Issue 31 / 17 August 2015

PRIMARY health care networks, clinical colleges, hospitals and consumer groups need to work together to ensure there is progress in reducing rates of inappropriate care, according to the Australian Commission on Safety and Quality in Health Care.
Adjunct Professor Debora Picone, the Commission’s CEO, told MJA InSight that one way to do this was to provide regular analysis and feedback to health services on the use of “do-not-do interventions”.
“Clinicians also need to ensure that patients are given all the information they need in order to make an informed decision about their care — including information about likely effectiveness, benefits and risks of care.”
Professor Picone was responding to an analysis of computerised hospital data, published this week in the MJA, which found five hospital procedures that are not supported by clinical evidence were, on average, performed more than 100 times a week across Australia. (1)
The research was based on more than 8 million discharge records from 709 Australian public hospital sites for the 2010–2011 financial year.
The authors measured the incidence of selected diagnosis-procedure pairs identified as inappropriate in the literature. These do-not-do procedures included vertebroplasty for painful osteoporotic vertebral fractures and laparoscopic uterine nerve ablation for chronic pelvic pain.
The authors found that the most frequently used do-not-do treatment was hyperbaric oxygen therapy for a range of specific conditions.
The rate of do-not-do procedures varied greatly, even among comparator hospitals that provided the procedure and that treated the relevant patient group.
Among comparator hospitals, an average of 3.3% of patients with knee osteoarthritis received arthroscopic lavage and debridement of the knee (a do-not-do treatment), but four hospitals had rates of more than 20%.
The authors said their results highlighted that current strategies were not doing enough to reduce inappropriate care in some places, and that “these hospitals should be alerted to the fact of their aberrant practice and be subject to clinical review if that practice continues”.
If a hospital still does not change its clinical practices, financial sanctions might be required, they wrote.
Dr Robyn Lindner, a spokesperson for Choosing Wisely Australia, told MJA InSight that financial sanctions were one approach that could possibly change behaviour.
“Any financial sanctions need to be matched with education and information to engage clinicians and patients in supporting a culture shift towards appropriate care.”
Professor Richard King, medical director of Medicine at Monash Health and chair of the Choosing Wisely Australia Advisory Group, said it would be “easy” for each state health department to impose these sanctions, as they could just stop subsidising the cost of all treatments and only pay for “proven procedures”.
However, he told MJA InSight that financially penalising hospitals would be like “using a sledgehammer to hit a tack”.
“I’d prefer the focus to be on quality, and sanctions should only be a second-line approach”, Professor King said.
In an MJA editorial, Professor Joseph Ibrahim, of Monash University, said it was important to recognise that for any inappropriate care to happen, complicit action on a large scale was required. (2)
“Therefore, the question we should be asking is: how is it possible for inappropriate care to occur?” he wrote.
The health community must be encouraged in their efforts to seek out the underlying factors causing inappropriate care and develop new solutions, Professor Ibrahim said.
Professor Picone said she hoped the Quality and Safety Commission’s extensive collection and analysis of data from clinical care registries would not only inform these solutions, but provide assurance that the health system was achieving “the best value for the health care dollar”.
However, Professor Picone said the hospital performance monitoring envisaged by the MJA study authors would only work if all states and territories were directly engaged in establishing and implementing policy to cease do-not-do interventions.
As a patient’s pathway to hospital treatment often began in primary care, interventions were required across the health system.
“The Commission is working with the National Health Performance Authority to produce an atlas of health care variation which will be published later in the year, and covers interventions in both primary and secondary settings.”
An MJA “For debate” article said very few clinical interventions were of no value in every clinical circumstance, which meant that efforts to label interventions as such would be met with professional resistance. (3)
Training and education programs could enhance and assess the ability of aspiring clinicians to recognise and practice high-value care, the authors wrote.
“Such bottom-up approaches are a good place to start and public policy interventions should support clinician-led efforts to seek professional consensus on what constitutes low-value care and the best means for reducing it”, they wrote.
Dr Lindner agreed, saying that rather than a top-down, institution- or payer-based approach, Choosing Wisely Australia was “working from the ground up with individuals and professional societies to lead the way in promoting awareness of appropriate care”.
(Photo: Naomi Bassitt / iStock)

4 thoughts on “Too much do-not-do care

  1. Christoph Ahrens says:

    very dangerous and inapropriate practice to have “bean counters” decide what “do not do” procedures are. I can only speak for the orthopaedic procedure listed as “do not do”. Unfortunately arthroscopy is more often miss-used as a money making tool for osteoarthritis, than sensibly used for appropriate problems in the presence of osteoarthritis. However that doesn’t make arthroscopy in arthritis patients a “do not do” procedure. It has a place and should not be put on a black list. Sooner or later, it will make it very difficult to get this procedure done even when it makes clinically a lot of sense.

  2. Alex Wood says:

    Do not do procedure “Vertebroplasty for painful osteoporotic vertebral fractures”, articles seem to quote Prof Rachel Buchbinder as a most prominent opponent of that procedure.

    My late wife had that very painful condition very succesfully treated by injection vertebroplasty, with relief of pain within hours and no adverse effects.

    As result (and because my wife & I saw Prof Buchbinder before we proceeded to injection vertebroplasty), I have twice carefully studied Prof Buchbinder’s article and that of orthopaedic opinion that differed and encouraged vertebroplasty.  My late wife and I were at that time more impressed (for several reasons) by other opinions.

    Pain in that condition abates as fractures heal, which in vertebrae seems fairly quick, with healing in about 3 months often, with pain relief sooner than that.  Prof Buchbinder’s series seems to include a number of patients later than 3 months after fractured vertebra(e), so naturally such patients would rarely be relieved of pain, in my opinion, (as a retired doctor (urologist)), but still alert enough to remember pathology and healing.  I am upset to see such uncritical acceptance  of what seems a flawed study, which seems quoted over and over and wonder if others have carefully read Prof Buchbinder’s article critically?  Has there been a contrary study made since Prof Buchbinder, I wonder? 

  3. Department of Health Victoria Clinicians Health Channel says:

    In the Tertiary referral centre in which I work there are many “stupid” and expensive procedures performed. When I see them to manage their post op pain it is clear they were destined to failure long before the surgery was performed. A “do not do” list may be a little harsh but maybe these procedures should be run through a multi-disciplinary panel before being scheduled. A recent case with a 500+ day stay and approximately 40 operations and 5-6 ICU stays and eventual death for a questionable indication weighs heavily on my mind.

  4. Mia Morocz says:

    “working from the ground up with individuals and professional societies to lead the way in promoting awareness of appropriate care”

    Yet, we know that clinical guidelines are vulnerable to bias and financial incentives/interests.

    We also know that self-regulation rarely works. I have no faith in the effectiveness of the ‘ground-up’ leadership. 

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