Six Australasian medical colleges and specialist societies released new recommendations at the end of August as part of the ongoing Choosing Wisely campaign to make health professionals and consumers question whether tests, treatments and procedures are appropriate or necessary.

Choosing Wisely chair Dr Derek Sherwood said ‘more isn’t always better’ when it came to medical tests, treatments and procedures.

“Unnecessary interventions are stressful, and potentially expose patients to harm, leading to more testing to investigate false positives.”

Amongst the groups releasing recommendations are the New Zealand College of Midwives and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) who agreed on avoiding unnecessary ultrasounds of pregnant women.

College of Midwives deputy chief executive Alison Eddy said maternity was an area where interventions can be applied more liberally than they should be and that we should stop, question and re-examine the evidence.

She said she and RANZCOG Chairperson Dr Celia Devenish agreed that it was important to question rather than just to accept that “this is normal, this is what I should have, this is what happened to my sister or my friend”.

A good example of this was ultrasounds. “They are a screening test and need to be undertaken for a specific clinical reason, based on informed decision making and knowing when to follow up if there are concerns but avoiding them if they are unnecessary. They can make women anxious and increase the likelihood of further tests or interventions that are not necessarily needed,” said Eddy.

Communicating risks

One of the Choosing Wisely questions that the campaign encourages patients and consumers to ask their health professional about a test, treatment or procedure is ‘what are the risks?’.

The New Zealand College of Public Health Medicine is recommending that when health professionals communicate health risks, harms and benefits that they use absolute risk ahead of relative risk as relative risk is frequently misunderstood and is potentially deceptive”.

An example is a treatment that gives a relative risk reduction in deaths of 50 percent can sound misleadingly good, but the absolute risk of dying from a condition may only decrease by a very small amount.

Health professionals, as well as the public, tend to over-estimate the effectiveness of an intervention when results are expressed in relative terms, because such results are naïve to the baseline risk, says the College.

“Absolute risk reduction and numbers-needed-to-treat are more direct measures of the relevance of an effect than relative risk reduction and are less likely to influence medical and public decision-making to inappropriately adopt an intervention. Relative risk has its place, but an absolute risk approach achieves a better balance between prevention and avoiding unnecessary intervention.”

New Choosing Wisely recommendations released at the end of August included:

New Zealand College of Midwives

  • It is not necessary to continuously monitor a baby’s heart rate during normal labour.
  • Cord clamping should be delayed for at least three minutes or until the cord has stopped pulsating (unless the baby requires resuscitation at birth).

New Zealand College of Public Health Medicine

  • Use absolute risk ahead of relative risk when assessing and communication risks, harms and benefits.
  • Apply established screening criteria, and consider health equity impacts when assessing potential screening programmes.

New Zealand Committee Royal New Zealand and Australian College of Obstetricians and Gynaecologists

  • Don’t routinely test FSH levels to establish menopausal status.
  • Don’t perform more than three ultrasound scans during a normal pregnancy.

New Zealand Rheumatology Association

  • Bone density scanning of patients at low risk of osteoporosis more frequently than every five years is not recommended.

Australasian Faculty of Occupational and Environmental Medicine

  • Any imaging for low back pain is not recommended.

Australia and New Zealand Child Neurology Society

  • CT scans are not needed to investigate first-time headache or fainting in children.

Choosing Wisely is a global initiative that began in the USA in 2012, launched across the Tasman in April 2015 and later in New Zealand where the initiative is being facilitated by the Council of Medical Colleges (CMC) in partnership with the Health Quality & Safety Commission and Consumer New Zealand.

Since the formal launch of the Choosing Wisely campaign in New Zealand, more than 30 Australasian and New Zealand colleges and specialist societies have endorsed more than 100 recommendations that healthcare professionals and patients and consumers should question.

More information can be found at http://choosingwisely.org.nz

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