Recommendations
Tests, treatments, and procedures for healthcare providers and consumers to question
Australia's peak health professional colleges, societies and associations have developed lists of recommendations of the tests, treatments, and procedures that healthcare providers and consumers should question.
Each recommendation is based on the latest available evidence. Importantly, they are not prescriptive but are intended as guidance to start a conversation about what is appropriate and necessary.
As each situation is unique, healthcare providers and consumers should use the recommendations to collaboratively formulate an appropriate healthcare plan together.
Australasian Chapter of Addiction Medicine
Australasian Chapter of Addiction Medicine
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Do not undertake elective withdrawal management in the absence of a post-withdrawal treatment plan agreed with the patient that addresses their substance use and related health issues.
Do not prescribe pharmacotherapies as stand-alone treatment for Substance Use Disorders (SUD) but rather as part of a broader treatment plan that identifies goals of treatment, incorporates psychosocial interventions and identifies how outcomes will be monitored
Do not deprescribe or stop opioid treatment in a patient with concurrent chronic pain and opioid dependence without considering the impact on morbidity and mortality from discontinuation of opioid medications
While managing patients with Substance Use Disorder (SUD), exercise caution in the use of treatment approaches that are not supported by current evidence or involve unlicensed therapeutic products.
Use a 'universal precautions' approach for all psychoactive medications that have known potential or liability for abuse including opioids, benzodiazepines, antipsychotic medications, gabapentinoids, cannabinoids and psychostimulants.
How this list was made
Through the RACP Evolve program, the Chapter Committee of the Australasian Chapter of Addiction developed a draft Evolve Top-5 Recommendations of low-value practices and interventions that pertain to the specialty. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest or professional engagement with addiction medicine.
The list was then consulted with other medical colleges including through Choosing Wisely Australia. The recommendations were also reviewed by the College’s Aboriginal and Torres Strait Islander Health Committee to ensure that the list adequately reflects the health needs of Indigenous Australians with substance use disorders.
Feedback received in the consultations led to further fine tuning of the list, which was then finalised and approved by the AChAM President and President-Elect.
Australasian Chapter of Sexual Health Medicine
Australasian Chapter of Sexual Health Medicine
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- Do not order herpes serology tests unless there is a clear clinical indication.
- Do not screen for chlamydia using serological tests.
- Do not treat recurrent or persistent symptoms of vulvovaginal candidiasis with topical and oral anti-fungal agents without further clinical and microbiological assessment.
- Do not test for ureaplasma species in asymptomatic patients.
- Do not prescribe testosterone therapy to older men except in confirmed cases of hypogonadism
How this list was made
With the assistance of the Royal Australasian College of Physicians as part of Evolve, the Australasian Chapter of Sexual Health Medicine (AChSHM) Council produced and distributed to its membership an online survey. The survey listed 5 examples of clinical practices in sexual health medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context.
Members were asked to comment on these examples and to suggest other low-value practices which may be a sizeable issue in the specialty. Based on the feedback, 8 items were identified for further investigation by AChSHM Council through an evidence review. This resulted in the final list of 5 recommendations which were endorsed by the Council on 15 December 2016.
In July 2018 the Australasian Chapter of Sexual Health Medicine undertook a review of their Top-5 recommendations. Due to changes in evidence, and physician support, recommendation 5 was replaced. The removed recommendation read: “Reconsider the use of nucleic acid amplification testing for gonorrhoea in low-prevalence (i.e. <1% prevalence) populations and people who do not belong to a higher risk group.”
Australasian College for Emergency Medicine
Australasian College for Emergency Medicine
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Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation*.
- Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
How this list was made
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
Australasian Faculty of Occupational and Environmental Medicine
Australasian Faculty of Occupational and Environmental Medicine
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- Do not request low back X-rays or other forms of low back imaging as part of a routine preplacement medical examination.
- Do not order X-rays or other imaging for acute non-specific low back pain, unless there are red flags or other clinical reasons to suspect serious spinal pathology.
Do not prescribe opioids for the treatment of acute or chronic pain without assessing the patient’s clinical condition, potential side effects, alternative analgesic options, work status, and capacity to perform safety-critical activities such as driving a motor vehicle.
- Do not certify a patient as totally unfit for work unless the work absence is clinically necessary and the patient is unfit for suitable alternative or restricted duties.
- Do not repeat chest X-rays when screening asbestos-exposed workers unless clinically indicated.
How this list was made
The College worked with the President and EVOLVE Lead Fellow of AFOEM to compile and refine a list of nine recommendations regarding low-value clinical practices in occupational and environmental medicine. This initial list served as the basis for an online survey. Based on survey responses, each of the nine recommendations was assigned a score and ranked accordingly. Based on the ranking of the initial nine, and the review of newly suggested items, these five low-value practices and interventions were chosen.
Australasian Faculty of Rehabilitation Medicine
Australasian Faculty of Rehabilitation Medicine
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- Do not discharge patients with osteoporotic fractures without an assessment and/or treatment for osteoporosis.
- Do not prescribe spinal orthotics or bed rest for patients with non-specific low back pain.
- Do not use Mini Mental State Examination as the only tool to assess cognitive deficit in acquired brain injury.
- Do not routinely use splinting for prevention and/or management of contractures after stroke.
- Do not use imaging for diagnosing non-specific acute low back pain in the absence of red flags.
How this list was made
A working group within AFRM initially identified 10 recommendations on low value practices in the field of rehabilitation medicine that may be widespread in Australia and New Zealand. Following a review of the evidence these were reduced to seven. An online survey based on these seven recommendations was distributed to all AFRM members asking them to rate these recommendations based on whether they thought they were evidence based, whether the low-value practices targeted were still being undertaken in significant numbers, and whether the recommendation was important in terms of reducing harm and unnecessary costs to patients. The working group reviewed the feedback and finalised the ‘top 5’ recommendations which were approved by AFRM Executive in mid-2017.
Australasian Paediatric Endocrine Group
Australasian Paediatric Endocrine Group
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- Do not rely on random measures of circadian hormones for diagnostic purposes.
- Do not rely solely on bone age measurement for assessing growth in young children with short stature under 2 years of age.
- Do not routinely measure insulin-like growth factor binding protein 3 (IGFBP-3) for workup and diagnosis of childhood short stature.
- Do not initiate gonadotropin-releasing hormone (GnRH) analogue treatment in children outside of central precocious puberty, for the target outcome of delaying puberty and improving final adult height.
- Do not routinely prescribe aromatase inhibitors to promote growth in children with short stature.
How this list was made
A working group of lead clinicians from APEG brainstormed an initial list of 11 low-value practices in paediatric endocrinology and a preliminary review of the evidence for each was undertaken. An online survey was developed based on these 11 recommendations along with a summary of the evidence for each, and circulated to APEG members for their feedback. For each recommendation, respondents were asked to assign a score from 1 to 5 (where 1 = strongly disagree and 5 = strongly agree) on two criteria: ‘The recommendation is evidence based’ and ‘The recommendation is relevant to paediatric endocrinology in Australasia’. Based on the recommendations which received the highest average total scores, and after a final in-depth review of the related evidence, the final top five were chosen and approved by APEG.
Australasian Society for Infectious Diseases
Australasian Society for Infectious Diseases
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- Do not use antibiotics in asymptomatic bacteriuria.
- Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection.
- Avoid prescribing antibiotics for upper respiratory tract infection.
- Do not investigate or treat for faecal pathogens in the absence of diarrhoea or other gastro-intestinal symptoms.
- In a patient with fatigue, avoid performing multiple serological investigations, without a clinical indication or relevant epidemiology.
How this list was made
An initial list of 10 low value interventions was compiled by the Lead Fellow of the Australasian Society for Infectious Diseases (ASID) Inc following an online discussion in ASID's discussion forum, Ozbug. The Royal Australasian College of Physicians (RACP) then facilitated a consultation of all ASID members via a survey distributed through the society’s e-newsletter. In the survey, members were asked to rank the 10 suggested interventions and suggest additional items for consideration. A subsequent shortlist of items was created by selecting the top 7 interventions as ranked by the members from the initial list.
The shortlist was sent to ASID’s special interest groups and selected members who had agreed to assist, who were asked to recommend the items to comprise the ‘top 5’. This final list was endorsed by ASID Council on 31 July 2015. The Top 5 was then circulated again to the ASID members for final comments before being signed off by ASID’s Executive Committee.
Australasian Society of Clinical Immunology and Allergy
Australasian Society of Clinical Immunology and Allergy
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- Don’t use antihistamines to treat anaphylaxis – prompt administration of adrenaline (epinephrine) is the only treatment for anaphylaxis.
- Alternative/unorthodox methods should not be used for allergy testing or treatment.
- Allergen immunotherapy should not yet be used for routine treatment of food allergy – research in this area is ongoing.
- Food specific IgE testing should not be performed without a clinical history suggestive of IgE-mediated food allergy.
- Don’t delay introduction of solid foods to infants - ASCIA Guidelines for Infant Feeding and allergy prevention recommend introduction of solid foods to infants, around 6 months of age.
How this list was made
The RACP Strategic Policy and Advocacy group assisted ASCIA in compiling the original list of 25 tests, treatments and services, that have been identified either in past work by ASCIA, other literature reviews or in evidence reviews performed by overseas specialist physician bodies or health agencies as being overused, inappropriate or of limited effectiveness.
Two electronic surveys were sent to ASCIA members who are Fellows of the RACP (256 members in total) in February 2015 and March 2015, to firstly rank a top 5 from the list of 25, and secondly to review the wording and rankings of the top 5 recommendations. The overall response rate for these surveys was 20%. All ASCIA members and relevant patient organisations were then invited to review the list.
Australian and New Zealand Association of Neurologists
Australian and New Zealand Association of Neurologists
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- Don’t perform imaging of the carotid arteries for simple faints.
- Don’t perform imaging of the brain for non-acute primary headache disorders.
- Don’t perform epidural steroid injections to treat patients with low back pain who do not have radicular symptoms in the legs originating from the nerve roots.
- Don’t use opioids for the treatment of migraine, except in rare circumstances.
- Don’t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms.
How this list was made
The ANZAN Council considered 12 clinical practices in neurology which may be overused, inappropriate or of limited effectiveness in a given clinical context. After choosing the top 5 items to prioritise, these were passed on to the appropriate subspecialty committees within ANZAN for comment and additional suggestions. The final list of the top 5 items chosen was compiled following a review of the evidence and the formulation of suitable recommendations and endorsed by the Council on 7th January 2016.
Australian and New Zealand College of Anaesthetists
Australian and New Zealand College of Anaesthetists
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- Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
- Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
- Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable.
- Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
- Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.
- Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place
How this list was made
ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.
Recommendation 1-5
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.
Recommendation 6
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.Download ANZCA Recommendations
Australian and New Zealand Intensive Care Society
Australian and New Zealand Intensive Care Society
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For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- Consider antibiotic de-escalation daily.
How this list was made
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
Australian and New Zealand Society for Geriatric Medicine
Australian and New Zealand Society for Geriatric Medicine
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- Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.
- Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.
- Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.
- Do not prescribe medication without conducting a drug regimen review.
- Do not use physical restraints to manage behavioural symptoms of hospitalized older adults with delirium except as a last resort.
How this list was made
Members of the Australian & New Zealand Society for Geriatric Medicine completed an online survey asking them to choose the 5 most relevant ‘low value’ practices from a list of 11. Respondents were also asked to nominate any additional practices which they regarded as overused, inappropriate or of limited effectiveness in the specialty of geriatric medicine. A total of 196 responses were received.
The list of items were then subject to consideration by the Federal Council. Specifically, members of Federal Council were asked to rate each of these 16 items in terms of their strength in meeting 7 criteria: Is there a reasonable evidence base upon which to drive change? Are older people likely to benefit from work we might do to change practice? Is the problem sizeable? Are there opportunities and a willingness within geriatric medicine to lead practice change? Are there opportunities to collaborate with other organisations with a shared interest in the area? Will this promote a positive profile for ANZSGM? Is this an area of potential conflict with other Societies?
Based on the ratings they assigned to these items the ‘Top 5’ list items were chosen and reformulated as recommendations for clinicians.
Australian and New Zealand Society of Blood Transfusion
Australian and New Zealand Society of Blood Transfusion
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Do not use peri-operative transfusion for otherwise reversible anaemia prior to elective surgery.
Do not transfuse red blood cells for iron deficiency where there is no haemodynamic instability.
Do not transfuse more units of blood than necessary.
Do not order a group and crossmatch when a group and antibody screen would be appropriate.
Do not transfuse standard doses of fresh frozen plasma to correct a mildly elevated (<1.8) international normalized ratio prior to a procedure.
How this list was made
As part of the Evolve program, the RACP Policy and Advocacy team has worked with the Australian and New Zealand Society of Blood Transfusion (ANZSBT) to develop and finalise this Evolve Top-5 list of low-value care that pertains to the specialty.
Per usual processes, the list of low value practices was first identified by the ANZSBT Council and condensed to the top-5 recommendations, through a membership survey, extensive research and rounds of redrafting under the guidance of the ANZSBT Council. The list was subjected to an extensive review and consultation process that involved RACP-affiliated specialty societies and other key colleges via the Choosing Wisely program. Feedback from the consultation has been integrated into the top-5 recommendations by the ANZSBT and approved by its Council in December 2021.
Version 1 published January 2022.
Australian and New Zealand Society of Palliative Medicine & the Australasian Chapter of Palliative Medicine
Australian and New Zealand Society of Palliative Medicine & the Australasian Chapter of Palliative Medicine
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- Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.
- Limit routine use of antipsychotic drugs to manage symptoms of delirium.
- Do not use oxygen therapy to treat non-hypoxic dyspnoea.
- Target referrals to bereavement services for family and caregivers of patients in palliative care settings to those experiencing more complicated forms of grief rather than as a routine practice.
- To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review.
How this list was made
Fellows from the Australian and New Zealand Society of Palliative Medicine and Australasian Chapter of Palliative Medicine (ANZSPM/AChPM) convened a working group to produce an EVOLVE list for palliative medicine. The Royal Australasian College of Physicians (RACP) assisted this working group in compiling a list of 15 clinical practices in palliative medicine which may be overused, inappropriate or of limited effectiveness in a given clinical context based on a desktop review of similar work done overseas.
This list was then sent out to all ANZSPM and AChPM members, seeking feedback on whether the items fully captured the concerns of clinicians in an Australasian palliative medicine context and if not, whether any items should be omitted and/or new items added. 40 responses to this email were received. Based on these, 3 items were removed leaving a shortlist of 12. An online survey was then sent to all ANZSPM and AChPM members asking respondents to rate each item against three criteria from 1 (lowest) to 5 (highest), and to nominate any additional practices worthy of consideration.
The criteria used to rate the practices were strength of evidence, significance in palliative care and whether palliative care physicians could make a difference in influencing the incidence of the practice in question. Based on the 114 responses to this survey, the top 5 were selected.
Australian College of Nursing
Australian College of Nursing
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- Don’t replace peripheral intravenous catheter unless clinically indicated.
- Don’t restrict the ability of people with diabetes to self-manage blood glucose monitoring unless there is a clinical indication to do so.
- Don’t routinely administer antipyretics with the sole aim of reducing body temperature in un-distressed children.
- Don’t use urinary catheters to manage urinary incontinence unless all other appropriate options have proved to be ineffective or to prevent wound infection or skin breakdown.
- Don’t initiate plain X-ray for foot and ankle trauma unless criteria of the Ottawa Ankle Rules are met.
How this list was made
The Australian College of Nursing (ACN) as nursing lead, established a collaborative working party incorporating a diverse range of nursing expertise. Professional nursing bodies involved in initial collaboration included: Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM); CRANAplus; Australian Primary Health Care Nurses Association (APNA); Australian College of Mental Health Nurses (ACMHN).
ACN’s membership was consulted via publications, web site and ACN’s National Nursing Forum. This consultation provided a broad view from our members regarding planning and delivery of nursing care across Australia. An interactive session invited delegates to actively participate in identifying those nursing practices, interventions, or tests that evidence shows provide no benefit or may even lead to harm. This informative stimulating session examined a range of nursing practices and their effects on healthcare consumers.
At this point specialist nursing groups were approached for comment on our recommendations. This group included: Australasian College for Infection Prevention and Control (ACIPC); Australian Diabetes Educators Association (ADEA); Continence Nurses Society Australia (CNSA); Australian and New Zealand Urological Nurses Society (ANZUNS); Medical Imaging Nurses Association (MINA); and the Australian and New Zealand Orthopaedic Nurses Association (ANZONA). Final consultation with ACN Members and Fellows prior to submission ensured a collaborative result.
Australian Rheumatology Association
Australian Rheumatology Association
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- Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
- Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
- Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
- Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
- Do not order anti-double stranded (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high.
How this list was made
An ARA Evolve working group comprising 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients.
A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare.
Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.
College of Intensive Care Medicine of Australia and New Zealand
College of Intensive Care Medicine of Australia and New Zealand
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For patients with limited life expectancy (such as advanced cardiac, renal or respiratory failure, metastatic malignancy, third line chemotherapy) ensure patients have a ‘goals of care’ discussion at or prior to admission to ICU and for patients in ICU who are at high risk for death or severely impaired functional recovery, ensure that alternative care focused predominantly on comfort and dignity is offered to patients and their families.
- Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible.
- Transfuse red cells for anaemia only if the haemoglobin concentration is less than 70gm/L or if the patient is haemodynamically unstable or has significant cardiovascular or respiratory comorbidity.
- Undertake daily attempts to lighten sedation in ventilated patients unless specifically contraindicated and deeply sedate mechanically ventilated patients only if there is a specific indication.
- Consider antibiotic de-escalation daily.
How this list was made
A working group of interested parties from both CICM and ANZICS was formed to develop a list of 12 items that they believe should be focused on to reduce the number of unnecessary tests and interventions performed in intensive care. All CICM Fellows and ANZICS members were surveyed to develop a consensus view of a final list of five items. There were 6 items clearly favoured and two of these were combined by the working group to develop the final 5 recommendations.
Faculty of Pain Medicine, ANZCA
Faculty of Pain Medicine, ANZCA
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- Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain (CNCP).
- Do not continue opioid prescription for chronic non-cancer pain (CNCP) without ongoing demonstration of functional benefit, periodic attempts at dose reduction and screening for long-term harms.
- Avoid prescribing pregabalin and gabapentin for pain which does not fulfil the criteria for neuropathic pain
- Do not prescribe benzodiazepines for low back pain.
- Do not refer axial lower lumbar back pain for spinal fusion surgery.
- Do not prescribe currently available medicinal cannabis products to treat chronic non-cancer pain (CNCP) unless part of a registered clinical trial.
- Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place
How this list was made
Recommendation 1-5
The Faculty of Pain Medicine (FPM), ANZCA established a working group to develop a preliminary list of pain medicine related practices that were identified, using current clinical evidence, as having possible limited benefit, no benefit or which may potentially cause harm to patients. An online survey tool was used to survey all FPM fellows and trainees inviting them to rank these recommendations and to provide any comment related to them. This engagement facilitated consensus and informed the Fellows and trainees about FPM’s involvement with the Choosing Wisely campaign.
FPM's final list of 5 Choosing Wisely recommendations reflects those that were the most broadly supported by the clinicians and which were considered to be the most relevant to community practice.
Recommendation 6
FPM Board directed that a poll of the fellowship be conducted to assess support for a sixth Choosing Wisely recommendation regarding the role of medicinal cannabis in chronic non-cancer pain treatment. The survey question was very similar to the final wording of the recommendation, and was supported by 79% of the fellows who responded (more than 25% of the active fellowship).
The final draft wording of the recommendation, explanation and list of key references was then approved by the Board and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the following Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.
Recommendation 7
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.
Gastroenterological Society of Australia
Gastroenterological Society of Australia
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- Do not repeat colonoscopies more often than recommended by the National Health and Medical Research Council (NHMRC) endorsed guidelines
- Do not undertake faecal occult blood testing in patients who report rectal bleeding, or require investigation for iron deficiency or gastrointestinal symptoms
- Do not continue prescribing long term proton pump inhibitor (PPI) medication to patients without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether
- Do not undertake genetic testing for coeliac genes as a screening test for coeliac disease
- Do not perform a follow-up endoscopy less than three years after two consecutive findings of no dysplasia from endoscopies with appropriate four quadrant biopsies for patients diagnosed with Barrett’s Oesophagus.
How this list was made
The Gastroenterological Society of Australia (GESA) initially engaged its members through its regular online communications, sharing the aims of the EVOLVE initiative, as well as background information on the US and Canadian versions of Choosing Wisely. Members were provided with a copy of the five recommendations made by the American Gastroenterology Association. GESA also consulted externally, with the EVOLVE Lead Fellow addressing the GUT club and the Inflammatory Bowel Disease Group on the initiative. All members of GESA were invited to submit proposed items for the Top 5 list. The GESA Council reviewed all items before reaching consensus on the recommended final list. A review of the evidence for the shortlisted items was then undertaken and the final list and its rationales were signed off by the GESA Council in May 2016.
Haematology Society of Australia and New Zealand
Haematology Society of Australia and New Zealand
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Do not conduct thrombophilia testing in adult patients under the age of 50 years unless the first episode of venous thromboembolism (VTE):
- occurs in the absence of a major transient risk factors (surgery, trauma, immobility),
- occurs in the absence of oestrogen-provocation,
- occurs at an unusual site
- occurs in the absence of a major transient risk factors (surgery, trauma, immobility),
- Limit surveillance computed tomography (CT) scans in asymptomatic patients with confirmed complete remission following curative intent treatment for aggressive lymphoma – except for patients on a clinical trial
- Do not extend anticoagulation beyond 3 months for a patient with a non-extensive, index venous thromboembolic event (VTE), which occurred in the setting of a major, transient risk factor
- Do not perform baseline or routine surveillance CT scans or bone marrow biopsy in patients with asymptomatic early stage chronic lymphocytic leukaemia (CLL)
- Do not treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a platelet count <30,000/L without risk factors for bleeding.
How this list was made
The Haematology Society of Australia and New Zealand (HSANZ) council, which includes 9 state representatives, convened to form the working group to produce a ‘top 5’ list for haematology.
Drawing on the list produced by the American and Canadian Societies of Haematology, the working group compiled a list of 5 clinical practices in haematology which may be overused, inappropriate or of limited effectiveness in a given clinical context.
This list was then sent out to all HSANZ members seeking feedback on whether these items fully captured the concerns of clinicians in an Australasian haematology medicine context and if not, whether any items should be omitted and/or new items added.
The criteria used to rate the practices were strength of evidence, significance in haematology and whether haematologists could make a difference in influencing the incidence of the practice in question.
Feedback on the items and the recommendations was received from 11 institutional haematology departments (following intradepartmental consultation) as well as an additional 10 individuals.
Based on these responses, the top 5 items were selected and finalised.
Human Genetics Society of Australasia
Human Genetics Society of Australasia
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- Don’t use brain magnetic resonance imagery (MRI) for routine surveillance of asymptomatic neurofibromatosis type 1
- Don’t undertake sequential testing for heterogeneous genetic disorders when targeted next generation sequencing (NGS) is available
- Don’t undertake genetic testing for methylenetetrahydrofolate reductase (MTHFR), apolipoprotein E (APOE) and other such tests where the clinical utility for diagnostic purposes is extremely low
- Don’t undertake carrier state testing for rare recessive disorders where a partner has a family history, the couple is non-consanguineous and there are no common causative mutations.
- Don’t undertake genetic testing when clinical diagnostic criteria exist and there are no reproductive or predictive testing implications.
How this list was made
A preliminary list was developed by the Lead Fellow which was then distributed to all the clinical geneticists in Australia who are all members of the Australasian Association of Clinical Geneticists (AACG), a special interest group of the HGSA. Following feedback the topic was revisited at a meeting of this group during the annual scientific conference of the HGSA, after which the list was finalised.
Internal Medicine Society of Australia and New Zealand
Internal Medicine Society of Australia and New Zealand
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- Avoid medication-related harm in older patients (>65 years) receiving 5 or more regularly used medicines by performing a complete medication review and deprescribing whenever appropriate.
- Don’t request daily full blood counts, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) as measures of response to antibiotic treatment if patients are clinically improving.
- Once patients have become afebrile (non-feverish) and are clinically improving, don’t continue prescribing intravenous antibiotics to those with uncomplicated infections and no high-risk features if they are tolerant of oral antibiotics.
- Don’t request Holter monitoring, carotid duplex scans, echocardiography, electroencephalograms (EEGs) or telemetry in patients with first presentation of uncomplicated syncope and no high risk features.
Don’t request computerised tomography pulmonary angiography (CTPA) as first-choice investigation in non-pregnant adult patients with low risk of pulmonary thromboembolism (PTE) by Wells’ score (score <= 4); imaging can be avoided in low risk patients if D-dimer test is negative after adjusting for age
How this list was made
A panel of IMSANZ members produced an initial list of 32 low value tests, treatments and management decisions frequently encountered in general medicine services. This initial list was distributed via e-mail to 350 members of a working group comprising approximately 50 general physicians as well as nurses and allied health professionals who ranked the items in terms of priority and were free to nominate additional items. Based on their responses, the list was condensed to 15 items including three which were not previously listed. These 15 items were the subject of a face-to-face forum of the working group which reached consensus on a final list of 10.
Recommendations on ‘what not to do’ were formulated around these 10 items and a summary of the evidence for each recommendation was prepared. An online survey based on this work was presented to, and approved by, IMSANZ Council. The survey was sent to all IMSANZ members asking respondents to assign a score from 1 to 5 for each recommendation on three criteria: ‘The clinical practice being targeted by this recommendation is still being undertaken in significant numbers’; ‘This recommendation is evidence-based’; and ‘This recommendation is important in terms of reducing harm to patients and/or costs to the healthcare system’. The survey attracted 182 respondents from all across Australia and New Zealand, which was a response rate of 26%. The final top five chosen were the recommendations with the five highest average total scores assigned to them.
Medical Oncology Group of Australia
Medical Oncology Group of Australia
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- Avoid cytotoxic chemotherapy in patients with advanced cancer who are unlikely to benefit from chemotherapy (ECOG performance status 3 or 4) and continue to focus on symptom relief and palliative care.
- Do not perform routine cancer screening, or surveillance for a new primary cancer, in the majority of patients with metastatic disease.
Avoid tests (biomarkers and imaging) for recurrent cancer in previously treated asymptomatic patients unless there is evidence that early detection of recurrence can improve survival or quality of life; including avoiding surveillance testing (biomarkers) or imaging (PET, CT and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
- Do not perform serum tumour marker tests except to evaluate or monitor a cancer known to produce these markers.
- Do not routinely offer pharmacological venous thromboembolism (VTE) prophylaxis to ambulatory outpatients who are undergoing oncological treatment.
How this list was made
An Evolve working group of MOGA members was established and compiled an initial list of 79 potentially low-value tests, treatments, and other clinical practices in medical oncology, drawing on the results of a desktop review and clinical experience. Anonymised email feedback on the list was collated and analysed and the initial list was reduced to 64 items. These were divided into seven categories, ranging from ‘Diagnosis and staging’ to ‘Therapy’. An online survey allowed members of the working group to anonymously choose the top six or the top three from each category (depending on the number in the category). From this, a list of the top-28 items was then presented to the MOGA Executive Committee. Following anonymised email feedback, this list was further reduced to 24 items. Each member of the Committee was invited to nominate their top-12 of these. Responses were consolidated and a list of 11 items compiled, which served as the basis of a final online survey, to which the entire MOGA membership was invited to respond. Respondents assigned a score of 1 to 5 for each item based on their level of agreement with each. Scores for each item were averaged and the top-5 list produced.
Pharmaceutical Society of Australia
Pharmaceutical Society of Australia
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Do not initiate medications to treat symptoms, adverse events, or side effects (unless in an emergency) without determining if an existing therapy or lack of adherence is the cause, and whether a dosage reduction, discontinuation of a medication, or another treatment is warranted.
- Do not promote or provide homeopathic products as there is no reliable evidence of efficacy. Where patients choose to access homeopathic treatments, health professionals should discuss the lack of benefit with patients.
- Do not dispense a repeat prescription for an antibiotic without first clarifying clinical appropriateness.
Do not prescribe medications for patients on five or more medications, or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements should or can be reduced or discontinued.
- Do not continue benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium for more than three months without review.
- Do not recommend complementary medicines or therapies unless there is credible evidence of efficacy and the benefit of use outweighs the risk.
How this list was made
A working party of members of the Pharmaceutical Society of Australia (PSA) was established. Members of the State and Territory Branch Committees were invited to contribute suggested recommendations. Over 40 recommendations were submitted. The working party grouped the recommendations into themes, eliminated ones that were out of scope, reduced the list to twelve and refined the wording. All PSA members were sent an online survey to rank the proposed recommendations, indicate how likely they would be to implement the recommendations in practice, and suggest additional items for consideration.
Based on the survey responses, six recommendations were shortlisted and supporting evidence gathered. The final list was signed off by the PSA Board in November 2018.
Note: PSA uses Vancouver reference style. Where there are more than three authors, only the first three are listed followed by et al.
RACP Paediatrics & Child Health Division
RACP Paediatrics & Child Health Division
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- Do not routinely prescribe oral antibiotics to children with fever without an identified bacterial infection
- Do not routinely undertake chest X-rays for the diagnosis of bronchiolitis in children or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis in children
- Do not routinely order chest X-rays for the diagnosis of asthma in children
- Do not routinely treat gastroesophageal reflux disease (GORD) in infants with acid suppression therapy.
- Do not routinely order abdominal X-rays for the diagnosis of non-specific abdominal pain in children
How this list was made
The Paediatrics & Child Health Division (PCHD) formed a group of interested Fellows to comprise a General Paediatrics EVOLVE Working Group. A review of low-value practices relevant to general paediatrics was conducted drawing on lists published by Choosing Wisely US and Canada, contributions to Choosing Wisely Australia by other medical colleges and published EVOLVE lists developed by other specialties in order to identify low-value practices of relevance while avoiding duplicating the mention of practices already identified in other EVOLVE lists. Based on this review, the Working Group shortlisted 15 items for further consideration.
These 15 items were then reviewed and discussed by participants at a workshop held at the RACP Annual Congress 2016. Following these deliberations, the list was further narrowed down to 10 items. These 10 items were incorporated into an online survey which also summarised the recent evidence on each of these items. A link to the survey was distributed to all Fellows and advanced trainees of the RACP Paediatrics & Child Health Division.
Survey respondents were asked whether they agreed, disagreed or were unsure about whether each item was undertaken in a significant number of paediatric patients, whether there was good evidence that the item should be undertaken less often and whether reducing use of the item was important in terms of reducing harm and/or costs to the healthcare system. Each item was assigned a score based on respondents’ answers to these three questions on each item. There were 269 respondents representing a survey response rate of approximately 22 per cent. The five highest scoring items were selected to be on this ‘top-five’ list.
Royal Australasian College of Surgeons
Royal Australasian College of Surgeons
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- Don’t perform repair of minimally symptomatic or asymptomatic inguinal hernias without careful consideration, particularly in patients who have significant co-morbidities.
- Do not use ultrasound for the further investigation of clinically apparent groin hernias. Ultrasound should not be used as a justification for repair of hernias that are not clinically apparent.
- Don’t transfuse more units of blood than absolutely necessary, noting that many hospitals have developed policies on indications for transfusion with a view to minimisation.
- Do not use endoscopy for investigation in gastric band patients with symptoms of reflux.
- Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children and young adults until after ultrasound has been considered as an option.
- Don’t order computed tomography (CT) scan of the head/brain for sudden hearing loss.
- Don’t prescribe oral antibiotics for uncomplicated acute discharge from grommets.
- Don’t prescribe oral antibiotics for uncomplicated acute otitis externa.
- Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
- Don’t obtain computed tomography (CT) or magnetic resonance imaging (MRI) in patients with a primary complaint of hoarseness prior to examining the larynx.
How this list was made
RACS collaborated with General Surgeons Australia (GSA) and the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) respectively on the development of lists for Choosing Wisely Australia. Each organisation worked closely with key members including the Sustainability in Healthcare Committee and Professional Development and Standards Board (RACS), and the Boards of Directors (GSA and ASOHNS) to develop the lists of tests/treatments/procedures for general surgery, and head and neck surgery.
Society of Obstetric Medicine of Australia and New Zealand
Society of Obstetric Medicine of Australia and New Zealand
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- Do not test for inherited thrombophilia for placental mediated complications
- Do not do repeat testing for proteinuria in established pre-eclampsia
- Do not undertake methylenetetrahydrofolate reductase (MTHFR) polymorphism testing as part of a routine evaluation for thrombophilia in pregnancy
- Do not measure erythrocyte sedimentation rate (ESR) in pregnancy
How this list was made
SOMANZ Council members considered potential low value clinical practices in obstetric medicine of relevance to SOMANZ members, and developed a shortlist of nine items. Council members then worked with the RACP to compile and review the published research on each of these practices. Based on the review, the list of potential items of interest was refined down to seven and recommendations for these were formulated.
All Fellows and advanced trainees of SOMANZ were surveyed online for their views on these seven draft recommendations and provided with evidence summaries for each, and for their suggestions of other practices not already included. They were asked to score each recommendation based on whether they thought it was evidence based, currently undertaken in significant volume, and important for reducing harms and/or unnecessary healthcare costs. Based on the scores and feedback, the final top-five recommendations were then finalised and approved by SOMANZ Council.
The Australasian College of Dermatologists
The Australasian College of Dermatologists
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- Do not assume that bilateral redness and swelling of both lower legs is due to infection unless there is clinical evidence of sepsis such as malaise, fever and neutrophilia, plus an expanding area of redness or swelling over a period of hours to days.
- Do not routinely prescribe antibiotics for inflamed epidermoid cysts (formerly called sebaceous cysts) of the skin.
Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
- Do not prescribe topical or systemic anti-fungal medication for patients with thickened, distorted toenails unless mycological confirmation of a dermatophyte infection has been obtained.
- Monotherapy for acne with either topical or systemic antibiotics should be avoided.
- Do not recommend that patients take systemic non-sedating antihistamine for itchy rashes, i.e. eczema, psoriasis. Non-sedating antihistamines can be prescribed for urticaria according to the ASCIA guidelines.
- Do not routinely prescribe or recommend topical steroids Class II and above on the face including periorbital areas, or flexural areas of skin (axilla/groin and natal cleft).
- Review your diagnosis and/or treatment/adherence if patient has not responded to adequate prescribed topical steroids after two weeks.
How this list was made
College’s Expert Advisory Committee, comprising seven longstanding Fellows considered four potential recommendations, together with supporting evidence, and agreed to proceed with three of them. The Committee then refined and finalised the recommendations. These were reviewed by the NPS Representatives Committee and finalised in response to the feedback received.
The Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists
The Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists
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- Recognise and stop the prescribing cascade.
- Reduce the use of medicines when there is a safer or more effective non-pharmacological management strategy.
- Avoid using a higher or lower dose than is necessary for the patient to optimise the ‘benefit-to-risk’ ratio and achieve the patient’s therapeutic goals.
- Stop medicines when no further benefit will be achieved or the potential harms outweigh the potential benefits for the individual patient.
- Reduce use of multiple concurrent therapeutics (hyper-polypharmacy).
How this list was made
A working party of members of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) was established to propose an initial list of recommendations. ASCEPT’s membership was then invited to participate in an online survey to comment on the appropriateness of the proposed recommendations and suggest additional items for consideration.
Based on the survey responses, six recommendations were shortlisted. Following an evidence review the top 5 list items were selected. The final list was signed off by the ASCEPT President in April 2016.
The Australia and New Zealand Child Neurology Society
The Australia and New Zealand Child Neurology Society
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- Do not routinely perform electroencephalographs (EEGs) for children presenting with febrile seizures.
- Do not routinely perform computed tomography (CT) scanning of children presenting with new onset seizures.
- Do not routinely undertake repeat blood level monitoring of antiepileptic drug (AED) treatments.
- Do not routinely undertake neuroimaging for new onset primary headache without first examining for neurological abnormality.
- Do not routinely perform electroencephalographs (EEGs) for children presenting with syncope (fainting).
How this list was made
Following deliberations, the ANZCNS Board determined to investigate the evidence for nine priority recommendations regarding low-value clinical practices in paediatric neurology. An evidence review was developed for these recommendations and served as the basis for an online survey sent to all ANZCNS members asking respondents if they agreed, disagreed or were unsure if these recommendations were evidence based, undertaken in significant numbers, and important in terms of reducing patient harm and unnecessary healthcare expenditure. Based on survey responses, each of the nine was assigned a score and ranked accordingly. Based on this information and a final evidence review, these top 5 recommendations were chosen.
The Australian Physiotherapy Association
The Australian Physiotherapy Association
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- Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
- Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule
- Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the rules).
- Don't routinely use incentive spirometry after upper abdominal and cardiac surgery
- Avoid using electrotherapy modalities in the management of patients with low back pain.
- Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder
How this list was made
The APA sought nominations from fellows and associates of the Australian College of Physiotherapy, directors of the Physiotherapy Evidence Database, clinical specialist APA members and academic physiotherapists to form an expert panel. The APA invited all members to submit evidence about interventions related to physiotherapy that should be questioned. From members’ submissions and the expert group’s research, the expert group formed a shortlist of 8 recommendations. The expert group then considered the shortlist in terms of the extent of the health problem, usage of the test or intervention, and the evidence that the test or intervention is inappropriate. From this analysis, the expert panel selected five recommendations to put to APA members. In a second round of consultation, the APA received nearly 2500 responses, and almost 900 comments. The expert panel then considered feedback and refined the recommendations. This resulted in the 6 recommendations put forward below, for which there was overwhelming majority support.
The Endocrine Society of Australia
The Endocrine Society of Australia
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- Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
- Don’t prescribe testosterone therapy unless there is evidence of proven testosterone deficiency.
- Do not measure insulin concentration in the fasting state or during an oral glucose tolerance test to assess insulin sensitivity.
- Avoid multiple daily glucose self-monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycaemia.
- Don’t order a total or free T3 level when assessing thyroxine dose in hypothyroid patients.
How this list was made
The Medical Affairs sub-committee of the Endocrine Society of Australia (ESA) collaborated with the Royal Australasian College of Physicians (RACP) to compile a list of 44 possible low-value interventions using desktop research.
The list was examined and refined down to 8 interventions: comprising 6 that were deemed sufficiently common or important to warrant consideration and two additional practices identified by the committee. A review of the evidence for these 8 was completed and circulated to the whole ESA membership for feedback via an on-line survey. Based on the results of the survey, which attracted 146 respondents, a top 5 was identified.
The Royal Australian and New Zealand College of Ophthalmologists
The Royal Australian and New Zealand College of Ophthalmologists
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- In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
- AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
- Don't prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
- Intravitreal injections may be safely performed on an outpatient basis. Don't perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
- In general there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit.
- Do not use corneal cross linking for every patient with keratoconus.
- Do not use topical antibiotics pre or post intravitreal injections.
- Do not investigate systemically well patients with a first, uncomplicated episode of acute anterior uveitis.
- Topical steroids should not be used unless infection has been ruled out in any patient with red eye.
How this list was made
RANZCO has undertaken a multi-stage consultation process to ensure that the entire spectrum of medical eye specialists in Australia and New Zealand can contribute to the process of identifying and refining the top five recommendations. The first stage included a survey of fellows to identify possible recommendations, which were then narrowed down and by a dedicated “Choosing Wisely” committee of RANZCO members. A second survey was then sent to all members to provide feedback on the list of five and received a high response rate. Based on the extensive feedback received via the survey, RANZCO’s “Choosing Wisely” committee crafted the final wording of the top five recommendations. Finally, the RANZCO board discussed and approved the recommendations.
The Royal Australian and New Zealand College of Radiologists
The Royal Australian and New Zealand College of Radiologists
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- Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
- Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- Don’t routinely use more than one fraction for palliation of non-complex bone metastases.
- Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- Do not proceed with any treatment for localised prostate cancer unless the man has been offered a consultation with a urologist and a radiation oncologist, and taken time to consider the advantages and disadvantages of each treatment option.
How this list was made
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-10 (September 2021)
Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement and Economics and Workforce Committees, with each being asked to rank the recommendations. The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council. Recommendations 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 is adapted from Choosing Wisely Canada’s Oncology list. Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely Australia campaign.
This initial list has now been reviewed with recommendations 7, 8 & 10 remaining unchanged, recommendation 9 has been updated based on the advice of the Faculty of Radiation Oncology Quality Improvement Committee and Recommendation 11 has been replaced based on the feedback of the Quality Improvement Committee and the Policy and Advocacy team.
The Royal Australian College of General Practitioners
The Royal Australian College of General Practitioners
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- Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing.
- Don’t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event.
- Don’t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only.
- Don't screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound.
- Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use.
- Don’t order colonoscopy as a screening test for bowel cancer in people at average or slightly above average risk. Use faecal occult blood screening instead.
- Don’t order chest x-rays in patients with uncomplicated acute bronchitis.
- Don’t routinely do a pelvic examination with a Pap smear.
- Don’t treat otitis media (middle ear infection) with antibiotics, in non-Indigenous children aged 2-12 years, where reassessment is a reasonable option.
- Don’t test thyroid function as population screening for asymptomatic patients.
How this list was made
Recommendations 1 - 5 (April 2015)
All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.
Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.
Recommendations 6-10 (March 2016)
The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.
The Royal College of Pathologists of Australasia
The Royal College of Pathologists of Australasia
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- Do not perform surveillance urine cultures or treat bacteriuria in elderly patients in the absence of symptoms or signs of infection.
- Do not perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years.
- Do not perform population based screening for Vitamin D deficiency.
Restrict the use of serum tumour marker tests to the monitoring of a cancer known to produce these markers. There may be a role, however, for tumour marker measurement in the initial investigation and assessment of high risk or symptomatic individuals.
- Do not routinely test and treat hyperlipidemia in those with a limited life expectancy.
How this list was made
A list of ten items was compiled after reviewing international literature associated with the Choosing Wisely campaign in Northern America. The College’s advisory committees were canvassed for further relevant evidence based literature and their expert opinions were sought.
The ten items were then adopted as a College Position Statement titled ‘Inappropriate Pathology Requesting’. This list was then sent to RCPA Fellows and Trainees based in Australia to rank the top five tests to include in the Australian Choosing Wisely initiative. The five items selected were approved by both the RCPA's Board of Professional Practice and Quality and the RCPA Board of Directors.
The Society of Hospital Pharmacists of Australia
The Society of Hospital Pharmacists of Australia
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- Don’t initiate and continue medicines for primary prevention in individuals who have a limited life expectancy.
- Don’t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date.
- Don’t initiate and continue antipsychotic medicines for behavioural and psychological symptoms of dementia for more than 3 months.
- Don’t recommend the regular use of oral non-steroidal anti-inflammatory medicines (NSAIDs) in older people.
- Don't recommend the use of medicines with sub-therapeutic doses of codeine (<30mg for adults) for mild to moderate pain.
How this list was made
A working party was formed and they sought suggestions from SHPA’s Committees of Specialty Practice, Reference Groups, State and Territory branches and Federal Council. More than 40 proposed statements were considered by the working party. A shortlist of 10 statements was identified for consideration by the SHPA’s membership through an online survey. All members were invited to comment on each proposed statement, specifically: whether it related to the practice of pharmacy, related to medicines that are frequently used, and if a significant cost. Members were also invited to rate the statements in order of preference. The survey results were used by the working party to identify the final six statements which were presented to SHPA’s Federal Council who ratified the choice of the five final statements.
The Thoracic Society of Australia and New Zealand
The Thoracic Society of Australia and New Zealand
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- Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
- Do not prescribe antibiotics for exacerbation of asthma.
- Do not use oral beta2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
- For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
- Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.
- Do not perform a D-Dimer in patients at high risk of pulmonary embolism
- Do not use long term systemic corticosteroids for management of chronic obstructive pulmonary disease (COPD)
- Do not initiate maintenance inhalers in minimally symptomatic COPD patients with a low risk of exacerbation
- Do not routinely follow-up solid pulmonary nodules smaller than 6 mm detected in low- risk patients
- Do not perform a serum ACE for the diagnosis or monitoring of sarcoidosis
How this list was made
In 2018 The Royal Australasian College of Physicians worked with a Lead Fellow nominated by The Thoracic Society of Australia and New Zealand (TSANZ) to review evidence for 12 paediatric thoracic recommendations on low-value care in paediatric thoracic medicine. These recommendations were the subject of email discussions and deliberation by members of the Paediatric Special Interest Group (SIG) of the TSANZ. They were further discussed at a workshop held at a meeting of the Asia Pacific Society of Respirology in 2017, which included TSANZ members. Based on the feedback provided at this workshop and through email discussions with members of the SIG, four were removed and two of the original 12 were considered for inclusion in the final recommendations with overwhelming support. Members of the Paediatric SIG were then invited to choose three out of the remaining six through an email based poll. This served as the basis for final recommendations, which were further refined and developed through successive drafts based on the input of the Lead Fellow, the results of consultation with other specialty groups and the views of the TSANZ Board.
In 2020 TSANZ worked with RACP’s Policy & Advocacy team as part of the Evolve program to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting under the guidance of the TSANZ Central Office and members of the TSANZ Board, the list was condensed to the top-5 recommendations for reducing low-value practices in adult thoracic medicine. After several rounds of internal consultations and revisions, the list of recommendations was subject to an extensive review process that involved key College societies with an interest in or professional engagement with thoracic medicine.
Per usual processes, the recommendations were then consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further work and refinements by Policy & Advocacy and TSANZ, which approved these top-5 recommendations.
The Australian and New Zealand Society of Nephrology
The Australian and New Zealand Society of Nephrology
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- Do not give multiple daily doses of aminoglycoside antibiotics to patients with normal and stable kidney function as the risk of toxicity is less with a single daily dose
- Do not use oral acetylcysteine before giving radiocontrast to patients at increased risk for contrast-induced acute kidney injury
- Do not give routine prophylactic antibiotics to a child after the first urinary tract infection if at low risk of recurrent urinary tract infections
Do not intensively lower HbA1C<6.5% to <8.0% in patients with early (stage 1-3) chronic kidney disease as intense lowering increases the risk of hypoglycaemia and mortality, noting that the individual target depends on factors such as severity of CKD, macrovascular complications, comorbidities, life expectancy and others
- Do not prescribe aspirin therapy for primary prevention of cardiovascular disease in patients with stage 1-3 chronic kidney disease as there is no proven benefit and it is associated with increased risk of impaired haemostasis
How this list was made
The Australian and New Zealand Society of Nephrology (ANZSN) Clinical Policy and Advisory Committee worked with the RACP, as part of the Evolve Program, to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting, the list was condensed to the top-5 recommendations for reducing low-value practices in nephrology. Dr David Tunnicliffe has been the Lead Fellow on the project.
The list of recommendations was then subject to an extensive review process that involved key College societies with an interest or professional engagement with nephrology as well as health equity. It was then further consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further research and finetuning of the list, which was then finalised and approved by the ANZSN.