Barriers to reforming low-value care

In their article in the MJA discussing low-value care, Scott and Duckett noted that “some physicians are establishing programs in their areas of practice that identify and remove low-value care”.1

However, a major barrier to reforming low-value care is that we have a rigid and only slowly moving mechanism for funding new initiatives, which prevents us from implementing new evidence-based care pathways.

An example with which I am well acquainted is low-value colonoscopy, performed in people who are extremely unlikely to have relevant colonic pathology, because patients, general practitioners and specialists fear missed pathology. We know that most young people with gastrointestinal symptoms without alarm features will have a normal colonoscopy2 and do not need this costly and invasive test to diagnose irritable bowel syndrome. We also know from data now widely published and endorsed by the National Institute for Health and Care Excellence in the United Kingdom (https://www.nice.org.uk/guidance/dg11) that using faecal calprotectin to screen this group would better target colonoscopy resources, as it has a high negative predictive value for organic disease and thus provides great reassurance to patients and doctors that colonoscopy is not required.

Yet, despite this and the huge number of colonoscopies performed annually, we do not yet have access to faecal calprotectin testing on the Medicare Benefits Schedule, with the submission on this matter having now been under consideration for over four years (the initial Medical Services Advisory Committee discussion occurred in August 2011). If physicians are being entreated to fix the system, we need our regulatory agencies to partner us in this by being sufficiently nimble to assess the tools we need to drive these changes proactively and promptly.