Choosing Wisely must mean choosing equity

A paper published in the latest New Zealand Medical Journal (7 June 2019) says the Choosing Wisely campaign must ensure the message 'more is not necessarily better' does not inadvertently worsen the under-treatment for Māori and other groups.

Choosing Wisely is an international campaign that promotes a culture where low-value and inappropriate clinical interventions are avoided, and patients and health professionals have well-informed conversations about treatment options, leading to better decisions and outcomes.

The article Choosing Wisely means choosing equity, authored by Belinda Loring, Sue Ineson, Derek Sherwood and David Tipene-Leach, considers whether there is a risk that Choosing Wisely interventions might unintentionally increase inequity.

Professor Tipene-Leach says new programmes and health services do not usually serve everyone equally.

'New interventions are known to exacerbate inequity as they are taken up first by those in society with the most resources and the least need.

'In New Zealand that means Māori and Pacific people and decile 9 and 10 communities are likely to miss out. Choosing Wisely projects need to look very carefully through an equity lens and ask ‘what is this going to do to Māori, Pacific and decile 9/10 communities?’.

'Choosing Wisely activity must then avoid making these inequities worse, moreover, it should aim to reduce inequity.'

Choosing Wisely clinical lead Dr Derek Sherwood says very little is known about who gets unnecessary care in New Zealand.

'For instance, data on some areas of low value care relevant to Choosing Wisely recommendations, like inappropriate prescribing of antibiotics and unnecessary urine testing in hospital, are not available by gender, ethnicity or other equity stratifiers.

'Much of the focus of routine data, such as the Health Quality & Safety Commission’s Atlas of Healthcare variation, is on variability in necessary care and we know that Māori receive fewer tests, prescriptions and referrals than other ethnic groups and subsequently, less treatment. Pacific people and other groups of low socioeconomic status are also less likely to receive the health care they need.

'The health sector needs to understand how the issue of low-value and inappropriate care affects different ethnic and social groups. Choosing Wisely, in the effort to reduce over-treatment, needs to make sure that the message 'more is not necessarily better' does not inadvertently restrict treatment for Māori and other groups who do not receive enough of the care that they need.'

Prof Tipene-Leach says the formulating of recommendations for the entire population is unlikely to be appropriate, or may even be contraindicated, for certain groups.

'For example, a Choosing Wisely recommendation not to prescribe antibiotics for acute upper respiratory tract infections may sound reasonable given the majority of these infections are viral and antimicrobial resistance is a rising concern. However, for Māori and Pacific children in New Zealand, who experience high rates of rheumatic fever, sore throats should be swabbed and treated with antibiotics until swab results are available.

'New Zealand colleges and specialty societies therefore have a responsibility to evaluate the potential impact on health inequities of their recommendations and be very clear when communicating where recommendations should not be applied for all population groups.'

He says the Choosing Wisely campaign encourages consumers to ask more questions of health professionals – but this may not be addressing the real obstacles for Māori.

'Improving shared decision-making for Māori requires health professionals to work with patient values and preferences; and ensure patient resources are informed by the views and needs of Māori.'

Dr Sherwood says, to address these challenges, Choosing Wisely is partnering with Te Ohu Rata o Aotearoa (Te ORA) — the Māori Medical Practitioners Association on a research project to improve shared decision making between health professionals and Māori consumers and their whānau, with the goal of supporting more equitable health outcomes for Māori.

'Project outputs will include tools, resources and approaches to improve shared decision making for use by all health professionals and providers.'

Prof Tipene-Leach says the process of proactively scoping potential unintended consequences on health inequities should be routine for all health promotion campaigns, and many of the approaches identified are not unique to Choosing Wisely or efforts to reduce unnecessary care.

'The need to improve equity in shared-decision making is an issue which involves the entire health sector in New Zealand and reinforces the need for broader efforts to improve the cultural safety of both health professionals and organisations.'