Healthcare Resources Stewardship - PowerPoint Presentation

Slide1

Healthcare Resources Stewardship

Foundation Module

Slide2

Learning Objectives

Define common terminology in healthcare resources stewardshipDiscuss the causes of inappropriate test ordering and prescribing behaviour

Describe the potential harms and adverse effects of inappropriate test ordering and prescribing

Outline the factors to consider when choosing the most appropriate tests and treatments

Apply practical strategies for healthcare resources stewardship in clinical practiceDescribe the key resources for best practice test ordering and prescribing

At the end of the session, participants will be able to:

Slide3

Overview

Part 1 – How wise is the use of healthcare resources?

Part 2

– What are the causes?

Part 3 – What are the harms? Part 4 – Making wise choices

Part 5 – Strategies & Resources

Slide4

Part 1:

How wise is the use of healthcare resources?

Slide5

An average day in Australian

healthcare resources

Australia's health system is a complex network of public and private services and providers.

On

an average day

there are: (Australian Institute of Health and Welfare 2016) 616,000

subsidised

prescriptions dispensed

381,000 visits to a general practitioner (GP)

246,000 pathology tests

79,000 visits to a specialist

27,000

hospitalisations

– 59% in the public sector

27,000 allied health services provided24,000 contacts made at community mental health care services20,000 presentations to public hospital emergency departments – 30% end up being admitted to hospital1,900 people admitted for elective surgery in public hospitals – 9% for cataract extraction

Slide6

How much is necessary or appropriate?

25–75% of tests in Australian primary care not supported by evidence or expert opinion (Morgan and Coleman 2014)

There is inappropriate use of many common tests, including: (Morgan and Coleman 2014)

FBC (full blood count) – LFT (liver function test)

TFT (thyroid function tests) – lumbar spine imaging

PSA (prostate specific antigen) – vitamin D

shoulder ultrasound imaging – B12/folate

A recent OECD study estimated average levels of waste of between 15% and 20% of total health care expenditure across all OECD nations (including Australia). (

Hensher

2019)

There are concerns about the high rates of antibiotic, opioid and benzodiazepine use in primary care

Approximately 190,000 hospital admissions annually are related to medications

(Australian Commission on Safety and Quality in Health Care 2011)

Over 90% of GPs and 95% of specialists agree that medical practitioners have a responsibility to help reduce the use of inappropriate tests, treatments and procedures. (Choosing Wisely Australia 2019)

64% of GPs surveyed had patients who asked for unnecessary tests, treatments or procedures every day to several times a week. (Choosing Wisely Australia 2019)

Growing body of evidence that inappropriate testing and treatment is a significant problem

Slide7

What is being done about it?

Choosing Wisely

Start a conversation

Effect a culture shift

22 countries and growing

Slide8

Choosing Wisely Principles

Slide9

Choosing Wisely Recommendations

Lists of

“5 things to question”

Transparent

Quality of care focus

Starts a conversation

Evidence-based

Slide10

Choosing Wisely Recommendations

Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (ANZCA)

5 things clinicians and consumers should question

(Faculty of Pain Medicine 2018)

1

Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic

non-cancer pain (CNCP)

2

Do not continue opioid prescription for chronic non-cancer pain (CNCP) without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms

3

Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain

4

Do not prescribe benzodiazepines for low back pain

5

Do not refer axial lower lumbar back pain for spinal fusion surgery

Slide11

What is being done about it?

2002 Medical Professionalism in the New Millennium: A Physician Charter

Co-authored by the American Board of Internal Medicine (ABIM), American College of Physicians (ACP) Foundation and the European Federation of Internal Medicine (EFIM), it stated:

(American Board of Internal Medicine 2002)

Principle of social justice

The medical profession must promote justice in the

health care system, including the fair distribution

of health care resources.

Slide12

What is being done about it?

Healthcare Resources Stewardship

In 2016 the AMA released a position statement:

(Australian Medical Association 2016)

The Doctor’s Role in Stewardship of Health Care ResourcesAvoid or eliminate wasteful expenditure in health care

Maximise quality of care and protect patients from harm while ensuring affordable care in the future

Doctors must balance their obligation to minimise wastage of resources with their primary obligation

to care for, and protect the health care interests of, the individual patient

Reduce diagnostic error, unnecessary or inappropriate tests, treatments and procedures

Slide13

What is being done about it?

Canadian Federation of Medical Students (CFMS) Position Paper

(Lakhani, Lass et al. 2016)

Principles

Medical overuse, defined as providing unnecessary treatment when the risk of harm exceeds its potential benefit, has become a worldwide public health concern of great relevance to the CFMS membership, practicing physicians, health care professionals, patients and the Canadian public.

Provision of unnecessary tests, treatments and procedures due to inadequate resource stewardship poses an unacceptable risk to the safety of patients and to the sustainability of the health care system.

Physicians are the primary gatekeepers of health care resources, controlling 80% of health care expenditures. As the next generation of physicians, medical students should undertake the responsibility of learning and practicing high-value care.

Medical education must include relevant training that prepares students to practice high-value care by curbing wasteful, inappropriate care. Formal curriculum changes may include integrating principles of parsimonious medicine and Choosing Wisely Canada recommendations into relevant lectures.

Slide14

Definitions of key concepts

Reduce diagnostic error...

Ten clinician-driven strategies for

maximising

value of Australian health care

(Scott 2014)

Diagnostic error is defined as delayed, missed or incorrect diagnoses.

It also includes overdiagnosis where ‘diseases’ are diagnosed that do not materially impact on patient longevity or quality of life.

Preventing overdiagnosis: how to stop harming the healthy

(Moynihan,

Doust

et al. 2012)

‘Overdiagnosis occurs when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death. 

More broadly defined, overdiagnosis refers to the related problems of overmedicalisation and subsequent overtreatment, diagnosis creep, shifting thresholds, and disease mongering, all processes helping to reclassify healthy people with mild problems or at low risk as sick.

Slide15

Definitions of key concepts

Over-testing

Over-testing: Why More Is Not Better

(Greenberg and Green 2014)‘Over-testing … is the use of: non-recommended screening tests in asymptomatic patients, or

more testing than necessary to diagnose patients with signs or symptoms’

Slide16

Definitions of key concepts

Over-treatment

The provision of therapeutics that are not indicated or otherwise inappropriate and treatment of

over-diagnosed disease. (Morgan, Dhruva et al. 2016)

When treatment has a low probability of benefitting the patient and may instead be harmful.

(Armstrong 2018)

With over-diagnosis and over-testing, over-treatment is an obvious outcome; such as the early detection of an incidental malignant thyroid

tumour

leading to treatment of this ‘abnormality’ which would have never caused harm itself, but treatment carries risk of surgical injuries and medication side effects. (Moynihan,

Doust

et al. 2012)

It may also occur when not supported by the evidence, but has become an established part of clinical practice such as arthroscopy for knee osteoarthritis. (Duckett,

Breadon

et al. 2015)

Slide17

Part 2: What are the causes?

Slide18

Choosing Wisely Australia surveys

Annual surveys have been conducted by Choosing Wisely Australia with GPs and specialists since 2015. Response rates for these surveys were:

2016: 12% for GPs (n=406) and 16% for specialists (n=337)

2017: 7% for GPs (n=264) and specialists (n=160)

2018: 6% for GPs (n=234) and 7% for specialists (n=194)

Reasons cited by GPs and

specialists

for requesting an unnecessary test, treatment or procedure

(Choosing Wisely Australia 2019)

Slide19

5 influences on test ordering and prescribing

1

Doctor

2

Patient

3

Clinical

4

System

5

Test / Treatment

(Choosing Wisely Australia 2019)

Slide20

Doctor factors

Knowledge and experience

Tolerance of uncertainty

Confidence

Fear of litigation

In-consultation information seekingTime to review results and provide results

Cognitive biases: (Scott, Soon et al. 2017)

illusion of control

commission bias

impact bias

availability bias

ambiguity bias

extrapolation bias

endowment effects

sunken cost bias

groupthink

Slide21

Patient and Clinical factors

Patient factors

(Dietrich 2010)

Demographics

Past experiencesPatient expectations – real or perceived/assumed

Patient health / medical literacyTime to go to have the test donePain/experience of the test itself

Clinical factors

(Callaghan 2012)

(Leep Hunderfund, Dyrbye et al. 2018)

Acute presentation or chronic disease

Clinical training (

ie

specialist or generalist)

Clinical experience (

ie

previously encountered or not)

Understanding of choices available to patient within public or private system, and locally or at specialist

centre

Age of the clinician, where younger clinicians/medical students more likely to be accepting of and take responsibility for implementing high-value (cost-conscious) care.

Slide22

System factors

Factors may include:

(Scott, Soon et al. 2017)

Time pressure

Lack of feedback on practiceLocation – rural vs. urban

Access to previous investigationsBilling practice (private, WorkCover)Technological advances

Clinical information sources

Marketing – to provider, to consumer

Slide23

Test and treatment factors

Factors that may influence ordering of tests and treatments:

Sensitivity -

highly sensitive test correctly identifies patients with the disease

Specificity -

highly specific test correctly identifies patients without the diseasePre-test probability – proportion of patients with target disorder in the population at risk at a specific time point or time interval. Prevalence may depend on how a disorder is diagnosed.

Efficacy -

Efficiency depends on whether a treatment is worth its cost to individuals or society. The most efficacious treatment, based on the best evidence, may not be the most cost-effective option.

Cost – financial (full/gap fees), time (getting off work, child care etc.), opportunity (what else could you do), travel/parking

Safety

Side effects

Slide24

Diagnostic uncertainty

Uncertainty

increases resource use

A 2017 systematic review of diagnostic uncertainty found that it is associated with increased:

(Alam, Cheraghi-Sohi et al. 2017)

admission rates

referrals

ordering more tests

health care costs

An example is a study of internist attitudes towards uncertainty and patient charges in a primary care clinic that found:

(Allison, Kiefe et al. 1998)

increased physician anxiety due to uncertainty and increased concern about disclosing uncertainty to patients translate into higher charges (costs)

each standard deviation of change in uncertainty scale corresponded to a change of mean charges of between 5% and 17%

Slide25

Part 3: What are the harms?

Slide26

Categories of harms

Health care costs

Direct costs

For example, a 2019 study found that the cost of low value care for 27 procedures (including endoscopy in adults <55, percutaneous coronary intervention, spinal fusion) was up to $99 million in 2016-17 in NSW public health hospitals alone.

(

Badgery-Parker, Pearson et al. 2019) Opportunity costs

Performing an unnecessary test on someone, reduces that’s person’s chance of doing work or personal activity, and means someone else who might need it, experiences a delay.

Doctor

Test interpretation

Time taken by the doctor to review tests and chase up false positives.

Patient

Financial

“Incidentalomas”

Anxiety

Overdiagnosis and overtreatment

Harm and adverse events

Slide27

Negative consequences for patients

Negative consequences

Description

Examples

Physical

Temporary or permanent pain, injury, illness, or impairment

Procedural complications, disability, adverse drug effects, death

Psychological

 

Negative emotions, mood symptoms, or psychiatric disorders

Anxiety, stress, major depression, self-identification in the role of a sick individual

Treatment burden

 

The workload patients must perform to manage health conditions

Understanding and implementing disease management strategies, time traveling to and attending appointments

Social

 

Disruption of relationships, altered

social identity or status owing to a medical condition

Loss of ability to participate in family or other social

networks, social

labeling

and stigma owing to diagnosis

Financial

 

 

Monetary costs, including direct medical (treatment expenses), direct nonmedical (nonmedical expenses incurred while obtaining treatment), and indirect (lost productivity)

Medical bills, travel costs, lost wages

Dissatisfaction with health care

Unhappiness with or mistrust of health care services or clinicians

Frustration with clinical encounter, erosion of faith in

clinician integrity and competence

Negative consequences from overuse of healthcare services (Korenstein, Chimonas et al. 2018)

Systematic review and expert panel review of overuse of tests and treatments (Korenstein, Chimonas et al. 2018)Identified negative consequences from overused services and downstream servicesThese harms can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop

Slide28

Harms of over-ordering tests

Harms may include:

(Morgan and Coleman 2014)

Pre-test probability of disease; it is relatively low in general practice, for example,

meaning false positive tests are common, even in tests with reasonable specificity.

False-positive results and incidental findings; leading to a cascade of further tests, which in turn leads to a greater risk of complications and patient harm, as well as the potential for significant patient anxiety.

Safety; for example, direct harm of tests such as radiation from CT scans

Overdiagnosis; where people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death. This can lead to unnecessary treatment, adding to the risk of patient harm.

Slide29

Example – Carotid artery screening

Carotid artery screening to detect stenosis

For 100 000 adults in the general population where the prevalence of carotid artery stenosis is 1%, carotid artery screening would result in 940 true-positive results and 7,920 false-positive results

(Jonas, Feltner et al. 2014)

If all positive tests were followed by angiography, as many as 1.2% of those people could have a resulting stroke

(Jonas, Feltner et al. 2014)

Slide30

Harms of unnecessary and

inappropriate prescribing

Patient

Adverse effects

Financial

Health care costsDirect costs

Opportunity costs

Ecological change

e.g. antimicrobial resistance

Windows into safety and quality in health care

(Australian Commission on Safety and Quality in Health Care 2011)

Over 1.5 million Australians suffer an adverse event from medications each year

2–3% of all hospital admissions are medication-related, of which approximately 50% are preventable

These adverse events result

in at least 400,000 visits to GPs and 190,000 hospital admissions

The cost is significant with estimates for medication-related hospital admissions in 2008 at $660 million

Slide31

Part 4: Making wise choices

Slide32

How to make wise choices

What is my clinical experience with this test or treatment?

What does the best available evidence say?

What does the patient want in terms of their values and expectations?

Patient values and expectations

Best

available evidence

Clinical experience

Slide33

Case study (1)

Janice is a 53 year old accountant who attends her GP with a 5 week history of left shoulder pain, especially when doing up her bra and reaching up to high shelves. There is no history of trauma or injury, and no red flags for serious disease. 

On examination there is tenderness over the lateral aspect of the shoulder and a ‘painful arc’ on shoulder abduction, but otherwise normal range of movement

Janice mentions she had a friend who had a shoulder ultrasound to “look for a tear” and would like to have one too

What is the likely diagnosis?

Is there any imaging that might help you and, if yes, would it change your management?

What would be the potential costs (financial, time etc.) for the patient to undergo the imaging test?

Slide34

Shoulder ultrasound

Shoulder pain accounts for 1.2% of all presentations to GPs in 2015-16 (NPS MedicineWise 2018)

Medicare Benefits Schedule (MBS) data show that shoulder problems were the 3rd most common reason for imaging in 2016-17 (NPS MedicineWise 2018)

Research reports high rates of incidental findings in asymptomatic individuals. One study on ultrasound reported that shoulder abnormalities were found in 96% of men who did not have shoulder symptoms (NPS MedicineWise 2018)

25% of new episodes of shoulder pain resolve in

1 month, 50% in 2-3 months

(Rheumatology Expert Group 2017)

Slide35

Recommendation

Do not use ultrasound to investigate shoulder pain if clinical assessment suggests rotator cuff pathology

(Rheumatology Expert Group 2017)

Therapeutic Guidelines

Slide36

Case study (2)

Bayley is a 3 year old boy who is brought to the ED by his mother Sonya, with a 36-hour history of runny nose, fevers and grisliness.

Bayley has a past history of otitis media x 3 episodes, and tongue tie repair.

Sonya tells you that the family are going on a ski holiday in three days time.

On examination, Bayley has a temperature of T 37.9C, but looks well.

ENT examination reveals a red, non-bulging right tympanic membrane, red throat, and multiple small cervical lymph nodes.Sonya asks about giving Bayley antibiotics.

What do you think is wrong with Bayley?

Are there any treatments that could make Bayley better faster?

Are there any risks to those treatments?

Slide37

Antibiotics for acute otitis media

Acute otitis media (AOM) is a common presentation, accounting for 7% of all GP consultations with children in Australia

(Del Mar, Glasziou et al. 2012)

Antibiotics are prescribed for 82.3% of consultations

(Del Mar, Glasziou et al. 2012)

Regardless of whether one or both eardrums are red or bulging, antibiotics do not reduce pain at 24 hours, and up to 20 children must be treated to prevent pain in one child at 2 to 7 days. (Royal Australian College of General Practitioners 2016)

One in 14 children will develop antibiotic side effects, particularly rash,

diarrhoea

, or vomiting. (Royal Australian College of General Practitioners 2016)

Clinical review at 24-48 hours is good practice, if available (Royal Australian College of General Practitioners 2016)

Slide38

Choosing Wisely Australia Recommendation

Do not treat otitis media with antibiotics, in non-indigenous children aged 2–12 years, where reassessment is a reasonable option

(Royal Australian College of General Practitioners 2016)

Slide39

Case study (3)

Bob, a 46-year-old male, presents to his GP for with a sprained ankle playing touch football the previous week.

He is asymptomatic, has no significant PMH, takes no medications, does not drink alcohol or smoke, and has no significant family history. He is not overweight.

After managing the ankle sprain, the GP orders ‘screening bloods’.

Bob is later recalled by his GP due to an abnormal TFT finding.

A repeat TFT and thyroid ultrasound are ordered. The thyroid ultrasound reveals a small nodule. Bob is referred by his GP to an endocrinologist.

Are routine annual physical check-ups worthwhile?

What are the costs of ordering "screening bloods” for:

your patient?

the healthcare system?

Slide40

Thyroid testing and imaging usage

In the 2014–15 about one in four Australians (5.7 million patients) had either a TSH test or a TFT (a total of 7.6 million tests). (Medicare Benefits Schedule Review Taskforce 2017)

The cost of these tests were $203m, increasing at 6.1% per year.

(Medicare Benefits Schedule Review Taskforce 2017)

In 2016–17, there were 308,247 MBS services for neck ultrasound (the majority for thyroid examination). The rate of neck ultrasound in Australia quadrupled between 1997 and 2017. (Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare 2018)

Slide41

Thyroid testing and imaging evidence

The prevalence in adults of subclinical hypothyroidism is about 4.3% (0.7% for subclinical hyperthyroidism), and prevalence is higher in older adults and women. About 2-5% of people with subclinical hypothyroidism and 1-2% with subclinical hyperthyroidism will develop overt thyroid disease per year. (Royal Australian College of General Practitioners 2016)

However, many patients with subclinical thyroid dysfunction revert to normal when followed over time. (Royal Australian College of General Practitioners 2016)

A 2014 systematic review of screening for thyroid dysfunction found that clear evidence on the benefits and harms of screening is unavailable. (Royal Australian College of General Practitioners 2016)

In the absence of evidence that early treatment reduces symptoms, lipid levels, or the risk of cardiovascular disease in patients with mild thyroid dysfunction detected by screening, screening is not recommended. (Royal Australian College of General Practitioners 2016)

Slide42

Choosing Wisely Australia Recommendation

Don’t test thyroid function as population screening for asymptomatic patients

(Royal Australian College of General Practitioners 2016)

Slide43

Choosing Wisely Australia Recommendation

Don’t routinely order a thyroid ultrasound in patients with abnormal TFTs in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland

(Endocrine Society of Australia 2016)

Slide44

Case study (4)

Mary is a 57-year-old woman who has been admitted into hospital to evaluate for acute coronary syndrome because of recurrent chest pain over the past 6 hours.

History includes:

hypertension

3 urinary tract infections (UITs) needing antibiotic treatment during the past year

no current UTI symptomsmedications; ramipril

Physical examination:

temperature normal

blood pressure 128/76 mm Hg

pulse rate 85/min

respiration rate is 18/min

cardiopulmonary examination is unremarkable

no suprapubic or flank tenderness on abdominal examination.

Laboratory studies:

normal electrolytes, kidney function, and complete blood count, with a leukocyte count of 5500/µL

troponin level is normal

ECG:

- nonspecific ST-T wave changes

Slide45

History of recurrent UTI

You also find that Mary’s urine was had the following testing:

urinalysis; dipstick and microscopic

urine culture.

Urinalysis results include:

dipstick is negative for leukocyte esterase, nitrites and bloodmicroscopic finds * 2-3 leukocytes/

hpf

* 0-2 erythrocytes/

hpf

* many bacteria

Urine culture grows 10

9

CFU(colony-forming units)/L of Escherichia coli

Which of the following is the most appropriate management of these findings?

Ciprofloxacin therapy for 7 days

Order for antibiotic sensitivity studies

Repeated urine culture

No further testing or treatment

Slide46

History of recurrent UTI

Correct answer: D – no further testing or treatment

Mary has asymptomatic bacteriuria (ASB). This is defined as 1 or more species of bacteria growing in the urine at ≥10

5

colony-forming units [CFU]/mL or ≥10

8 CFU/L, irrespective of the presence of pyuria, in the absence of signs or symptoms attributable to urinary tract infection (UTI). (Nicolle, Gupta et al. 2019)

The prevalence of ASB in healthy, premenopausal women ranges from 1–5%, and in healthy postmenopausal women in the community from 2.8 - 8.6%.

(Nicolle, Gupta et al. 2019)

The evidence shows that although women with ASB may also be at increased risk of symptomatic UTI, ASB, even when persistent, appears not to be associated with other adverse outcomes, and there is no

evidence to suggest that episodes of symptomatic UTI are attributable to the ASB.

(Nicolle, Gupta et al. 2019)

Moreover, treatment of ASB may not decrease the frequency of symptomatic UTI, including pyelonephritis.

(Nicolle, Gupta et al. 2019)

To the contrary, antibiotics may increase rather than decrease the risk of subsequent UTI.

(Nicolle, Gupta et al. 2019) There is also high-quality evidence that antibiotics have an increased risk of adverse effects, that screening and treating ASB is extremely costly, use of antibiotics promotes emergence of antimicrobial resistance. (Nicolle, Gupta et al. 2019) and there is an increased risk of antibiotic-associated Clostridium difficile infection. (Brown, Khanafer et al. 2013)

Slide47

Choosing Wisely Australia Recommendation

Don’t treat asymptomatic bacteriuria with antibiotics.

(Infectious Diseases Society of America 2015)

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Slide48

Part 5: Strategies

& Resources

Slide49

Strategies – Choosing Wisely

Starting conversations

(Choosing Wisely Australia and Consumers Health Forum of Australia 2019)

Choosing Wisely is creating a cultural shift toward health professionals and consumers engaging in conversations about what care is

truly needed – what is helpful and what is not.

The right choice should be based on the best available evidence and discussion between consumers and clinicians.

Shared decision making

(Choosing Wisely Australia and Consumers Health Forum of Australia 2019)

In partnership with their clinician, patients are encouraged to consider available screening, treatment, or management options and the likely benefits and harms of each, to communicate their preferences, and help

select the course of action that best fits these.

Good conversations support shared decision making between healthcare providers and consumers

Slide50

Strategies – consultations

Pre-consultation

:

Aim to provide the Choosing Wisely Australia 5 questions to patients, such as located in the waiting room

Undertake quality improvement such as a clinical audit of common conditions based on patient data

Set up a guideline for use in your department/practice to follow best practice standardsIdentify validated clinical decision support tools that can be used

Use NPS MedicineWise visits to obtain feedback on your prescribing/testing habits

During the consultation, ask yourself

:

What are the benefits and risks of this approach for the patient?

How will this test change my management?

How does this option fit with the patient’s values?

Before prescribing a new medication or sending a patient for a test or procedure:

Slide51

Strategy – Medicolegal

Choosing Wisely: Law's Contribution as a Cause of and a Cure for Unwise Healthcare Choices

2017 Journal of Law and Medicine

Doctors who defensively order tests, give treatments or make referrals are motivated by worry that if they fail to do so, some harm may

materialise

for their patients, who may then pursue legal redress.

Yet legal standards require that a doctor act reasonably, not infallibly, in taking precautionary measures to reduce the risk of harm.

(

Ries

2017)

Slide52

Strategy – Medicolegal

Choosing Wisely: Law's Contribution as a Cause of and a Cure for Unwise Healthcare Choices

2017 Journal of Law and Medicine

Medical Board Of Western Australia v Richards 2010 the court found:

…

there are relatively few clinical presentations where there is near certainty in the diagnosis.

For many common presentations, the patient's description of the illness, coupled with the doctor's understanding of the pattern of disease in the community, allows the doctor to arrive at the most likely diagnoses and to discount those which appear highly unlikely. Investigations are then chosen on the basis of those probable diagnoses.

It is simply not possible to investigate all symptoms to the point of absolute certainty, the health system and the budget would collapse under the weight of a huge increase in investigations, with a clearly

unfavourable

cost benefit analysis.

Diagnosis therefore comprises a constant tension between under investigation, and missing serious diagnoses, and over investigation, exposing the patient to unnecessary risk and unnecessary procedures. In most clinical encounters there remains an element of uncertainty.

(

Ries

2017)

Slide53

Strategies – Resident Doctors of Canada (

RDoC)

Five Things Medical Residents and Patients Should Question

Choosing Wisely Canada (CWC)

(Resident Doctors of Canada 2017)

Don’t order investigations that will not change your patient’s management plan.

Don’t order repeat laboratory investigations on inpatients who are clinically stable.

Don’t order intravenous (IV) when an oral (PO) option is appropriate and tolerated.

Don’t order non-urgent investigations or procedures that will delay discharge of hospital inpatients.

Don’t order invasive studies if less invasive options are available and as effective.

Slide54

Resources for health professionals - Tests

Royal College of Pathologists of Australasia (

RCPA) Manual

Lab Tests Online

Diagnostic Imaging Pathways (WA)

Health Pathways

Learning Resources

Investigate

http://investigate.med.unsw.edu.au/home.jsf

Common Sense Pathology

http://www.rcpa.edu.au/Publications/CommonSensePathology.htm

NPS MedicineWise CPD for health professionals

https://www.nps.org.au/cpd

Slide55

Resources for health professionals – Treatments

Australian Medicines Handbook

Therapeutic Guidelines

Health Pathways

Cochrane Reviews

RACGP

HANDI

Slide56

Do I really need this test, treatment or procedure?

What are the risks?

Are there safer options?

What if I do nothing?

What are the costs?

Resources for patients – Choosing Wisely

‘5 questions to ask’

Slide57

Implementation Toolkit – Better Care Victoria

Conversation starter kit

Resources – Choosing Wisely toolkits

Slide58

Resources – NPS MedicineWise

Professional education

for students and health professionals:

National Prescribing Curriculum

for students

Case Studies

Clinical e-audits

Educational visits

Slide59

References

The full list of references

for this presentation

is found here on the choosing wisely website

Slide60

Evaluation

How likely is this Australian Health Resource Stewardship course to change your practice?Not at allSomewhat

Significantly

Reasons for your answer

Slide61

choosingwisely.org.au

Choosing Wisely is facilitated by NPS MedicineWiseLevel 7/418A Elizabeth Street Surry Hills NSW 2010 PO Box 1147 Strawberry Hills NSW 02 8217 8700 02 9211 7578 info@nps.org.au

nps.org.au

Independent, not-for-profit and evidence-based, NPS MedicineWise enables better decisions about medicines, medical tests and other health technologies. Our programs are funded by the Australian Government Department of Health.

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