Choosing Wisely international update

Annually Choosing Wisely holds an international round table for up to two delegates for each Choosing Wisely country to share experiences and plan strategies. This year due to COVID-19 the meeting was held by Zoom and was attended by Dr John Bonning of the Council of Medical Colleges (CMC).

The keynote address was a presentation by Dr Don Berwick, president emeritus and senior fellow, Institute for Healthcare Improvement. This special presentation, Addressing Overuse in the ‘New Normal’, highlighted how health care systems and providers are rapidly learning and changing in response to COVID-19. It outlined how considerations of sustainability, reducing waste, and improving value are vital to meet the complex health needs posed not just by COVID-19 but by our changing society. The Berwick talk has been made available to all Choosing Wisely stakeholders and is on the Canadian Choosing Wisely website for 30 days under events. You can watch the presentation here.

Dr John Bonning of CMC gave a presentation on Choosing Wisely means Choosing Wisely Equity – based on the research report of the same name developed by CMC and Te ORA with Dr David Tipene Leach and Anna Adcock.

We will pass on other public Choosing Wisely international presentations as they come to hand.

Choosing Wisely New Zealand

Recently new recommendations on pharmacy and addiction medicine were published on the Choosing Wisely website.

Choosing Wisely Australia

Choosing Wisely Australia produces a monthly newsletter with useful updates and information relevant to New Zealand as many of the Choosing Wisely recommendations are the same on both sides of the Tasman. Last month’s newsletter included reference to new Choosing Wisely recommendations and implementation in services. It also featured a new health resource stewardship toolkit for clinical educators – with presentation slides and case studies. The toolkit has been developed for use in universities, hospitals and health professional colleges.

Royal Australasian College of Physicians (RACP) Congress Evolve session on shared decision-making

Evolve is a physician-led initiative aiming to reduce low-value tests, procedures and practices. But reducing low-value care for improved patient outcomes is not just about having the latest evidence, we also need to use shared decision-making. In this Congress session we will be exploring the importance of shared decision-making in the context of reducing low-value practices. Evolve now works closely with Choosing Wisely:

• Speaker 1: Dr Cilla Haywood, geriatrician at Austin Health and Northern Health
• Speaker 2: Mrs Debra Letica, RACP consumer advisory group member, chair WA Primary Health Alliance Community South Committee, WA pharmacy registration board member.
• Chair: Professor Donald Campbell, director of general medicine at Monash Health, professor of medicine at Monash University, president of internal medicine society ANZ.

Watch the session here.

New Evolve case studies

To support the implementation of Evolve and Choosing Wisely recommendations in clinical practice, we have launched a series of case studies exploring a clinical scenario based on one of the Evolve and Choosing Wisely recommendations on low-value care. Dr Sern Wei Yeoh and Dr Su Win Htike through the RACP Evolve programme have recently led the development of three new case studies about genetic testing for coeliac genes, using thyroid ultrasound in patients with abnormal thyroid function, and glucose self-monitoring in adults with stable type 2 diabetes.

Choosing Wisely in Canada

Choosing Wisely Canada holds regular webinars on issues of interest and a wealth of resources that may be useful to New Zealand services. The Not Necessary. Policy Ideas for Limiting Low-Value Care in Canada document draws on the campaign’s grassroots clinician leadership and evidence-based recommendations. Dr Wendy Levinson reflects on the role of clinicians in advocating for positive system changes to help ensure health care resources are used wisely.

The Cold Standard: A Toolkit for Using Antibiotics Wisely in the Era of COVID-19 and Virtual Care

The delivery and organisation of health care services has changed rapidly in response to COVID-19. Many primary care clinics have increased the adoption of virtual care due to being unable to provide in-person assessments. As primary care providers adjust to these changes, emerging challenges exist around how to manage respiratory tract infections (RTIs) including when to test, when to prescribe antibiotics, and when to see a patient in-person.

In response to these challenges, the Using Antibiotics Wisely campaign has released the second edition of The Cold Standard toolkit to address the management of RTIs with considerations of COVID-19 and virtual care. This practical toolkit provides three clinical tools that can support both virtual and in-person management of RTIs.

Choosing Wisely Canada has also released new public health recommendations under the leadership of Public Health Physicians of Canada, with five new recommendations of tests, treatments, or procedures to question:

• Don’t routinely do serologic testing post-immunisation (ie, hepatitis B and measles)
• Don’t give rabies post-exposure prophylaxis unless indicated by a structured assessment of risk
• Don’t prescribe medications or recommend a management plan where there are financial and social barriers that might make the plan impractical for patients
• Don’t do unnecessary screening tuberculin skin tests (TSTs)
• Don’t provide antibiotic prophylaxis to all contacts of severe invasive group A streptococcus (iGAS) infections.

See Five Tests and Treatments to Question in Public Health to view the full list, including a rationale and references for each.

With the Canadian Nurses Association and the Canadian Association of Critical Care Nurses, Choosing Wisely Canada released five new recommendations of tests, treatments or procedures for nurses to question:

• Don’t insert or leave in place a urinary catheter without an acceptable indication
• Don’t administer benzodiazepines to treat symptoms of delirium
• Don't use physical restraints with critically ill patients as the first choice to prevent self-extubation or removal of lines or tubes
• Don’t repeatedly attempt intravenous access during a life-threatening event when intraosseous access is available
• Don’t prolong use of central venous or peripherally inserted central catheters without daily reassessment.

See Five Tests and Treatments to Question in Nursing: Critical Care to view the full list, including a rationale and references for each recommendation.

With the Canadian Society of Allergy and Clinical Immunology, Choosing Wisely released of seven new recommendations of tests, treatments or procedures to question:

• Don’t order specific IgG testing to panels of foods
• Don’t order specific immunoglobin E (IgE) tests (skin or serum) unless indicated by the patient’s history specific to that food
• Don’t use antihistamines as first-line treatment in anaphylaxis
• Don’t diagnose or manage current or chronic or persistent asthma in patients >6 years of age without objective testing such as spirometry or a methacholine challenge
• Don’t prescribe antibiotics for uncomplicated acute rhinosinusitis
• Don’t order sinus computed tomography (CT) for uncomplicated acute rhinosinusitis
• Don’t order non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.

See Seven Tests and Treatments to Question in Allergy and Clinical Immunology to view the full list, including a rationale and references for each recommendation.