When not doing something may be the best choice
X-rays for sprained ankles, antibiotics for ear infections and colds and colonoscopies to screen for bowel cancer are among more than 60 tests, treatments and procedures medical experts say should be avoided because they are wasteful and unnecessarily risky.
Fourteen specialist colleges, societies and associations have taken the lead in identifying 61 tests and procedures that should no longer be used because they expose patients to harm, undermine the effectiveness of lifesaving antibiotics and are a poor use of scarce health dollars.
The list, compiled under the Choosing Wisely initiative of NPS Medicinewise, includes many practices and treatments often considered routine and uncontroversial, but which evidence shows achieve little and are potentially harmful.
An area of particular focus is the use of antibiotics, amid fears that they are being overused, fostering bacterial resistance and the rise of superbugs impervious to known medicines.
In changes that could improve patient outcomes and potentially save millions of dollars, doctors and parents are being urged to make much more careful use of antibiotics, including in the treatment of middle ear infections in children, and in the treatment of colds and other upper respiratory tract infections.
The Royal Australian College of General Practitioners (RACGP) has recommended against the initial use of antibiotics for children aged between two and 12 years with a middle ear infection, where a review is possible in the following 24 to 48 hours.
AMA President Professor Brian Owler said it was important advice that would avert unnecessary treatment while helping to preserve the effectiveness of antibiotics.
“In the case of an ear infection, if there is a chance of review in 24 to 48 hours and the ear looks red, just come back and have a review rather than going straight to antibiotics, so that we try and reduce this over-prescribing of antibiotics,” Professor Owler told Channel Nine’s Today show.
The AMA President said it was advice aimed not only at doctors, but also parents and patients.
“Part of the problem here is not just to educate doctors in terms of when antibiotic prescribing is or isn’t called for, it is also to educate parents and patients themselves so that we don’t prescribe too many antibiotics, because we know if we do that we are likely to see more resistant infections. That’s going to mean that people’s infections are going to be much harder to treat in the future,” he said.
Two Bond University academics, Professor of Clinical Epidemiology Tammy Hoffmann and Professor of Public Health Chris Del Mar said the Choosing Wisely initiative was important not because of the money that could be saved, but because of a change in a approach that it represented.
They wrote in The Conversation that clinicians were guilty of doing too much rather than too little, and Choosing Wisely helped to signal “a very important departure from normal business for clinicians – thinking about not doing things”.
“The premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients,” they wrote.
Other therapies that have come under question include chest x-rays, one of the test most commonly ordered by GPs.
The RACGP has advised that GPs should no longer, as a matter of routine, order chest x-rays for patients with acute uncomplicated bronchitis.
The Royal Australasian College of Surgeons, meanwhile, has recommended against CT scans for suspected appendicitis without first considering an ultrasound, the Australian Physiotherapy Association has advised that there is “no advantage from routine imaging of non-specific low back pain”, and the Australian and New Zealand Society of Palliative Medicine has advised against the use of stomach feed tubes for patients with advanced dementia.
Professor Owler said the initiative demonstrated that doctors were keen to get rid of wasteful and potentially harmful practices, and supported efforts to improve the effectiveness of health spending.
He said doctors took seriously their responsibility as stewards of the health care system, and were constantly reviewing their practices and the evidence to ensure patients received the best possible care.
His comments were echoed by Australasian College of Dermatologists President Associate Professor Chris Baker, who said that one of the challenges of modern medicine was to determine which of the multiplicity of tests and treatments available were of benefit to patients.
A/Professor Baker said his College had identified several instances where the use of antibiotics was unnecessary and could help undermine their effectiveness, including in the treatment of acne vulgaris, epidermal cysts and redness and swelling of both lower legs.
The Choosing Wisely campaign is running in parallel with, but is unrelated to, a Federal Government taskforce review of the Medicare Benefits Schedule, which was set up last year and is not expected to complete its work until 2017.
The goal of updating the MBS to reflect modern clinical practice has been backed by the AMA, but there are concerns that the Government wants to use it primarily as a cost-cutting exercise that will be quick to de-list old treatments but slow to add new ones.