and are not put at risk by having unnecessary tests, treatments and procedures. While savings of cost, time and resource within New Zealand’s healthcare systems are always worthwhile – it’s the personal outcomes for patients and their families that we are ultimately working to improve.
Just because a large number of medical tests, treatments and procedures are available, there’s not always a benefit in using them. Many studies indicate that scans can frequently identify things that require further investigation but turn out to be ‘false positives’. This means patients can undergo stressful and potentially risky follow-up tests and treatments for no reason.
Over-use of antibiotic treatments is associated with side effects like diarrhoea and thrush, and also builds antibiotic resistance in individuals and populations. Antibiotics do not help viral illnesses such as the common cold, sinusitis, pharyngitis and bronchitis, and should not be prescribed for these illnesses.
The use of a particular test, treatment or procedure needs to be discussed and decided with each patient, taking into account their condition, their experience of illness, social circumstances, attitude to risk, goals, values, preferences and support needs.
Procedures such as X-rays and CT scans can expose patients to potentially cancer-causing radiation – and ‘false positive’ results can lead to stressful and potentially risky follow-up tests and treatments for no reason.
A CT scan of a patient’s neck in trauma, for example, (often done with limited indications) has a 20 percent chance of creating an incidental finding that is unlikely to be a problem but can often lead to further investigation.
Society has developed an underlying belief that more is always better in medical treatment, but this is not always the case. We need to change professional and patient attitudes.
‘Choosing Wisely’ focuses on areas where evidence overwhelmingly shows that a test, treatment or procedure provides little or no benefit to a patient, and could even cause harm. These are not grey areas where the evidence is debatable.
Two key criteria that we ask health organisations and medical colleges to consider – when developing recommendations about tests etc that health professionals should question – are that the procedures and tests that they are questioning are used frequently, and also that there is evidence that they may expose patients to harm.
The Council of Medical Colleges worked with the Association of Salaried Medical Specialists and the New Zealand Medical Association to survey health professionals about this. The survey, which had 1318 responses, found:
• if a patient approached them requesting a specific test, procedure or treatment the professional deemed unnecessary, 77.1% of respondents said they would advise their patients against the test and not do it.
• 49.7% of respondents believe the provision of unnecessary tests, treatment and procedures is a serious or somewhat serious issue in their area of practice.
• when this question was expanded to ask about the New Zealand health sector as a whole, these numbers rose to 61.6%.
The CMC also worked with Consumer New Zealand to survey consumers on their sentiment around unnecessary tests, treatment and procedures. There were 1024 respondents.
When they visited a doctor, 56% of respondents generally expected the doctor to provide a prescription or send them for a test, 31% didn’t and 13% were unsure. 41% of these agreed some tests or treatments which are carried out do not benefit the patient in any meaningful way. Nearly one in five felt their doctor had recommended a test or treatment to them which wasn’t necessary.
Other findings from this group:
• 42% asked their doctor further questions about the test or treatment.
• 29% followed the doctor’s advice even though they thought the test or treatment wasn’t necessary.
• 20% ignored the advice but didn’t discuss it with their doctor.
The ‘Choose Wisely’ campaign encourages patients to talk with their health professional about tests, treatments and procedures being proposed. These messages are delivered in a range of channels to people seeking health treatment – online, or in medical practices – as well as through discussions with health professionals, public relations activity and the Choose Wisely website. Consumer NZ is also promoting patient information and resources.
Patients are encouraged to ask four questions – to help them ‘Choose Wisely’:
Do I really need to have this test/procedure?
What are the risks?
Are there simpler safer options?
What happens if I do nothing?
Doctors and other health professionals are encouraged to listen to what matters to patients and make joint decisions with them.
Medical Colleges, specialty societies and other groups in New Zealand are identifying tests, treatments and procedures that evidence shows may be of limited or no benefit to patients, or which may cause harm. They then work within their services to implement recommendations about the use of these tests etc and encourage conversations with patients.
This approach ensures that the list of recommendations has credibility with members of the particular specialty.
A survey of clinicians in the USA found that:
73 percent of physicians say the frequency of unnecessary tests and procedures is a very or somewhat serious problem
66 percent of physicians feel they have a great deal of responsibility to make sure their patients avoid unnecessary tests and procedures
70 percent of physicians say that after they speak with a patient about why a test or procedure is unnecessary, the patient often avoids it.
The common factors across countries that contribute to clinicians ordering unnecessary services include patient expectation, fear of missing a diagnosis or malpractice concerns, reimbursement incentives, the way clinicians are taught and avoiding the challenge of telling a patient they do not need specific tests.
Availability of appropriate care is a problem especially in some areas and for some groups of people. Choosing Wisely has the potential to free up resources by reducing the use of unnecessary tests, treatments and procedures.
CMC is currently surveying doctors to learn more about their attitudes – but previous research shows the common factors across countries that contribute to clinicians ordering unnecessary services include patient expectation, fear of missing a diagnosis or malpractice concerns, reimbursement incentives, the way clinicians are taught and avoiding the challenge of telling patients they do not need specific tests.
The New Zealand Medical Students’ Association has developed a list of recommendations which they encourage all medical students to consider.
Doctors are trained in diagnosis. They use tests, interventions and procedures to aid decision making. But they also need to ensure they are aware of the evidence about the use of these interventions. Some doctors have become over-reliant on tests and some patients may doubt what their doctor says unless tests have been done.
Health professionals should also talk with their patients about the care that is being recommended and share decision making with them, listen to the patient about their own experience of illness, social circumstances, attitude to risk, goals, values, preferences and support needs.
The ‘Choose Wisely’ campaign is not suggesting tests, treatments and procedures be stopped, but that the use of some should be reviewed with more careful consideration of what the particular patient needs and the evidence of effectiveness.
Most of the recommendations depend on the situation and what the patient’s condition or illness is. We’re not advising ‘never‘ to test – just not to test under certain clear circumstances.
It is ultimately up to the health professional and patient to make a choice together. Our aim is to make that choice as informed as possible, by encouraging open dialogue between the patient and health professional.
Currently ‘Choosing Wisely’ has funding and sponsorship from:
Council of Medical Colleges
Ministry of Health
Health Quality Safety Commission
Southern Cross Health Society
There has also been support in various forms from many health sector groups and assistance from all New Zealand medical colleges.