Common dilemmas in kids

2015

Up front

Shaping our own destiny by 
Choosing Wisely

Volume 44, No.6, 2015 Pages 425-426

Claire Jackson

The year 2014 was surely a challenging year for Australian general practice. The potential introduction of a Medicare Benefits Schedule (MBS) co-payment, the movement of private health insurance companies into practice care delivery, the demise of Medicare Locals and arrival of Primary Health Networks, and the inevitable and constant change in technology and clinical best practice all seemed sometimes overwhelming.

Yet amid all the uncertainty, two inescapable and defining determinants of our future became increasingly apparent. The first is that the health system is fast running out of resources to deliver care in traditional fashion. Second, despite the mudslinging and horse-trading between state-funded and Commonwealth-funded care, high-quality, well-supported primary care is the only way forward for both of them and for our communities.

Unfortunately, however, those guiding the helicopter can often only faintly make out movement at ground level. From the Commonwealth policy helicopter, general practice is seen as responsible for a very large chunk of taxpayer resourcing. From the state government perspective, we are largely an unknown, despite tentative and encouraging investment in some states.1

It is critical this year to provide decision makers with the evidence and strategy they require to achieve their aims of high-quality, cost-effective care for our communities. Our task is to highlight and promote the enormous opportunity that high-quality, widely accessible general practice offers in this endeavour.

An excellent resource to help us make early ground is Choosing Wisely, a North American initiative to unite health consumers and clinicians in identifying poorly targeted investment in common procedures, investigations and services.2 It was launched several years ago via the American Board of Internal Medicine Foundation to improve care quality and cost-effectiveness. Choosing Wisely involves academies and colleges identifying settings, tests or procedures where evidence now questions safety or efficacy. As part of its commitment, the College of Family Physicians of Canada has created the ‘Eleven Things Physicians and Patients Should Question’ list. This includes imaging for lower-back pain in the absence of red flags, chest X-rays and electrocardiograms (ECGs) for asymptomatic patients, Pap smears for women aged <21 or >69 years, annual blood tests for asymptomatic individuals, and antibiotics for viral upper respiratory tract infections.3 The American Academy of Family Physicians list also includes prostate-specific antigen (PSA) screening for prostate cancer, screening for carotid artery stenosis in asymptomatic adults, and dual energy X-ray absorptiometry (DEXA) screening for osteoporosis in women aged <65 years or men <70 years without risk factors.4 The aim of the listing and its wide promotion is to encourage productive discussion between physicians and patients regarding practices where evidence now clearly shows limited benefit and some risk.

The Royal College of Pathologists of Australia (RCPA) released its Choosing Wisely recommendations in November 2014 as a national first. In the 10 practices on their discussion list, they targeted inappropriate population-based testing for vitamin D, prostate cancer and hyperlipidaemia screening in some Australians, and routine pre-operative screening in low-risk surgery.5

Choosing Wisely allows the profession and consumers to champion the best use of finite resources for maximal impact, focusing on care quality rather than reactive funding reduction. This approach also allows consumers and providers of healthcare to take the lead in driving an evidence-based, quality-led health resource agenda. In future, this could integrate primary and secondary care in an all-of-system approach to optimal care delivery.

It is one thing to identify effective strategy; it is entirely different and equally challenging to embed them into health policy and practice. The Royal Australian College of General Practitioners (RACGP), working with the National Prescriber Service (NPS) and United General Practice Australia*, is now working hard to make the broader health environment aware of the opportunities to utilise the health spend in primary care to achieve best outcomes. We as clinicians, however, are the frontline – without our active involvement, leadership and commitment, little will change. Much of the very considerable downstream referral and investigation costs in the health sector are within our control – we must use this power wisely.

If we fail to engage policymakers, governments and the Australian community in working with us to build a viable healthcare future, we will all lose. The RACGP, with a number of other colleges, has taken the lead in identifying current practices that are poor investments in a resource-challenged health environment. Our job is to translate that direction into our own clinical care and lead change that is effective, contemporary and of the highest quality.

Clinician leadership at the grassroots level is immensely preferable to unexpected helicopter fire from above.

*United General Practice Australia (UGPA), Australia’s peak general practice coalition, comprises the most prominent national GP organisations working together to address primary healthcare issues requiring urgent action.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.

References

  1. NSW Government Health. Integrated Care – Info Summary. NSW Health, 2014. Available at www.health.nsw.gov.au/integratedcare/Documents/integrated-care-info-summary.pdf [Accessed 6 March 2015].
  2. The ABIM Foundation. Choosing Wisely. Lists. Philadelphia: ABIM Foundation, 2014. Available at www.choosingwisely.org/doctor-patient-lists/ [Accessed 6 March 2015].
  3. Choosing Wisely Canada. Family Medicine: Eleven things physicians and patients should question. Released 2014. Available at www.choosingwiselycanada.org/recommendations/family-medicine/ [Accessed 6 March 2015].
  4. American Academy of Family Physicians. Choosing Wisely. Leawood: AAFP, 2015. Available at www.aafp.org/about/initiatives/choosing-wisely.html [Accessed 6 March 2015].
  5. Royal College of Pathologists of Australia. RCPA’s top ten targets aims to beat inappropriate pathology requesting. 5 November 2014. Available at www.rcpa.edu.au/getattachment/370d3951-fa61-43a7-8ce7-5e55da8e584c/RCPA-s-Top-Ten-targets-aims-to-beat-inappropriate.aspx [Accessed 6 March 2015].

Correspondence afp@racgp.org.au

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