Choosing Wisely Australia: changing behaviour in health care

Challenging the notion that “more is better” in our health care system

The key to addressing low value care in Australia’s health care system is reducing unnecessary tests, treatment and procedures. With consumer demand reported as a main driver of unnecessary tests and treatments,1 Choosing Wisely Australia encourages health care providers to have conversations with patients around the necessity for and risks of certain health care practices.

A growing international movement

Launched in the United States in 2012, Choosing Wisely is a global social movement working to improve the quality and safety of health care. Australia — where NPS MedicineWise implemented it in April 2015 — is one of 20 countries that have adopted the initiative.

Choosing Wisely is a clinician-led initiative that engages medical colleges, societies and associations to identify tests, treatments and procedures that, according to the available evidence, may be unnecessary or harmful. It also provides consumers with trustworthy information to raise awareness of unnecessary interventions and encourage better conversations with their health professionals. Thirty-two organisations, including 80% of medical colleges, have joined Choosing Wisely Australia, with 158 published recommendations that cover themes such as imaging, medicines, pathology, and end-of-life care.

Bridging the great divide

While Australians say they understand the importance of reducing unnecessary medical testing, the Choosing Wisely in Australia, 2017 report1 revealed contradictory attitudes among consumers around tests and the need for better conversations between consumers and health care professionals around their options. Sixty-one per cent of people agreed they should play role in reducing unnecessary care; however, 61% indicated that if they were sick, their doctor should conduct all available medical tests related to their condition.1

Health professionals need to play a leading role to reduce unnecessary health care, with ineffective interventions accounting for a considerable proportion of health care costs.2 There is a disconnect around unnecessary testing: according to the report, 62% of general practitioners and 42% of specialists cite patient expectations as a driver of unnecessary tests, treatments and procedures, whereas 84% of consumers said they had tests at their health care provider’s recommendation.1

Surveys with Australian GPs and medical specialists expose the drivers of low value care. Patient expectations were the most common reason for GPs to use unnecessary tests, and the third most commonly cited reason for specialists (Box 1). In general, patients overestimate the benefits of medical interventions and underestimate the harms. Without accurate expectations of benefits and harms by clinicians, patients may not have the right assistance to make informed decisions.3

A recent study on the cognitive biases that may influence a clinician’s decision towards a low value intervention highlighted shared decision making between clinicians and patients as a good countermeasure.4 It suggested familiarising patients with the available options to manage their condition, including advantages and disadvantages, and exploring their preferences to inform final decisions. This approach provides a means for declining patients’ requests for low value interventions without losing their trust.

Supporting implementation

Choosing Wisely is reaching clinicians through the work of medical colleges, societies and associations, for example:

• the Royal Australian and New Zealand College of Radiologists has developed clinical decision rules and online modules to assist in determining when imaging is truly needed;

• the Royal Australian College of General Practitioners promotes its recommendations through member newsletters and its Red Book Guidelines for preventive activities; and

• the Royal Australasian College of Physicians, in conjunction with specialty societies, has released “top five” lists through Choosing Wisely and the EVOLVE program (https://evolve.edu.au), which are promoted among its membership. The Royal Australasian College of Physicians Congress 2017 discussed techniques to manage the concerns patients might have about not having a procedure or not receiving a prescription. It also modelled the ways clinicians may promote the delivery of high value care and improve interactions between junior and senior doctors.

Growing movement among health services

The 2017 Choosing Wisely Australia National Meeting showcased health service programs to reduce patient exposure to unnecessary tests. For example, Gold Coast Health has developed demand-management strategies to improve pathology ordering patterns — an online dashboard is supporting clinical monitoring and auditing of pathology-ordering practices, with the ultimate goal of improving patient safety and experience while providing high quality care. Over 15 months, a multidisciplinary collaboration saw a 2% drop in the number of unnecessary pathology tests ordered — from an average of 96 000 a month to 93 500 — despite a 10% increase in patient activity. The health service reported that clinicians were making wiser choices as a result of seeing the data on pathology orders first-hand.5

Measuring impact and outcomes

An evaluation of the initiative requires a multifaceted approach, including process indicators, short and intermediate term impacts and long term outcomes (Box 2). Choosing Wisely Australia’s first 2 years have shown significant engagement by health professionals, organisations and services, with early results highlighting the potential of this initiative to significantly change the mindsets and behaviours of health professionals and consumers to successfully challenge the notion that “more is better” in managing health.