61 recommendations for Choosing Wisely Australia

choosing wisely 61 recommendationsSparking conversations between patients and clinicians about what care and management is truly necessary for specific conditions is the goal of the Choosing Wisely Australia initiative. The campaign has released 61 recommendations of tests, treatments and procedures that may not be necessary and could cause harm to Australian patients as the global healthcare initiative continues to expand and gain momentum in Australia.

Want to know more about the initiative outside of your own scope of practice? The 61 recommendations are listed below.

Australasian College for Emergency Medicine (ACEM)

  1. Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
  2. Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication
  3. Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture
  4. For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
  5. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
  6. Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule

The ACEM has made a number of recommendations as part of its involvement in the Choosing Wisely Australia campaign, including regarding use of CT imaging in cases of minor head injury. “It’s important that patients are seen as active participants in their own healthcare process,” said Dr Anthony Cross, President, Australasian College for Emergency Medicine, “Patients in the ED should feel able to question a doctor or healthcare professional about a procedure, and ask if there are alternatives.”

Australasian Society for Infectious Diseases (ASID)

  1. Do not use antibiotics in asymptomatic bacteriuria
  2. Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection
  3. Avoid prescribing antibiotics for upper respiratory tract infection
  4. Do not investigate or treat for faecal pathogens in the absence of diarrhoea or other gastro-intestinal symptoms
  5. In a patient with fatigue, avoid performing multiple serological investigations, without a clinical indication or relevant epidemiology

Australasian Society of Clinical Immunology & Allergy (ASCIA)

  1. Don’t use antihistamines to treat anaphylaxis – prompt administration of adrenaline is the only treatment for anaphylaxis
  2. Alternative/unorthodox methods should not be used for allergy testing or treatment.
  3. Allergen immunotherapy should not yet be used for routine treatment of food allergy – research in this area is ongoing
  4. Food-specific IgE testing should not be performed without a clinical history suggestive of potential IgE-mediated food allergy
  5. Don’t delay introduction of solid/complementary foods to infants – ASCIA Infant Feeding Advice recommends early introduction of solid foods to infants, from 4-6 months old

The ASCIA has been concerned for some time that in the area of allergy and immunology there are tests and treatments where there is little or no evidence to support them. Dr David Gillis, of the ASCIA, said, “We are very excited about Choosing Wisely Australia because it is one of the first initiatives of its kind to have strong consumer engagement. It gives us the ability to inform consumers. Educated consumers who make informed choices make our job a great deal easier.”

Australian and New Zealand Intensive Care Society (ANZICS)

  1. For patients with limited life expectancy, ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families
  2. Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible
  3. Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity
  4. Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication
  5. Consider antibiotic de-escalation daily

Australian and New Zealand Society of Palliative Medicine & the Australasian Chapter of Palliative Medicine (ANZSPM)

  1. Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment
  2. Do not delay conversations around prognosis, wishes, values and end of life planning (including advance care planning) in patients with advanced disease
  3. Do not use oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety or routinely use oxygen therapy at the end of life
  4. Do not use percutaneous feeding tubes in patients with advanced dementia; instead use oral assisted feeding
  5. To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review

Australian College of Nursing (ACN)

  1. Don’t replace peripheral intravenous catheter unless clinically indicated
  2. Don’t restrict the ability of people with diabetes to self-manage blood glucose monitoring unless there is a clinical indication to do so
  3. Don’t routinely administer antipyretics with the sole aim of reducing body temperature in un-distressed children
  4. Don’t use urinary catheters to manage urinary incontinence unless all other appropriate options have proved to be ineffective or to prevent wound infection or skin breakdown
  5. Don’t initiate plain X-ray for foot and ankle trauma unless criteria of the Ottawa Ankle Rules are met

College of Intensive Care Medicine of Australia and New Zealand (CICM)

  1. For patients with limited life expectancy, ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families
  2. Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible
  3. Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity
  4. Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication
  5. Consider antibiotic de-escalation daily

Haematology Society of Australia and New Zealand (HSANZ)

  1. Do not conduct thrombophilia testing in adult patients under the age of 50 years unless the first episode of venous thromboembolism (VTE):
    –   occurs in the absence of a major transient risk factors (surgery, trauma, immobility), or
    –   occurs in the absence of oestrogen-provocation, or
    –   occurs at an unusual site
  2. Limit surveillance computed tomography (CT) scans in asymptomatic patients with confirmed complete remission following curative intent treatment for aggressive lymphoma – except for patients on a clinical trial
  3. Do not extend anticoagulation beyond 3 months for a patient with a non-extensive, index venous thromboembolic event (VTE), which occurred in the setting of a major, transient risk factor
  4. Do not perform baseline or routine surveillance CT scans or bone marrow biopsy in patients with asymptomatic early stage chronic lymphocytic leukaemia (CLL)
  5. Do not treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a platelet count <30,000/L without risk factors for bleeding

Royal Australasian College of Surgeons (RACS)

  1. Don’t perform repair of minimally symptomatic or asymptomatic inguinal hernias without careful consideration, particularly in patients who have significant co-morbidities
  2. Do not use ultrasound for the further investigation of clinically apparent groin hernias. Ultrasound should not be used as a justification for repair of hernias that are not clinically apparent
  3. Don’t transfuse more units of blood than absolutely necessary, noting that many hospitals have developed policies on indications for transfusion with a view to minimisation
  4. Do not use endoscopy for investigation in gastric band patients with symptoms of reflux
  5. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children and young adults until after ultrasound has been considered as an option

Australasian College of Dermatologists (ACD)

  1. Do not assume that bilateral redness and swelling of both lower legs is due to infection. Do not prescribe antibiotics unless there is clinical evidence of sepsis or microbiological confirmation of infection
  2. Do not routinely prescribe antibiotics for inflamed epidermal cysts of the skin evaluated in the first 3-4 days of appearance unless infection is confirmed microbiologically
  3. Do not investigate episodes of acute urticaria of less than 6 weeks duration unless the clinical history or examination reveals a likely infective, inflammatory or neoplastic trigger or swelling and skin changes persist longer than 24 hrs
  4. Do not prescribe topical or systemic anti-fungal medication for patients with thickened, distorted toenails unless microbiological confirmation of a dermatophyte infection has been obtained
  5. Monotherapy for acne with either topical or systemic antibiotics should be avoided. Combine with topical antiseptics such as benzoyl peroxide to reduce antibiotic resistance

President of the ACD, Associate Professor Chris Baker, said regarding new dermatology recommendations on antibiotics, “Antibiotic resistance – when bacteria change so antibiotics are no longer effective and may not be useful to treat infections in the future – is a major issue in healthcare and has consequences worldwide. We found that, when identifying examples of unnecessary treatments in the dermatology area, antibiotics came up a few times and, as a result, we are outlining new guidelines.”

Australian Physiotherapy Association (APA)

  1. Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain
  2. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule
  3. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules)
  4. Don’t routinely use incentive spirometry after upper abdominal and cardiac surgery
  5. Avoid using electrotherapy modalities in the management of patients with low back pain
  6. Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder

The APA stated that their recommendations are not prescriptive. Instead, they should help to start a conversation about what is appropriate and necessary. As each situation is unique, clinicians and consumers should use the recommendations to collaboratively formulate their own appropriate healthcare plan together.

Endocrine Society of Australia (ESA)

  1. Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland
  2. Don’t prescribe testosterone therapy unless there is evidence of proven testosterone deficiency
  3. Do not measure insulin concentration in the fasting state or during an oral glucose tolerance test to assess insulin sensitivity
  4. Avoid multiple daily glucose self-monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycaemia
  5. Don’t order a total or free T3 level when assessing thyroxine dose in hypothyroid patients

Royal Australian & New Zealand College of Ophthalmologists (RANZCO)

  1. In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated
  2. AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease
  3. Don’t prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery
  4. Intravitreal injections may be safely performed on an outpatient basis. Don’t perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication
  5. In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit

Royal Australian and New Zealand College of Radiologists (RANZCR)

  1. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules)
  2. Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive
  3. Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging
  4. Don’t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
  5. Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule
  6. Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule

Dean of the Faculty of Clinical Radiology, Dr Greg Slater, said that the six items on RANZCR list are commonly used tests that are not always necessary for every patient. Dr Slater said, “We have drawn on an extensive evidence base in compiling this list so patients and health practitioners can be assured that it represents best clinical practice. While imaging can be a great resource for patients, it should be used within the clinical decision making rules so it is always appropriate and accountable.”

Royal Australian College of General Practitioners (RACGP) List 1

  1. Don’t use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
  2. Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
  3. Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
  4. Don’t screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
  5. Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use

Royal Australian College of General Practitioners (RACGP) List 2

  1. Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead
  2. Don’t order chest x-rays in patients with uncomplicated acute bronchitis
  3. Don’t routinely do a pelvic examination with a Pap smear
  4. Don’t treat otitis media with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option
  5. Don’t test thyroid function as population screening for asymptomatic patients

The top five list includes recommendations created by RACGP are aimed at encouraging GPs and their patients to think about and discuss medical tests, treatments and procedures where evidence shows they provide no overall benefit and, in some cases, may lead to harm. RACGP President Dr Frank R Jones, said, “Providing patients with information is the key to helping them understand that more tests and treatments is not always better. When patients understand the issues, they’re more likely to have the confidence to speak up and let their GP know they aren’t necessarily expecting or wanting a particular intervention unless it’s really needed.”

Royal College of Pathologists of Australasia (RCPA) 

  1. Do not perform surveillance urine cultures or treat bacteriuria in elderly patients in the absence of symptoms or signs of infection.
  2. Do not perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years.
  3. Do not perform population based screening for Vitamin D deficiency.
  4. Do not perform serum tumour marker tests except for the monitoring of a cancer known to produce these markers.
  5. Do not routinely test and treat hyperlipidemia in those with a limited life expectancy.

The Society of Hospital Pharmacists of Australia (SHPA)

  1. Don’t initiate and continue medicines for primary prevention in individuals who have a limited life expectancy
  2. Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date
  3. Don’t initiate and continue antipsychotic medicines for behavioural and psychological symptoms of dementia for more than 3 months
  4. Don’t recommend the regular use of oral non-steroidal anti-inflammatory medicines (NSAIDs) in older people
  5. Don’t recommend the use of medicines with sub-therapeutic doses of codeine (<30mg for adults) for mild to moderate pain

SHPA five recommendations were developed so that treatments should be questioned by consumers, pharmacists and doctors. SHPA President, Professor Michael Dooley said, “SHPA joined Choosing Wisely Australia because our vision and mission align well with the aims of the Choosing Wisely initiative. Our members are passionate about evidence-based medicine and minimising harm from medicines. By partnering with Choosing Wisely we can get our messages to a broader audience.”

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