THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION. Developed by the Australasian Chapter of Sexual Health Medicine

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1 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australasian Chapter of Sexual Health Medicine 1 Do not order herpes serology tests unless there is a clear clinical indication Herpes serology is not an appropriate screening test in asymptomatic patients and does not accurately confirm whether the person is infected or is a transmission risk to others from asymptomatic shedding. Clinicians also need to consider whether test results will influence treatment or outcomes because, if they do not, then testing is a waste of finite health resources and is not indicated. Herpes serology tests only have good sensitivity and specificity in high prevalence populations. However, selective use of herpes serological tests may be justified for particular groups, such as those at high risk for STIs and human immunodeficiency virus (HIV) infection who are motivated to reduce their sexual risk behaviour; HIV-infected patients; patients with sexual partners with genital herpes; and in cases where a woman appears to have a first episode of herpes simplex virus (HSV) during pregnancy. This recommendation is endorsed by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2 Do not screen for chlamydia using serological tests There is no role for chlamydia serology as a screening test as antibodies elicited during infection are long-lived, meaning a positive antibody test will not distinguish between a previous and a current infection and are nonspecific for genital serovars. Chlamydia serology may be useful in specific circumstances, for example, investigating atypical pneumonia in babies or in identifying late stage Lymphogranuloma Venereum (LGV) infection. Laboratory tests based on nucleic acid amplification (NAAT) technologies remain the first choice for diagnosis of chlamydial infections during pregnancy and in other settings. NAAT testing for identifying LGV serovars of Chlamydia trachomatis has superseded the use of serology for diagnosis but is only available in some specialist settings. This recommendation is endorsed by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

2 3 Do not treat recurrent or persistent symptoms of vulvovaginal candidiasis (thrush) with topical and oral anti-fungal agents without further clinical and microbiological assessment While topical and oral anti-fungal agents are the recommended treatment for candidiasis, an adequate clinical and microbiological assessment should be undertaken before they are prescribed or self-administered by patients for recurrent or persistent symptoms of vulvovaginal candidiasis. It is important to rule out other causes of vulvovaginal symptoms such as bacterial vaginosis or genital herpes first so that the other infections are not left untreated. Moreover, inappropriate use of antifungal drugs can lead to increased fungal resistance, especially in non-albicans species of candida. This recommendation is endorsed by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 4 Do not test for ureaplasma species in asymptomatic patients Ureaplasma species are part of the normal genital microbiota and there are typically high rates of colonisation of the organism in sexually active adults. Testing or screening for genital infection with ureaplasma species is not recommended outside specialist or research settings as they have not been established as a cause of lower genital tract disease. This recommendation is endorsed by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 5 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 The introduction of a duplex testing item into the MBS for nucleic acid amplification testing (NAAT) of chlamydia and gonorrhoea has resulted inlaboratories performing this duplex test even if a test for only one organism was requested. Use of NAATs as a screening test for gonorrhoea in low-prevalence populations is not advised due to their low positive predictive value. However, an adequate sexual history needs to be taken in all cases to allow for the identification of higher risk groups within the population including men who have sex with men (MSM), the Aboriginal and Torres Strait Islander population, heterosexuals who travel overseas and people with multiple sexual partners. There are potential harms associated with false positive test results and incorrect diagnosis of gonococcal infections. Therefore it is recommended that use of NAAT for gonorrhoea should be reconsidered in low prevalence (i.e. <1% prevalence) populations. This recommendation is endorsed by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)

3 SUPPORTING EVIDENCE 1. Guerry SL, Bauer HM, Klausner JD, Branagan B, Kerndt, PR. Recommendations for the selective use of herpes simplex virus type 2 serological tests. Clinical Infectious Diseases 2005; 40(1): New Zealand Herpes Foundation. Guidelines for the Management of Genital Herpes in New Zealand. 10th Ed, Scoular A. Using the evidence base on genital herpes: optimising the use of diagnostic tests and information provision. Sexually Transmitted Infections 2002; 78(3): Strick L, Wald A. Type specific testing for herpes simplex virus. Expert Review of Molecular Diagnostics 2004; 4: Chernesky MA. The laboratory diagnosis of Chlamydia trachomatis infections. The Canadian Journal of Infectious Diseases & Medical Microbiology 2005; 16(1): Papp JR, Schachter J, Gaydos CA, Van Der Pol B. Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae Morbidity and Mortality Weekly Report (MMWR) 2014; 63(RR02): Davies S, Johnson E, White D. How to treat persistent vaginal yeast infection due to species other than Candida albicans. Sexually Transmitted Infections 2013; 89: Dun E. Antifungal resistance in yeast vaginitis. Yale Journal of Biology & Medicine 1999; 72(4): Sobel JD. Vulvovaginal candidosis. Lancet 2007; 369: Patel MA, Nyirjesy P. Role of Mycoplasma and ureaplasma species in female lower genital tract infections. Current Infectious Disease Reports 2010; 12(6): Donovan B, Dimech W, Ali H, Guy R, Hellard M. Increased testing for Neisseria gonorrhoeae with duplex nucleic acid amplification tests in Australia: implications for surveillance. Sexual Health 2015; Epub ahead of print. doi: /SH Fifer H, Ison CA. Nucleic acid amplification tests for the diagnosis of Neisseria gonorrhoeae in low-prevalence settings: a review of the evidence. Sexually Transmited Infections 2014; Epub ahead of print. doi: sextrans

4 HOW THIS LIST WAS MADE With the assistance of the Royal Australasian College of Physicians, 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 December 15, Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Australasian Chapter of Sexual Health Medicine (AChSHM) The Australasian Chapter of Sexual Health Medicine (AChSHM) is a Chapter of the Royal Australasian College of Physicians (RACP) Adult Internal Medicine Division that connects and represents Sexual Health Medicine Fellows and trainees in Australia and New Zealand. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

5 things clinicians and consumers should question Developed by the Australasian College for Emergency Medicine Avoid requesting 1 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 Acute flank pain due to suspected renal colic is a common clinical presentation in the emergency department. While a CT-KUB allows a rapid, contrast-free diagnosis of kidney stones, it is a high ionizing-radiation technique. Younger patients with typical renal colic pain that remits spontaneously, or with analgesia, and have no features on history, examination or laboratory investigations that suggest complicated renal stones or a serious alternate diagnosis, can be managed without repeated imaging. Concerning features include fever, features of urinary tract infection, lack of haematuria, ongoing high analgesia requirements, or palpable abdominal mass. 2 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* *Point of care testing (POCT) devices are unreliable in assessment of snakebite envenomation Abnormal coagulation test results in conditions such as acute coronary syndrome can usually be predicted by history, and they rarely affect patient management. Routine coagulation studies in the emergency department therefore represent a substantial added cost, with no benefit to patients. Coagulation studies should be performed based on a history of warfarin or heparin use, or a history of severe liver disease. Please refer to the joint ACEM/Royal Australian College of Pathologists Guideline on Pathology Testing in the Emergency Department, for further guidance on appropriate pathology test requesting in emergency departments.

6 3 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 Blood cultures taken in an emergency department do not add more information that would aid clinical management; they also represent a significant cost. The rate of false positives in blood cultures has been reported as approximately 50% and other, more direct tests have been shown to have a markedly higher yield i.e. a diagnostic procedure that often results in a definitive diagnosis. Please refer to the joint ACEM/Royal Australian College of Pathologists Guideline on Pathology Testing in the Emergency Department, for further guidance on appropriate pathology test requesting in emergency departments. 4 For emergency department patients approaching end-oflife, ensure clinicians, patients and families have a common understanding of the goals of care The emergency department is a challenging environment for end-of-life care, presenting ethical and quality of life issues. Research indicates that over 50% of Australians who die an anticipated or expected death, will die in acute hospitals, even though the majority approaching end-of-life wish to die at home. In this context, clinicians, patients and their families should work together to ensure they have a common understanding of the goals of care. Values and wishes around medical treatment should be documented. Monitoring and investigations should be appropriate. Clinicians should advocate for the patient by initiating discussion about end-of-life care with inpatient clinicians and community health professionals. When possible, arrange for end-of-life patients to be transferred to a palliative care facility to avoid admission to acute wards. 5 Don t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. Clinical decision rules have been developed that identify patients who can be safely managed without imaging. These rules include the Canadian C-Spine Rule or Nexus Low Risk Criteria. The Canadian C-Spine Rule provides higher specificity and lower imaging requirements, and should be used if possible. This is a joint recommendation with The Royal Australian and New Zealand College of Radiologists (RANZCR)

7 6 Don t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule Most head injuries presenting to emergency departments will be minor and do not require immediate neurosurgical intervention or inpatient care. Mild head injury patients can be risk stratified into low or high risk groups based on the presence or absence of identified clinical risk factors. Current validated clinical decision rules include the Canadian CT Head Rule (for adults) or the PECARN (Paediatric Emergency Care Applied Research Network) Tool (for children). These rules can safely identify patients who can be discharged home, without CT scanning. This is a joint recommendation with The Royal Australian and New Zealand College of Radiologists (RANZCR)

8 supporting evidence 1. Moore CL, Bomann S, Daniels B, Luty S, Molinaro A, Singh D, Gross CP. Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone the STONE score: retrospective and prospective observational cohort studies. BMJ. 2014;348:g2191. Katz SI, Saluja S, Brink JA, Forman HP. Radiation dose associated with unenhanced CT for suspected renal colic: impact of repetitive studies. Am J Roentolog. 2006;186(4): Patatas K, Panditaratne N, Wah TM, Weston MJ, Irving HC Emergency department imaging protocol for suspected acute renal colic: re-evaluating our service. Emergency. 2014;85(1016). Broder J, Bowen J, Lohr J, Babcock A, Yoon J. Cumulative CT exposures in emergency department patients evaluated for suspected renal colic. J Emerg Med. 2007;33(2): Smith-Bindman R, Aubin C, Bailitz, J, Bengiamin, RN, Camargo CA Jr, Corbo J, Dean AJ, Goldstein RB, Griffey RT, Jay GD, Kang TL, Kriesel DR, Ma OJ, Mallin M, Manson, W, Melnikow J, Miglioretti DL, Miller, SK, Mills LD, Miner JR, Moghadassi M, Noble VE, Press GM, Stoller ML, Valencia VE, Wang J, Wang RC, Cummings SR. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med : Schwartz D. Utility of routine coagulation studies in emergency department patients with suspected acute coronary syndromes. Isr Med Assoc J. 2005;7(8): Martin D, Beardsell I. Is routine coagulation testing necessary in patients presenting to the emergency department with chest pain? Emerg Med J. 2012;29(3): Hodgson D, Burdett-Smith P. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary: Routine coagulation testing in adult patients with epistaxis. Emerg Med J 2011;28(7):633-4 Segall J, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence based review. Transfusion. 2005; 45(9): Darcy MD, Kanterman RY, Kleinhoffer MA, Vesely TM, Picus D, Hicks ME, and Pilgram TK. Evaluation of coagulation tests as predictors of angiographic bleeding complications. Radiology. 1996; 198 (3): Murphy E, MacGlone S, McGroarty. A novel approach to improving sample ordering in an emergency department. BMJ Qual Improv Report 2015;4 Geoffrey K Isbister, Simon G A Brown, Colin B Page, David L McCoubrie, Shaun L Greene and Nicholas A Buckley Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013; 199 (11): * NSW Ministry of Health Snakebite and Spiderbite Clinical Management Guidelines. 3rd edition Cham G, Yan S, Heng BH, Seow E. Predicting positive blood cultures in patients presenting with pneumonia at an ED in Singapore, Ann Acad Med Singapore. 2009;38(6): Kennedy M, Bates DW, Wright SB, Ruiz R, Wolfe RE, Shapiro NI. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005; 46(5): Shah SS, Dugan MH, Bell LM, Grundmeier RW, Florin TA, Hines EM, and Metlay JP. Blood cultures in the Emergency Department Evaluation of Childhood Pneumonia. Pediat Inf Dis J. 2011; 30(6): Makam AN, Auerbach AD, Steinman MA. Blood culture use in the ED in patients hospitalised for community-acquired pneumonia. JAMA Intern Med. 2014; 174(5):803 Kelly AM. Clinical impact of blood cultures taken in the emergency department. J Acc Emerg Med 1998; 15(4): Mountain D, Bailey PM, O Brien D, Jelinek GA. Blood cultures ordered in the adult emergency department are rarely useful. Eur J Emerg Med. 2006; 13(2): Lukin W, Douglas C, O Connor A. Palliative care in the emergency department: An oxymoron or just good medicine? Emerg Med Austral 2012;(24): Forero R, McDonnell G, Gallego B, McCarthy S, Mohsin M, Shanley C, Formby F, Hillman K. A Literature Review on Care at the End-of-Life in the Emergency Department. Emerg Med Internat 2012;1-11. Article ID Australasian College for Emergency Medicine Curriculum Framework.

9 5. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Esenhauer MA, Greenberg GH, MacPhail I, Morrison L, Reardon M, and Worthington J. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15): Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS lowrisk criteria in patients with trauma. N Engl J Med. 2003;349(26): Anderson PA, et al. Clearance of the asymptomatic cervical spine: a meta-analysis. J Orthop Trauma. 2010;24(2): Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011;71(1): Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and economic evaluation. Health Technol Assess. 2011;15(27): Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, and Wells GA. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center. Acad Emerg Med. 2012;19:2 10. 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 5 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. Last printed: April 2015 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About Australasian College for Emergency Medicine (ACEM) ACEM is the not-for-profit organisation responsible for training emergency physicians and advancing professional standards in emergency medicine in Australia and New Zealand. As Australasia s peak professional organisation for emergency medicine, ACEM has a significant interest in ensuring the highest standards of medical care for patients are maintained in emergency departments. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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11 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australasian Society for Infectious Diseases 1 Do not use antibiotics in asymptomatic bacteriuria Antibiotic treatment of patients with asymptomatic bacteruria is generally not indicated as it does not decrease the incidence of symptomatic urinary tract infection. This also includes patients with indwelling urinary catheters. Exceptions to this are pregnant women and those undergoing an urological procedure. 2 Do not take a swab or use antibiotics for the management of a leg ulcer without clinical infection Lower leg ulcers, most commonly venous ulcers are often treated with oral antibiotics even in the absence of evidence of clinical infection. There is no evidence to support this use, except if screening for carriage of multiresistant organisms. Also a swab for microscopy and culture, in the absence of signs of infection is not recommended. Unnecessary antibiotics and swabbing will add to healthcare costs, antimicrobial resistance and patient allergy. 3 Avoid prescribing antibiotics for upper respiratory tract infection Most uncomplicated upper respiratory infections are viral in aetiology and antibiotic therapy is not indicated. Oral antibiotic therapy of presumed URTI in febrile young infants is not only low value but can be actively dangerous, in delaying presentation to hospital (inappropriately reassuring parents and confounding investigations of sepsis). This is a major issue for paediatrics primary care and ED presentations. Patient education is an important component of management together with symptomatic treatment. Infections with Streptococcus pyogenes and Bordetella pertussis do require antibiotic therapy.

12 4 Do not investigate or treat for faecal pathogens in the absence of diarrhoea or other gastro-intestinal symptoms Testing of faeces for microscopy and culture or by PCR methods should not be performed in the absence of diarrhoea or other gastro-intestinal symptoms. Similarly antimicrobial treatment for a gastrointestinal pathogen is not indicated in the absence of symptoms. For immunocompetent nontraveller children with acute gastroenteritis, there are very few circumstances when a stool test for infection would alter clinical management. Possible exceptions include refugee screening and some neurological syndromes such as enteroviral testing for acute flaccid paralysis. 5 In a patient with fatigue, avoid performing multiple serological investigations, without a clinical indication or relevant epidemiology Multiple serological testing as investigation for a patient with fatigue is not recommended. If such testing is not clinically indicated there is a risk of false positive results leading to further unnecessary investigations and useless treatments.

13 SUPPORTING EVIDENCE 1. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clinical Infectious Diseases 2005;40: Ariathianto Y. Asymptomatic bacteriuria: Prevalence in the elderly population. Australian Family Physician. 2011:40(10): Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; Jarvis TR, Chan L, Gottlieb T. Assessment and management of lower urinary tract infection in adults. Australian Prescriber 2014;37: O Meara S, Al-Kurdi D, Olugun Y, Antibiotics and antiseptics for Venus ulcers. Cochrane Database Systematic Review 2014; CD Hansson C, Hoborn J, Moller A, Swanbeck G. The microbial flora in venous leg ulcers without clinical signs of infection. Repeated culture using a validated standardised microbiological technique. Acta Dermato Venereologica 1995;75: Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Systemic Review 2013; CD Hersh AL, Jackson MA, Hicks LAl. Principles of judicious antibiotic prescribing for upper respiratory tract infections in paediatrics. Paediatrics 2013;132(6): Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; Cohen SH, Gerding DN, Johnson S. Clinical practice guidelines for clostridium difficile infection in adults: 2010 Update. Infection Control and Hospital Epidemiology 2010;31(5): Letter,dated 26/05/15, from the Australian and New Zealand Paediatric Infectious Diseases Group (ANZPID) to the Royal College of Pathologists of Australasia (RCPA) concerning the significant impact that stool multiplex PCR was having on requests for ID physician opinions and appointments for children, particularly regarding positive results for Blastocystis hominis and Dientamoeba fragilis. Hewison CJ, Heath CH, Ingram PR. Stool culture. Australian Family Physician 2012:41(10). Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; Oldmeadow M, Lloyd A. Fatigue states following infection. Infectious Diseases: A clinical approach. Third Edition. 2010, Chapter 17, Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue. The American Journal of Medical Science 1990:299(5): Therapeutic Guidelines Limited. Fatigue: diagnostic approach to fatigue in primary care. Melbourne, 2011.

14 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 The Top 5 was then circulated again to the ASID members for final comments before being signed off by ASID s Executive Committee. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Australasian Society for Infectious Diseases The Australasian Society for Infectious Diseases (ASID) Inc. is an independent organisation, founded in Melbourne in 1976 by an eminent group of physicians, pathologists and scientists. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

15 things clinicians and consumers should question Developed by the Australasian Society of Clinical Immunology and Allergy 1 Don t use antihistamines to treat anaphylaxis prompt administration of adrenaline is the only treatment for anaphylaxis For emergency treatment of a severe allergic reaction (anaphylaxis) it is important to promptly administer adrenaline by intramuscular injection using an adrenaline autoinjector if available, or by using adrenaline ampoules and syringe (the latter is only suitable in a medical setting). There is a high risk of potential harm (disability or death) from anaphylaxis if it is not treated promptly with adrenaline. There are also cost implications from delayed or inappropriate treatment of anaphylaxis, such as additional ambulance, emergency department and hospital costs, as well as additional anxiety for patients and their families or carers. Antihistamines are recommended for treatment of mild and moderate allergic reactions, including allergic rhinitis (hay fever), but have no role in treating or preventing respiratory and cardiovascular symptoms of anaphylaxis. In particular, oral sedating antihistamines should never be used in patients with anaphylaxis as side effects (drowsiness or lethargy) may mimic some signs of anaphylaxis. Injectable promethazine should not be used in anaphylaxis as it can worsen hypotension and cause muscle necrosis. 2 Alternative/ unorthodox methods should not be used for allergy testing or treatment Whilst there is currently no cure for allergy, reliable tests and a range of treatments for allergy are available, which are backed up by scientific studies that demonstrate proven safety and efficacy. In contrast, numerous studies have demonstrated the uselessness of several alternative/unorthodox methods that claim to test or treat allergy. These methods continue to be promoted in the community and some even make false claims that they can cure allergy. There is also currently no stringent regulation of alternative/unorthodox diagnostic techniques and devices, so they can be listed in Australia without having to prove that they work. There is a risk of potential harm if individuals with allergies are incorrectly diagnosed and inappropriately treated using alternative/unorthodox methods, particularly if they have severe allergies. The costs of alternative/ unorthodox methods are significant, and are usually paid for by individuals, with rebates from some private health funds. There are cost implications for healthcare services as well as individuals, as these funds are being directed

16 into non-productive areas, and are therefore not available for more useful medical tests and treatments. Examples of alternative/unorthodox methods that have been demonstrated to lack evidence for testing or treating allergy include food specific IgG and IgG4 tests, homeopathy, cytotoxic testing and kinesiology. 3 Allergen immunotherapy should not be used for routine treatment of food allergy research in this area is ongoing Research into allergen immunotherapy for food allergy is ongoing and until further work determining safety and efficacy is determined, it should not be performed outside of well defined medical research studies, as there is a high risk of potential harm in individuals with severe food allergy. Allergen immunotherapy is currently only recommended for treatment of allergic rhinitis (hay fever) due to pollen or dust mite allergy (and sometimes asthma) in appropriate patients when symptoms are severe, the cause is difficult to avoid (such as grass pollen) and medications don t help or cause adverse side effects. 4 Food specific IgE testing should not be performed without a clinical history suggestive of IgEmediated food allergy Reliable and proven diagnostic tests for food allergy include skin prick testing, blood tests for food specific IgE antibodies and medically supervised food allergen challenges. Allergy test results should never be used on their own, and must be considered together with the patient s clinical history. In the absence of a history of clinical symptoms, low levels of allergen-specific IgE are usually of little diagnostic significance. Allergy testing of individuals where there is no evidence that food allergy plays a role in their clinical symptoms increases the likelihood of irrelevant false positive results. This may lead to potential harm due to inappropriate and unnecessary dietary restrictions, with nutritional implications for the individual (particularly in children) and unnecessary fear and anxiety (particularly for the family or carers). 5 Don t delay introduction of solid/complementary foods to infants ASCIA Infant Feeding Advice recommends early introduction of solid foods to infants, from 4-6 months old This recommendation is consistent with ASCIA Infant Feeding Advice (first developed in 2008) which recommends early introduction of solid foods to infants, from 4-6 months old (including foods considered to be highly allergenic such as peanut) preferably whilst breast feeding, with no delayed introductions, unless an allergic reaction occurs. It is important to seek medical advice if an allergic reaction occurs and also regarding the safe introduction of foods if an infant has a sibling or parent with food allergy. This recommendation is also consistent with findings from recent studies, including the 2015 LEAP (Learning Early About Peanut Allergy) trial published in the New England Journal of Medicine (NEJM). The LEAP trial

17 concluded that the early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts. Whilst a recent Cochrane review cautioned against the use of this treatment despite finding benefits, this was on the basis that it had only found one valid study with 28 subjects and therefore randomised controlled trials with larger samples were needed to strengthen the evidence. The recent LEAP trial occurred after the publication of this review and had 640 subjects.

18 supporting evidence 1. Sheikh et al, H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review, Allergy Aug;62(8):830-7 Cox et al, Allergen immunotherapy: a practice parameter third update, J Allergy Clin Immunol Jan;127(1 Suppl):s1 55 Lieberman et al, The diagnosis and management of anaphylaxis practice parameter 2010 update, J Allergy Clin Immunol Sep;126(3): e1 42 Andreae, D. and M. Andreae, Should Antihistamines be Used to Treat Anaphylaxis?, BMJ. 2009;338:b Beyer and Teuber, Food allergy diagnostics: scientific and unproven procedures, Curr Opin Allergy Clin Immunol Jun;5(3): Antico et al Food-specific IgG4 lack diagnostic value in adult patients with chronic urticaria and other suspected allergy skin symptoms, Int Arch Allergy Immunol. 2011;155(1):52-6. doi: / Epub 2010 Nov 26.; Bernstein et al, Allergy Diagnostic Testing: An Updated Practice Parameter, Ann Allergy Asthma Immunol Mar;100(3 Suppl 3):S National Health and Medical Research Council NHMRC Information Paper: Evidence on the effectiveness of homeopathy for treating health conditions. Canberra: National Health and Medical Research Council; 2015 Barton et al 1983, Controversial techniques in allergy treatment, J Natl Med Assoc Aug;75(8): Garrow, J. S. Kinesiology and food allergy. Br Med J (Clin Res Ed) 1988; 296: Nurmatov et al, Effectiveness and safety of orally administered immunotherapy for food allergies: a systematic review and meta-analysis, Br J Nutr Jan 14;111(1): doi: /S Epub 2013 Aug 15. Lucendo et al, Relation between eosinophilic esophagitis and oral immunotherapy for food allergy: a systematic review with meta-analysis, Ann Allergy Asthma Immunol Dec;113(6): doi: /j.anai Epub 2014 Sep 10. Wang, J. and H. Sampson, Oral and sublingual immunotherapy for food allergy, Asian Pac J Allergy Immunol Sep;31(3): Sicherer and Wood, Allergy Testing in Childhood: Using Allergen-Specific IgE Tests, Pediatrics Jan;129(1): doi: /peds Epub 2011 Dec 26. Bernstein et al, Allergy Diagnostic Testing: An Updated Practice Parameter, Ann Allergy Asthma Immunol Mar;100(3 Suppl 3):S Du Toit et al 2015, Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy, N Engl J Med Feb 26;372(9): doi: /NEJMoa Epub 2015 Feb 23. Nurmatov et al 2012, Allergen-specific oral immunotherapy for peanut allergy, Cochrane Database Syst Rev Sep 12;9:CD doi: / CD pub2. Agostoni et al, Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition, J Pediatr Gastroenterol Nutr Jan;46(1): Allen et al, Food allergy: is strict avoidance the only answer?, Pediatr Allergy Immunol Aug;20(5): doi: /j x. Greer et al, Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas, Pediatrics 2008; 121: Snijders BE et al, Age at first introduction of cow milk products and other food products in relation to infant atopic manifestations in the first 2 years of life: The KOALA Birth Cohort Study, Pediatrics 2008; 122:e115-e122.

19 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 invited to review the list for a 2 week review period. Last printed: April 2015 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About Australasian Society of Clinical Immunology and Allergy (ASCIA) ASCIA was established in 1990 as the peak professional body for allergy and clinical immunology in Australia and New Zealand. ASCIA is a member society of the World Allergy Organisation (WAO and a specialty society affiliated with the Royal Australasian College of Physicians (RACP). ASCIA currently represents 546 members, including specialist physicians and other health professionals who work in the areas of allergy and clinical immunology. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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21 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australian and New Zealand Association of Neurologists 1 Don t perform imaging of the carotid arteries for simple faints Syncope is common, with a lifetime prevalence of 40%. Carotid imaging studies such as carotid duplex are commonly performed in patients presenting with syncope. When symptomatic, occlusive carotid artery disease causes focal neurologic symptoms such as weakness, altered sensation or speech, and not syncope. In addition, studies demonstrate that even elderly patients with syncope are unlikely to have carotid occlusive disease. Therefore, performing carotid imaging studies in patients with syncope increases cost without adding benefit. Furthermore, carotid imaging may identify incidental asymptomatic occlusive carotid artery disease that may be inappropriately assumed to be the cause of the syncope. This can delay the identification of the true cause of syncope and may subject the patient to additional risk-associated procedures such as catheter angiography, carotid endarterectomy (CEA), or carotid stenting. 2 Don t perform imaging of the brain for non-acute primary headache disorders Headache is a common disorder with many potential causes. The primary headache disorders, which include migraine and tension headaches, account for the majority of headaches. Secondary headaches, which are those with underlying pathology (e.g., tumour, aneurysm, or giant cell arteritis) are far less common. Most patients presenting with headache will not have a serious underlying condition. Neuroimaging is not usually warranted for patients with recurrent migraine or tension headaches and a normal neurological examination. The likelihood of significant intracranial lesions on CT or MRI in this group ranges from 0.3% to 0.4%. Headache worsened by Valsalva maneuver, headache causing awakening from sleep, new headache in the older population, or progressively worsening headache may indicate a higher likelihood of finding significant abnormalities on CT or MRI as does the presence of abnormal neurological signs on examination.

22 3 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 Lumbar epidural steroid injections may provide limited short term benefit (less than 3-6 months) for patients with an acute lumbar radiculopathy causing back pain and symptoms in the legs (Level C evidence). When there is low back pain alone, the outcomes of epidural steroid injections are poor. Although serious adverse events are rare, catastrophic events can occur and any symptom relief from the injection is typically brief. The inconsequential benefits of epidural steroid injections for low back pain without radicular symptoms do not outweigh its risks, no matter how small they may be. 4 Don t use opioids for the treatment of migraine, except in rare circumstances Migraine is the most frequent cause of headache seen in the medical office, urgent care, or emergency department. Almost all patients should receive migraine-specific medications or non-opioid analgesics because these medications are the most effective migraine treatments. However, many patients continue to receive opioids for migraine treatment. Use of opioids increases the risk of headache and chronic migraine arising from medication overuse. The per capita cost of headache and chronic migraine arising from medication overuse is 3 times that of episodic migraine. When medical conditions such as cardiovascular disease or pregnancy preclude use of migraine-specific treatments, or when migraine-specific treatments fail, opioids are sometimes considered for rescue therapy. In these circumstances, use should be limited to 9 days per month or less to avoid medication overuse headache, and doctors should continue to focus on preventive and behavioural aspects of migraine care. In addition, long-term follow-up is needed to prevent treatment complications. 5 Don t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms Best medical therapy is generally the appropriate management of patients with asymptomatic carotid stenosis. Medical treatment has improved since trials comparing carotid endarterectomy (CEA) plus best medical treatment with best medical treatment in asymptomatic carotid stenosis were conducted. There is evidence that the annual stroke rate in patients with asymptomatic carotid stenosis receiving best medical treatment has fallen to 1% annually. The effectiveness of CEA compared with current best medical therapy is not established. Additionally, randomised trials suggested equivocal benefit in women and patients aged >75. It may be reasonable to consider CEA for highly selected patient aged <75 years with >70% stenosis of the internal carotid artery. Where the perioperative risk of stroke, death and myocardial infarction is <3% and the patient is estimated to have a life expectancy of more than 3 to 5 years, consultation with a physician with expertise in stroke care is recommended prior to surgery.

23 SUPPORTING EVIDENCE 1. Kadian-Dodov D, Papolos A, Olin JW. Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason. Eur Heart J Cardiovasc Imaging 2015;16(6): Maung AA, Kaplan LJ, Schuster KM, et al. Routine or protocol evaluation of trauma patients with suspected syncope is unnecessary. J Trauma 2011;70(2): Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF Scientific Statement on the Evaluation of Syncope. J Am Coll Cardiol 2006;47: Morey SS. Headache Consortium releases guidelines for use of CT or MRI in migraine work-up. Am Fam Physician 2000;62(7): Medical Advisory Secretariat. Neuroimaging for the evaluation of chronic headaches: an evidence-based analysis. Ont Health Technol Assess Ser 2010;10(26): Choi HJ, Hahn S, Kim CH, et al. Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health Care 2013;29(3): Quaraishi NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis. Eur Spine J 2012;21(2): Staal JB, de Bie R, de Vet HCW, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev 2008;16:(3). 4. Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8): Evers S, Afra J, Frese A, et al. European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine revised report of an EFNS task force. Eur J Neurol [Online] 2009;16(9): Tepper SJ. Opioids should not be used in migraine. Headache 2012;52; S1: MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004;363: Lanzino G, Rabinstein AA, Brown RD. Treatment of carotid artery stenosis: medical therapy, surgery, or stenting? Mayo Clin Proc 2009;84(4): Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41:e11-7.

24 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 Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About Australian and New Zealand Association of Neurologists ANZAN aims to ensure that high standards of clinical neurology are practised in Australia and New Zealand by playing an active role in training, continuing education and encouragement of teaching and research. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

25 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australian and New Zealand College of Anaesthetists 1 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 Preoperative testing aims to provide results that will guide preoperative, intraoperative and postoperative care, particularly results that may change the intended plans. Preoperative laboratory blood investigations in asymptomatic patients undergoing low risk surgery are of little value in detecting abnormalities that will alter patient management and/or improve outcomes. Even when minor abnormalities in laboratory values are detected in asymptomatic patients, adverse outcomes are rare. Clinical history and physical examination should be used to determine the need for laboratory blood testing before low risk surgery; that is, test on the basis of patient and surgical factors. Similarly, in the absence of positive clinical findings, or significant history, abnormal chest X-ray or spirometry results are uncommon. Positive results, in the absence of symptoms or signs, are unlikely to significantly influence perioperative management. Although the diagnostic yield of preoperative chest X-rays increases with age, most abnormalities reflect chronic disorders and when performed in asymptomatic patients do not impact on anaesthetic management or perioperative outcome. In other words, chest X-ray results are not predictive of postoperative pulmonary complications in most patients. Preoperative chest X-rays may, however, be appropriate prior to cardiac and thoracic surgery and as part of oncological evaluation. There is insufficient evidence to support spirometry as an appropriate tool to stratify risk of postoperative adverse respiratory events. Spirometry may be of value in lung resection surgery, unexplained dyspnoea, and uncertainty about whether known airflow obstruction is optimally reduced. Rather than performing these investigations routinely for surgery, decisions should be individualised, depending on patient history and examination. Further, for all of these tests, lack of symptoms, signs or known disease increases the likelihood that positive findings are false positives exposing patients to the risks of unnecessary further testing.

26 2 Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery Unnecessary cardiac stress testing increases the patient risk profile for the intended surgery by exposing the patient to the inherent complications of the investigation employed. A further consequence may be the invasive treatment of asymptomatic non-critical coronary disease leading to further patient risk and delay of surgery. Cardiac stress testing should be reserved for symptomatic patients who would normally qualify for the investigation regardless of the need for an operation, and asymptomatic patients at high risk of coronary disease with a significant risk of major adverse cardiac events due to co-morbidity or the high risk nature of the surgery. 3 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 The optimal haemoglobin criterion for transfusion remains controversial and under investigation, varying between 60 and 100 g/l. Compared with higher haemoglobin thresholds, a lower haemoglobin threshold is associated with fewer red blood cell units transfused, without adverse associations with mortality, cardiac morbidity, functional recovery or length of hospital stay in young otherwise healthy patients. Hospital mortality is lower in younger patients randomised to a lower haemoglobin threshold for transfusion versus those randomised to a higher haemoglobin threshold. The decision to transfuse should be based on a combination of both haemoglobin level and assessment of the patient s clinical status, in particular, haemodynamic indicators and underlying cardiovascular pathology. Currently there is no evidence of benefit and some evidence of harm in the transfusion of packed red blood cells to young healthy haemodynamically stable patients without symptoms. 4 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 The high risk of postoperative morbidity and mortality in the elderly population in particular has been well documented. Patients over 70 years of age having major surgery in Australia and New Zealand health care facilities are at high risk for postoperative events, with 20% experiencing complications within 5 days, 10% requiring critical care admission and 5% dying within 30 days. Frailty is the state of increased vulnerability to stressors and increases the risk of adverse outcomes including falls, delirium and disability. Such stressors may include hospitalisation and surgery. Functional capacity, one aspect of frailty assessment, has been shown to be an independent predictor of mortality with each ASA class. There is currently much research into the implementation of frailty assessment as part of clinical practice and into whether preoperative measures and postoperative management can improve outcomes. Discussion with the patient and family about the risks and benefits of hospitalisation and surgery in this context are important.

27 Discussion must centre on patient values and preferences for care and the goals of care when there is significant risk of perioperative morbidity or mortality. This is particularly pertinent in patients with limited life expectancy due to advanced cardiac, renal or respiratory failure and / or metastatic malignancy. Discussions around expected functional recovery and treatment limitations have been demonstrated to reduce stress and anxiety in patients and their families. Many healthcare facilities now require advanced care directives or goals of care plans on or shortly after admission in the appropriate clinical setting. For patients at highest risk, and where time allows, the discussions should be led by a multidisciplinary, consultant level team, particularly where there is a risk of futile surgery and/or futile intensive care. It is important to ensure that alternative care, focused predominantly on comfort and dignity, is offered to patients and their families 5 Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs The ability to provide adequate perioperative care for patients with significant co-morbidities including morbid obesity is a crucial factor in determining whether surgery should be performed in a particular facility. The complexity of the proposed surgery should also be considered. Adequate and timely preoperative assessment must be facilitated to ensure that scheduling of a procedure is appropriate for the facility. In particular, small private hospitals which have no on-site medical practitioners overnight and no intensive care backup must have robust pre-admission processes in which higher risk patients are screened to ensure that they are not accepted for overnight admission unless they have been assessed as suitable for that facility by an anaesthetist or medical specialist. Intraoperative staffing, equipment and infrastructure are crucial. Postoperatively, staffing ratios and skill sets, requirements for monitoring, medical support and high dependency unit care, as well as optimal pain management, must be considered. Patients with obstructive sleep apnoea (OSA) and obese patients who may or may not have a formal diagnosis of OSA and/or obesity hypoventilation syndrome represent a particularly high risk group when pain management includes opioid analgesics. The inherent risks of postoperative respiratory depression demand adequate post procedure monitoring by skilled staff. In summary, the patient and the proposed surgery must be appropriate for the facility. Importantly, patients in rural and remote locations may accept higher risk to be closer to home and a discussion may be required with the patient and treating physicians about whether performing a procedure at a local facility is an acceptable risk.

28 SUPPORTING EVIDENCE 1. Merchant R, Chartrand D, Dain S, et al. Guidelines to the practice of anesthesia revised edition Can J Anesth 2016;63: Keay L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2012;3:CD Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, lowrisk ambulatory surgery. Ann Surg 2012;256(3): Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anesth 2005;52: De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28(10): Johansson T, Fritsch G, Flamm M, et al. Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. British Journal of Anaesthesia 2013;110(6): O Neill F, Carter E, Pink N, Smith I. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ 2016;353:i3292. Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144: Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015;373: Fleisher LA, Fleischmann KE, Auerbach AD, et al ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e Kristensen SD, Knuuti J, Saraste A, et al ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;35: Wijeysundera DN, Beattie WS, Austin PC, et al. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study. BMJ 2010;340:b Patient Blood Management Guidelines: Module 2 Perioperative. National Blood Authority au/pbm-guidelines. Carson JL, Patel MS. Is there an optimal perioperative hemoglobin level? In Fleisher L, Evidence-based practice of anesthesiology. 3rd ed, Philadelphia (PA): Elsevier Saunders. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet 2013;381: Carson JL, Carless PA, Hebert PC. Transfusion threshold and other strategies for guiding allogeneic red blood cell transfusion (Review). Cochrane Database Syst Rev 2012;4:CD Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study. Anaesthesia 2010;65: Visnjevac O, Davari-Farid S, Lee J, et al. The effect of adding functional classification to ASA status for predicting 30-day mortality. Anesthesia & Analgesia 2015;121(1): Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345. Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015;23:10.

29 5. Coroner s Court of South Australia. Finding of Inquest. Adelaide From: CoronersFindings/Lists/Coroners%20Findings/Attachments/581/RYAN%20John%20William%20and%20WALTON%20 Patricia%20Dawn.pdf McNicol, L (ed). Safety of anaesthesia: a review of anaesthesia-related mortality reporting in Australia and New Zealand Melbourne: Australian and New Zealand College of Anaesthetists, 2014 From: documents/soa-mortality-report_p4.pdf. Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012;109(6): ANZCA Professional Document PS07 Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. From: patient_preparation.pdf. Good medical practice: a code of conduct for doctors in Australia. Medical Board of Australia From: medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx. Report of the Review of Hospital Safety and Quality Assurance in Victoria. Targeting zero. Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care. Victorian Government From: www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/hospital-safety-and-quality-review.

30 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. 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. Current as at: January 2017 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Australian and New Zealand College of Anaesthetists The Australian and New Zealand College of Anaesthetists (ANZCA), including the Faculty of Pain Medicine, is one of Australasia s largest specialist medical colleges and is responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice. ANZCA also plays a significant role in the advancement of anaesthesia in South East Asia and South Pacific island countries. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

31 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australian and New Zealand Society for Geriatric Medicine 1 Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia People with dementia may exhibit aggression, resistance to care and other challenging or disruptive behaviours. In such instances, the modest effectiveness of atypical antipsychotics may be offset by the higher risks for adverse events and mortality. Non-pharmacological interventions can be an effective substitute for antipsychotic medications. Use of these drugs should therefore be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. 2 Do not prescribe benzodiazepines or other sedativehypnotics to older adults as first choice for insomnia, agitation or delirium There is strong evidence that use of sedative-hypnotics (both benzodiazepines and non-benzodiazepines) is associated with various adverse effects in elderly people such as falls and fractures. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Thus these drugs should be prescribed with caution, and their use monitored closely. 3 Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present Studies have found that asymptomatic bacteriuria frequently resolves without any treatment and frequently reoccurs after treatment. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and, in fact, often show increased adverse antimicrobial effects. 4 Do not prescribe medication without conducting a drug regimen review Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk of side effects. Evidence shows that polypharmacy is associated with adverse drug reactions and an increased risk of hospital admissions. Medication review with regular, scheduled follow ups are recommended for improving quality of life in older adults with polypharmacy.

32 5 Do not use physical restraints to manage behavioural symptoms of hospitalized older adults with delirium except as a last resort There is little evidence to support the effectiveness of physical restraints to manage people with delirium who exhibit behaviours that risk injury. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Restraints should therefore be used as a last resort and should be discontinued at the earliest possible time, particularly given that effective non-pharmacological alternatives are available.

33 SUPPORTING EVIDENCE 1. Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer s disease. Cochrane Database Syst Rev 2006;(1):CD Declerq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013;(3):CD Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a metaanalysis of randomized placebo-controlled trials. J Alzheimers Dis 2014;42(3): Richter T, Meyer G, Mohler R, Kopke S. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2012;(12):CD Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer s disease. New England Journal Med 2006;355(15): Allain H, Bentue-Ferrer D, Polard E, at al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging 2005;22(9): Finkle WD, Der J, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. Journal of the American Geriatric Soc 2011;59(10): Park SM, Ryu J, Lee DR, et al. Zolpidem use and risk of fractures: a systematic review and meta-analysis. Osteoporosis Int 2016; Apr 22. Sithamparanathan K, Sadera A, Leung L. Adverse effects of benzodiazepine use in elderly people: A meta-analysis. Asian J Gerontol Geriatr 2012;7: Stockl KM, Le L, Shang S, Harada ASM. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. American Journal Manag Care 2010;16(1):e Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA 2014;311(8): Nicolle LE, Mayhew WJ, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. American Journal of Medicine 1987;83(1): Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults Zalmanovici Trestioreaunu, Lador A, et al. Antibiotic treatment for asymptomatic bacteriuria. Cochrane Database of Systematic Reviews 2015, Issue 4, Art No CD Fried TR, O Leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. Journal of American Geriatric Society 2014;62(12): Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. American Journal Geriatr Pharmacotherapy 2007;5(4): Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-utility analysis of a medication review with follow-up service for older adults with polypharmacy in community pharmacies in Spain: The consigue Program. PharmacoEconomics 2015;33: Lu WH, Wen YW, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ 2015;187(4):e Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatric Soc 2011;59(S2):S Lach HW, Leach KM, Butcher HK. Evidence-based practice guideline: changing the practice of physical restraint use in acute care. Journal of Gerontological Nursing 2016;42(2): Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: their potential impact on the rehabilitation of older people. Int J Nurs Pract 2005;11(3):

34 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. Last reviewed: August 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Australasian and New Zealand Society for Geriatric Medicine (ANZSGM) The Australian and New Zealand Society for Geriatric Medicine is the professional society for geriatricians and other medical practitioners with an interest in the medical care of older people. The society acts to represent the needs of its members and the wider community in a bid to constantly review and improve the care of the older people in Australia and New Zealand. Its major functions are around education, policy development and review, and political advocacy. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

35 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australian and New Zealand Society of Palliative Medicine and the Australasian Chapter of Palliative Medicine 1 Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen. Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs. 2 Do not delay conversations around prognosis, wishes, values and end of life planning (including advance care planning) in patients with advanced disease Advance care planning is a process, which includes choosing a surrogate or alternate decision-maker and communicating values or wishes for medical care. Evidence shows that advance care planning conversations improve patient and family satisfaction with care and concordance between patients and families wishes, reduce the likelihood of unnecessary hospital care and increase the likelihood of receiving hospice care. 3 Do not use oxygen therapy to treat nonhypoxic dyspnoea in the absence of anxiety or routinely use oxygen therapy at the end of life Oxygen is frequently used to relieve shortness of breath in patients with advanced illness. However, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air is equally as effective as oxygen under these circumstances. The use of a fan for facial air streaming can also be effective.

36 4 Do not use percutaneous feeding tubes in patients with advanced dementia; instead use oral assisted feeding Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or longterm benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient s comfort or reduce suffering; it may cause fluid overload, diarrhoea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems. 5 To avoid adverse medication interactions and adverse drug events in cases of polypharmacy, do not prescribe medication without conducting a drug regime review Older patients disproportionately use more prescription and non-prescription drugs than other populations. Evidence shows that such polypharmacy increases the risk of adverse drug reactions and hospital admissions. Medication review with follow up is therefore recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.

37 SUPPORTING EVIDENCE 1. Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. Journal of Clin Oncology 2012;30(4): Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine 2010;363(8): Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302(7): Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. Journal of Palliative Medicine 2008;11(2): Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168(16): Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15(7): Poppe M, Burleigh S, Banerjee S. Qualitative evaluation of advanced care planning in early dementia (ACP-ED). PLoS One 2013;8(4):e Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c Chronic obstructive pulmonary disease (COPD) evidentiary framework. Ont Health Technol Assess Ser 2012;12(2):1-97. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a doubleblind, randomised controlled trial. Lancet 2010;376(9743): Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008;98(2): Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage 2006;32(6): Teno JM, Gozalo P, Mitchell SL, et al. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012;172(9): Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: a systematic review, J Am Geriatr Soc 2011;59(3): Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009;2:CD Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999;282(14): Lu WH, Wen YW, Chen LK, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ 2015;187(4):E Scott IA, Hilmer SN, Reeve E, et la. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Intern Med 2015;175(5): Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The consigue Program, PharmacoEconomics 2015;33: Fried TR, O Leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatr Soc 2014;62(12): Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. American Journal of Geriatric Pharmacotherapy 2007;5(4): Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007;167:781-7.

38 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 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Australian and New Zealand Society of Palliative Medicine and the Australasian Chapter of Palliative Medicine ANZSPM is a specialty medical society that facilitates professional development and support for its members and promotes the practice of palliative medicine. AChPM is a Chapter of the RACP s Adult Medicine Division. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

39 THINGS NURSES AND CONSUMERS SHOULD QUESTION Developed by the Australian College of Nursing 1 Don t replace peripheral intravenous catheter unless clinically indicated Peripheral intravenous catheter (IV) are routinely used for vascular access. The unnecessary removal and replacement of a functional IV catheter breaches skin integrity, posing an increased risk of healthcare-associated infection and trauma to patients. This in turn, frequently results in increased length of stay, less than optimal health care outcomes and unnecessary use of health resources. Evidence suggests there is no significant difference in cases of phlebitis if peripheral IV catheters are replaced only when clinically indicated. Common clinical indications for replacement include phlebitis, infiltration and blockage. Catheter related trauma and infection may also be minimised by vigilant monitoring of the insertion site by health care staff and removal of catheters as soon as it is no longer required. 2 Don t restrict the ability of people with diabetes to self-manage blood glucose monitoring unless there is a clinical indication to do so Imposing unnecessary blood glucose monitoring regimes, that needlessly change a person s routine, and are random, low frequency or do not provide patients or health care professionals with information that is of value in managing diabetes, will not enhance therapeutic goals. Glycaemic control is pertinent to the management of Diabetes Mellitus (DM), with self-management a valuable tool in reducing the incidence of complications, improving HbA1c levels*, enhancing quality of life and reducing related health care costs. The ability to self-care also empowers people and helps to engage them in developing and maintaining behaviours and lifestyle choices that result in improved long-term health outcomes. Blood glucose monitoring should provide feedback relevant to a person s management plan, including frequency of timing and testing. In addition, unclear or inconsistent monitoring interventions can be needlessly traumatic, may confuse patients and even discourage them from the self-management process. *The glycosylated haemoglobin (HbA1c) test shows an average blood glucose level over weeks.

40 3 Don t routinely administer antipyretics with the sole aim of reducing body temperature in undistressed children Fever is defined as a rise in body temperature above the normal range of approximately 37.8 degrees Celsius and is commonly seen as a primary indication of illness in children. It is a normal physiological response to infection and illness and will not place a generally healthy child at harm. The benefits of fever in slowing the growth and replication of bacteria and viruses are well documented within the literature, however the administration of pharmacological antipyretic therapy to reduce fever remains a common clinical intervention. Current evidence does not support the routine use of antipyretics solely to reduce body temperature but to maximise the comfort and well-being of the distressed child as an adjunct to the investigation and management of the cause of fever. Antipyretic therapy is not effective in managing adverse symptoms of fever such as febrile convulsion. Supportive care that includes parental education is also important to increase understanding and to decrease anxiety. 4 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 Urinary tract infections (UTIs) are the most common healthcare associated infection, the majority of which can be associated with the use of indwelling urinary catheters (IDC). Urinary tract infections in hospitalised patients increase morbidity and mortality, antibiotic exposure and often prolong length of hospital stay. The use of indwelling urinary catheters to manage incontinence is not recommended unless as a last resort or to prevent wound infection or skin breakdown and should be removed as soon as possible. 5 Don t initiate plain X-ray for foot and ankle trauma unless criteria of the Ottawa Ankle Rules are met Traumatic injury to the foot and ankle are a common reasons for presentation to the emergency department. The Ottawa Ankle Rules (OAR) are an effective screening tool to guide the use of plain x-ray in the evaluation of these injuries. Validation studies have found that the OARs have an almost 100% sensitivity in many studies in a number of clinical settings. The correct application of the OARs can identify patients who are likely to have a clinically significant fracture and reduce unnecessary use of diagnostic imaging resources by 30-40%.

41 SUPPORTING EVIDENCE 1. National Clinical Guideline Centre (UK). Infection: prevention and control of healthcare-associated infections in primary and community care: Partial update of NICE clinical guideline 2. London: Royal College of Physicians (UK) Morrison K, Holt K. The effectiveness of clinically indicated replacement of peripheral intravenous catheters: an evidence review with implications for clinical practice. World Views on Evidence Nursing 2015;12:(4) Webster J, Clarke S, Paterson D, Hutton A, van Dyk S, Gale C, Hopkins T. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trail. BMJ 2008;337:a339. Darvill J, Gardner A, Milbourne K, Gardner G. Routine replacement of short peripheral intravenous cannulae in children: evidence of an unnecessary practice. Australian Infection Control 2004;9:(4) Brown D, Rowland K. Optimal timing for peripheral IV replacement? BMC Medicine 2010;8:53. Webster J, Osborne S, Richard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database of Systemic Reviews 2015, Issue Pulvirenti M, McMillan J, Lawn S. Empowerment, patient centred care and self-management. Health Expectations 2014;17(3): Funnell M, Anderson RM. Empowerment and self-management of diabetes. Clinical Diabetes 2004;22(3): Ahola AJ, Groop PH. Barriers to self-management of diabetes. Diabetic Medicine 2013;30(4): *National Diabetes Services Scheme 2015, Blood Glucose Monitoring, viewed 4 March 2016, < blood-glucose-monitoring-information-sheet> 3. National Institute for Health and Clinical Excellence (NICE). Feverish Illness in Children Assessment and Management in Children Younger than 5 years. NICE Clinical Guideline 47, 2013, London, UK. Carey, JV. Literature review: should antipyretic therapies routinely be administered to a patient fever? Journal of Clinical Nursing 2010;19(17-18): Greisman LA, Mackowiak PA. Fever: beneficial and detrimental effects of antipyretics. Current Opinion in Infectious Diseases 2002; 15(3): Sullivan, JE & Farrar, HC. Clinical report: Fever and antipyretic use in children. American Academy of Paediatrics 2011; 127(3). Van den Anker, J.N. Optimising the management of fever and pain in children. The International Journal pf Clinical Practice. 2013;67(Suppl.178). 4. DeMaagd GA, Davenport TC. Management of urinary incontinence. Pharmacy and Therapeutics 2012; 37(6): Meddings J, Rogers M AM, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Quality and Safety 2013;0;1-3. Saint, S, Greene TM, Kowalski CP, Watson SR, Hofer TP & Krein SL. Preventing catheter-associated urinary tract infection in the United States: A comparative study. JAMA Intern Med 2013; 173(10): Tominaga GT, Dhupa A, McAllister SM, Calara R, Peters SA & Stuck A. Eliminating catheter-associated urinary tract infections in the intensive care unit: is it an attainable goal? The American Journal of Surgery 2014; 208: Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP & Wright RB. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Academic Emergency Medicine 2009;16(4): Stiell IG, Greenburg GH, McKnight RD, Nair RC, McDowell I & Worthington JR. A study to develop decision rules for the use of radiography in acute ankle injuries. Annals of Emergency Medicine 1992;21: Sudhir S, Pankaj K & Prakhar, G. Application of ottawa ankle rule. International research Journal of Medical Sciences 2014;2(10):7-12.

42 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Australian College of Nursing ACN is the national professional organisation for nurses in health and aged care settings. ACN provides nursing expertise to government and key stakeholders, and seeks to enhance the expertise of nurses when providing leadership and contribution to policy, practice and delivery of health care. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

43 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the College of Intensive Care Medicine of Australia and New Zealand and the Australian and New Zealand Intensive Care Society 1 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 The ANZICS Statement on Care and Decision Making at the End of Life for the Critically Ill states that the goal of intensive care is to return patients to a quality of life that is acceptable to them. In order to achieve this goal, it is essential that clinicians explore the values and preferences of each patient. Engaging with patients and their families in the discussions around treatment limitations or withdrawal can improve the quality of dying and reduce family and staff stress and bereavement. 2 Remove all invasive devices, such as intravascular lines and urinary catheters, as soon as possible Patients in the intensive care unit often require invasive devices as part of their treatment as well as monitoring of therapy. These lines however are a potential source of healthcare related infections. Preventative bundles of care including simple measures such as hand hygiene and aseptic methods of insertion and care of devices have reduced the risk of health care related infections. Infections related to invasive devices are a significant cause of morbidity and mortality. Hence, all invasive devices such as arterial lines, central lines, urinary catheters should be removed as soon as possible.

44 3 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 Numerous studies have highlighted the adverse outcomes that may be associated with blood transfusion. Randomised and other trials have indicated that transfusion of red blood cells for the treatment of anaemia in otherwise haemodynamically stable patients is either of no benefit or even harmful. There appears to be little or no proven benefit of transfusing beyond a threshold haemoglobin level of 70gm/L though the precise threshold for any given patient is unknown. Patients with active cardio-respiratory disease or neurological injury may warrant a higher threshold although harm associated with liberal transfusion in this group has also been reported. 4 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 Critically ill patients requiring mechanical ventilation are frequently treated with sedatives and analgesics, to treat pain, anxiety, dyspnoea and reduce tissue oxygen consumption. However prolonged or excessive sedation can be associated with delirium, critical illness weakness, prolonged ventilation and length of stay. Protocol-based approaches to limit deep sedation, by explicating titrating the sedation to a sedation goal, and daily interruptions of sedation, have been shown to improve patient outcomes, including a reduction in mortality. Exceptions to the daily sedation holiday are for patients requiring muscle paralysis, who should not be woken until the paralytic agent has worn off. 5 Consider antibiotic de-escalation daily Infection can precipitate a need for intensive care admission and can occur as a complication of an ICU admission. The earliest administration of the most appropriate antibiotic and source control confer mortality benefit. However, antibiotics are also frequently used for the presumptive management of patients with sepsis that may later prove to not have an infectious aetiology. In most circumstances, data regarding the appropriate duration of antibiotic administration are very difficult to interpret. In some conditions such as endocarditis or osteomyelitis longer courses of antibiotics have been recommended. However, there is increasing evidence that shorter courses of antibiotics for common infections such as hospital acquired pneumonia do not confer worse outcomes or increased mortality than longer courses. Moreover, shorter courses probably help to prevent the development of antibiotic resistance. In the absence of microbiological evidence of ongoing infection and with an improvement in clinical status, consideration should be given to discontinuing antibiotics at the earliest opportunity possible.

45 SUPPORTING EVIDENCE 1. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC. Recommendations for endof-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Critical Care Medicine 2008;36(3): Australian and New Zealand Intensive Care Society. ANZICS Statement on Care and Decision-Making at the End of Life for the Critically Ill (Edition 1.0). Melbourne, ANZICS, Fields MJ, Cassel CK. Approaching death, improving care at the end of life. Washington, D.C.: National Academy Press; 1997;437. Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD, Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004;32(3): Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Amer J Respir Crit Care Med 2005;171: Gries CJ, Engelberg RA, Kross EK, Zatzick D, Nielsen EL, Downey L, Curtis JR. Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU. Chest 2010;137(2): Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol 2015;1(6): Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis. Infection 2015;43(1): O Horo J, et. al. Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. Crit Care Med 2014;42: Pronovost P, et. al. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM 2006;355: Trautner BW, Hull RA, Darouiche RO. Prevention of catheter-associated urinary tract infection. Curr Opin Infect Dis 2005;18: The Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010); book/australian-guidelines-prevention-and-control-infection-healthcare-2010/b4-2-2-intravascular-acc CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, guidelines/bsi-guidelines-2011.pdf 3. Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. New England Journal of Medicine 2011;365(26): Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340: [Erratum, N Engl J Med 1999;340:1056]. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA 2010; Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med 2013;173: Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C. Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine 2013;368(1): Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, Johansson PI, Åneman A, Vang ML, Winding R, Nebrich L. Lower versus higher hemoglobin threshold for transfusion in septic shock. New England Journal of Medicine 2014;371(15): Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Griesdale D, Desjardins P, Lacroix J, Fergusson D, Turgeon AF. Red blood cell transfusion in patients with traumatic brain injury: a systematic review and meta-analysis. Transfusion Medicine Reviews 2016;30(1): Griesdale DE, Sekhon MS, Menon DK, Lavinio A, Donnelly J, Robba C, Sekhon IS, Taylor A, Henderson WR, Turgeon AF, Gupta AK. Hemoglobin area and time index above 90 g/l are associated with improved 6-month functional outcomes in patients with severe traumatic brain injury. Neurocritical Care 2015;23(1):78-84.

46 National Blood Authority Australia: Patient Blood Management Guidelines 2012 Module 4- Critical Care gov.au/system/files/documents/pbm-module-4.pdf National Blood Authority Australia The Patient Blood Management Guidelines Companion Restrictive Transfusion Strategy 4. Brook AD, Ahrens TS, Schai R, Prentice D, Sherman G, Shannon W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999;27: Kress JP, Pohlman AS, Hall JB. Sedation and analgesia in the intensive care unit. American Journal of Respiratory and Critical Care Medicine 2002:166(8) Marshall J, Finn C, Theodore A. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Critical Care Medicine 2008;36(2): Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008;371(9607): Jacobi J, Fraser GL, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine 2002;30(1): Kress JP, Pohlman AS, O Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Eng J Med 2000;342: Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012;308(19): Miller MA, Bosk EA, Iwashyna TJ, Krein SL. Implementation challenges in the intensive care unit: the why, who, and how of daily interruption of sedation. Journal of Critical Care 2012;27(2), 218-e1. 5. Garnacho-Montero J, Gutiérrez-Pizarraya A, Escoresca-Ortega A, Fernández-Delgado E, López-Sánchez JM. Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality. Critical Care 2015;19:302 Kumar, A et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34: Pugh R, Grant C, Cooke RPD, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database of Systemic Reviews 2015;8. Australian Therapeutic Guidelines - Antibiotic, version 15, Sawyer RG, Claridge JA, Nathens AB, Rotstein OD, Duane TM, Evans HL, Cook CH, O Neill PJ, Mazuski JE, Askari R, Wilson MA. Trial of short-course antimicrobial therapy for intraabdominal infection. New England Journal of Medicine 2015;372(21):

47 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the College of Intensive Care Medicine of Australia and New Zealand and the Australian and New Zealand Intensive Care Society CICM is responsible for intensive care medicine specialist training and education in Australia and New Zealand. ANZICS is the leading advocate on all intensive care related matters. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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49 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Gastroenterological Society of Australia 1 Do not repeat colonoscopies more often than recommended by the National Health and Medical Research Council (NHMRC) endorsed guidelines Colonoscopy, with or without polypectomy, is an invasive procedure with a small but not insignificant risk of complications, including perforation or major haemorrhage postpolypectomy, depending on size of lesion. Surveillance colonoscopies place a significant burden on endoscopy services. Consequently, surveillance colonoscopy should be targeted at those who are most likely to benefit and at the minimum frequency required to provide adequate protection against the development of cancer. Cancer Council Australia guidelines, endorsed by NHMRC, state that if one to two adenomas less than one cm in diameter are removed via a high quality colonoscopy, a follow up interval of five years is recommended. For larger adenomas, three or more adenomas or adenomas containing villous features or high grade dysplasia, which are removed via a high quality colonoscopy, the recommended follow-up period is three years. 2 Do not undertake faecal occult blood testing in patients who report rectal bleeding, or require investigation for iron deficiency or gastrointestinal symptoms The faecal occult blood test (FOBT) was developed for use in the outpatient setting for colorectal cancer screening in asymptomatic patients with average risk of colorectal carcinoma. Studies suggest that it has limited positive impact for hospitalised patients who report rectal bleeding or require investigation for iron deficiency or gastrointestinal symptoms, as it is unlikely to change patient management and may in fact delay investigations while waiting for the results of the test. Inappropriate use of the FOBT may lead to unnecessary additional investigations (e.g. colonoscopy), which also carries risks and may limit the availability of such investigations for more appropriate indications.

50 3 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 While proton pump inhibitors (PPIs) are effective drugs for the treatment of gastroesophageal reflux disease (GERD), their use has been linked to increased risk of fractures, pneumonia, enteric infections, vitamin and mineral deficiencies, and acute interstitial nephritis, particularly among older people who make up the largest proportion of PPI users. While there is insufficient evidence to establish causation, these reports deserve consideration when prescribing long term PPI use. This is especially because some patients may be able to stop PPI use immediately after the initial course of therapy without experiencing symptoms. Even though GERD is often a chronic condition, over time the disease may not require acid suppression and it is important that patients do not take drugs that are no longer necessary. 4 Do not undertake genetic testing for coeliac genes as a screening test for coeliac disease The value of testing for coeliac genes is primarily as a negative test if the gene test is negative then coeliac disease may be excluded. However as a coeliac gene can be found in approximately one third of the population, a positive result does not make coeliac disease a certainty. Serological testing, in a patient consuming an appropriate amount of gluten, is the appropriate first line screening test for coeliac disease. A small bowel biopsy is then required if serology is positive. 5 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 Barrett s Oesophagus (or Barrett s mucosa) is the term given to a change which occurs in the lining of the lower oesophagus. It occurs in a small proportion of patients with longstanding gastro-oesophageal reflux. The condition requires surveillance because of an increased risk of oesophageal adenocarcinoma (EAC). This usually develops slowly over a period of some years and can be predicted by the finding of pre-cancerous changes (dysplasia) on biopsies. However, systematic surveillance of Barrett s Oesophagus patients has not been shown to be cost-effective, and no randomised controlled trials have been conducted to compare surveillance with the natural history of Barrett s Oesophagus. According to currently-accepted guidelines, it is appropriate and safe to examine the oesophagus and check for dysplasia every three years, as cellular changes occur very slowly.

51 SUPPORTING EVIDENCE 1. Cancer Council Australia, Clinical Practice Guidelines for Surveillance Colonoscopy, December Winawer SJ, Zauber AG, O Brien MJ, et al. Randomised comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. N Engl J Med 1993; 328(13): Friedman A, Chan A, Chin LC, et al. Use and abuse of faecal occult blood tests in an acute hospital patient setting. Int Med Journal 2010;40: Ip S, Sokoro AAH, Kaita L, et al. Use of fecal occult blood testing in hospitalized patients: results of an audit. Can J Gastroenterol Hepatol 2014;28(9): Sharma VK, Komanduri S, Nayyar S, et al. An audit of the utility of in-patient fecal occult blood testing. Am J Gastroenterol 2001;96(4): Choudhry MN, Soran H, Ziglam HM. Overuse and inappropriate prescribing of proton pump inhibitors in patients with Clostridium difficile-associated disease. QJ Med 2008;101: Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemiol Drug Saf 2010;19: National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline Fasano A, Catassi C. Celiac disease. N Engl J Med 2012; 367: Megiorni F, Pizutti A. HLA-DQA1 and HLA-DQB1 in Celiac disease predisposition: practical implications of the HLA molecular typing. J Biomed Sci 2012;19: Spechler SJ, Souza RF. Barrett s Esophagus. N Engl J Med 2014;371: Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG clinical guideline: diagnosis and management of Barrett s esophagus. Am J Gastroenterol 2016;111:30-50.

52 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 Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Gastroenterological Society of Australia The Gastroenterological Society of Australia (GESA) sets, promotes and continuously improves the standards of practice, training and research in gastroenterology and hepatology in Australia. The membership includes Fellows and members of the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons interested in the study of gastroenterology. It also extends to medical graduates, trainees, pathologists, radiologists, scientists, allied health professionals, dietitians, and others interested in the science, study or practice of gastroenterology. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

53 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Haematology Society of Australia and New Zealand 1 Do not conduct thrombophilia testing in adult patients under the age of 50 years unless the first episode of venous thromboembolism (VTE): a. Occurs in the absence of major transient risk factors (surgery, trauma, immobility), or b. Occurs in the absence of oestrogen-provocation or c. Occurs at an unusual site Thrombophilia testing is costly and can result in harm to patients if the duration of anticoagulation is inappropriately prolonged or if patients are incorrectly labelled as thrombophilic. Thrombophilia testing does not change the management of VTEs occurring in the setting of major transient VTE risk factors. 2 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 CT surveillance in asymptomatic patients in remission from aggressive lymphoma may be harmful through a small but cumulative risk of radiation-induced malignancy. It is also costly and has not been demonstrated to improve survival. Therefore the anticipated benefits of post-treatment CT scans should be weighed against the potential harm of radiation exposure. Due to a decreasing probability of relapse with the passage of time and a lack of proven benefit, CT scans in asymptomatic patients more than 2 years beyond the completion of treatment are rarely advisable.

54 3 Do not extend anticoagulation beyond 3 months for a patient with a nonextensive, index venous thromboembolic event (VTE), which occurred in the presence of a major, transient risk factor Anticoagulation is potentially harmful and costly. Patients with a first VTE triggered by a major, transient risk factor are at low risk for recurrence once the risk factor has resolved and an adequate treatment regimen with anticoagulation has been completed. Evidence-based and consensus guidelines recommend three months of anticoagulation over shorter or longer periods of anticoagulation in patients with VTE in the setting of a reversible provoking factor. 4 Do not perform baseline or routine surveillance CT scans or bone marrow biopsy in patients with asymptomatic early stage chronic lymphocytic leukaemia (CLL) In patients with asymptomatic, early-stage CLL, baseline and routine surveillance CT scans do not improve survival and are not necessary to stage or prognosticate patients. CT scans expose patients to small doses of radiation, and can detect incidental findings that are not clinically relevant but lead to further investigations and are costly. For asymptomatic patients with early-stage CLL, clinical staging and blood monitoring is recommended over CT scans. 5 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 Treatment for ITP should be aimed at treating and preventing bleeding episodes and improving quality of life. Unnecessary treatment exposes patients to potentially serious treatment side effects and can be costly, with little expectation of clinical benefit. Unless they are preparing for surgery or an invasive procedure, or have a significant additional risk factor for bleeding, ITP treatment is rarely indicated in adult patients with platelet counts greater than 30,000/L. In patients preparing for surgery or other invasive procedures, shortterm treatment may be indicated to increase the platelet count prior to the planned intervention and during the immediate post-operative period.

55 SUPPORTING EVIDENCE 1. Chong LY, Fenu E, Stansby G, Hodgkinson S. Management of venous thromboembolic diseases and the role of thrombophilia testing: summary of NICE guidance. British Medical Journal 2012;344:e3979. Wai KH, Hankey GJ, Eikelboom JW. Should adult patients be routinely tested for heritable thrombophilia after an episode of venous thromboembolism? Medical Journal of Australia 2011;195 (3): Wu O, Robertson L, Twaddle S, Lowe GD, Clark P, Greaves M, Walker ID, Langhorne P, Brenkel I, Regan L, Greer I, Screening for thrombophilia in high-risk situations: systematic review and cost-effectiveness analysis. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) study. Health Technology Assessment 2006;10(11): Thompson CA, Ghesquieres H, Maurer MJ. Utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma. Journal of Clinical Oncology 2014;32: Huntington SF, Svoboda J, Doshi JA. Cost-effectiveness analysis of routine surveillance imaging of patients with diffuse large B-cell lymphoma in first remission. Journal of Clinical Oncology 2015;33(13): Cheah CY, Dickinson M, Hofman MS. Limited clinical benefit for surveillance PET-CT scanning in patients with histologically transformed lymphoma in complete metabolic remission following primary therapy. Annals of Haematology 2014; 93: Lin TL, Kuo MC, Shih LY, Dunn P, Wang PN, Wu JH, Tang TC, Chang H, Hung YS, Lu SC. Value of surveillance computed tomography in the follow-up of diffuse large B-cell and follicular lymphomas. Annals of Haematology 2012;91(11): Thompson CA, Charlson ME, Schenkein E. Surveillance CT scans are a source of anxiety and fear of recurrence in long-term lymphoma survivors. Annals of Oncology 2010;21: Shenoy P, Sinha R, Tumeh JW, Lechowicz MJ, Flowers CR. Surveillance computed tomography scans for patients with lymphoma: is the risk worth the benefits? Clinical Lymphoma Myeloma Leukemia 2010;10(4): Guppy AE, Tebbutt NC, Norman A, Cunningham D. The role of surveillance CT scans in patients with diffuse large B-cell non-hodgkin s lymphoma. Clinical Lymphoma Myeloma Leukemia 2003;44(1): Kearon C, Akl EA, Comerota AJ. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 141(suppl 2):e419Se494S. Boutitie F, Pinede L, Schulman S, Agnelli G, Raskob G, Julian J, Hirsh J, Kearon C. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants data from seven trials. British Medical Journal 2011;342:d Oscier D, Dearden C, Eren E, Fegan C, Follows G, Hillmen P, Illidge T, Matutes E, Milligan DW, Pettitt A, Schuh A, Wimperis J. British Committee for Standards in Haematology. Guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia. British Journal of Haematology 2012;159(5): Eichhorst B, Hallek M, Dreyling M, Group EGW. Chronic lymphocytic leukaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology 2010;21 Suppl 5: Hallek M, Cheson BD, Catovsky D. Guidelines for the diagnosis and treatment of chronic lymphocytic leukemia: a report from the International Workshop on Chronic Lymphocytic Leukemia updating the National Cancer Institute-Working Group 1996 guidelines. Blood 2008;111: Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA. The American Society of Hematology evidence-based practice guideline for immune thrombocytopenia. Blood 2011;117(16):

56 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Haematology Society of Australia and New Zealand Founded in 1998, The Haematology Society of Australia and New Zealand (HSANZ) seeks to promote, foster, develop and assist the study and application of information concerning haematology, and to promote improved standards, interest and research in all aspects of haematology. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

57 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Human Genetics Society of Australasia 1 Don t use brain magnetic resonance imagery (MRI) for routine surveillance of asymptomatic neurofibromatosis type 1 Neurofibromatosis type I (NF-1) is a tumour disorder caused by the mutation of a gene on chromosome 17 that is responsible for control of cell division. It causes tumours along the nervous system that can grow anywhere in the body. Routine screening investigations are not recommended for the detection of the majority of complications associated with the condition. Baseline brain and spine MRI, and routine imaging of the chest and abdomen to identify asymptomatic tumours, do not influence management and should not be undertaken. 2 Don t undertake sequential testing for heterogeneous genetic disorders when targeted next generation sequencing (NGS) is available A heterogeneous genetic disorder is one where the same disease or condition can be caused, or contributed to, by a number of different genes. The traditional strategy for genetic testing involves sequential sequencing of individual genes, selected according to the patient s clinical presentation and family history. By contrast, next generation sequencing (NGS) involves the sequencing of millions of small fragments of DNA at the same time. Reductions in the cost of NGS now make it a more attractive solution for clinical diagnostic testing to identify the disease-causing mutation(s) in patients with genetically heterogeneous disorders than traditional sequential testing. In particular, the targeted NGS approach which restricts analysis to genes known to be implicated in a particular phenotype has been also successfully applied to heterogeneous disorders such as inherited peripheral neuropathy (IP). Don t undertake 3 genetic testing for methylenetetrahydrofolate reductase (MTHFR), apolipoprotein E (APOE) and other such tests where the clinical utility for diagnostic purposes is extremely low While genetic testing can help indicate susceptibility to particular genetic conditions, there are some conditions where the presence of particular alleles is neither necessary nor sufficient to cause the condition or where the alleles have a higher prevalence in the general population than the condition itself. This is the case for instance with apolipoprotein E as a genetic marker for Alzheimer s disease and methylenetetrahydrofolate as a marker for venous thromboembolism.

58 4 Don t undertake carrier state testing for rare recessive disorders where a partner has a family history, the couple is nonconsanguineous and there are no common causative mutations With a rare recessive disorder, although the individual with the family history will have an increased risk of being a carrier, their unrelated partner will have a low general population risk. Therefore, their a priori combined risk of having a child with this rare recessive condition will generally be less than 1%. If the gene has no known common disease causative mutations then testing the unrelated partner for carrier status has low sensitivity and specificity. 5 Don t undertake genetic testing when clinical diagnostic criteria exist and there are no reproductive or predictive testing implications Like other screening or diagnostic tests, genetic tests do not have inherent utility. It is the adoption of therapeutic or preventive interventions that influences health outcomes. If clinical diagnostic criteria already exist for the condition in question and there are no reproductive or other predictive testing implications as a result of definitively identifying a genetic cause for the condition, then this renders genetic testing unnecessary.

59 SUPPORTING EVIDENCE 1. Ferner RE, Huson SM, Thomas N, et al. Guidelines for the diagnosis and management of individuals with neurofibromatosis 1. Journal of Medical Genetics 2007;44: Antoniadi T, Buxton C, Dennis G, et al. Application of targeted multi-gene panel testing for the diagnosis of inherited peripheral neuropathy provides a high diagnostic yield with unexpected phenotype-genotype variability. BMC Medical Genetics 2015;16:84. Ellard S, Lindsay H, Camm N, et al. Practice guidelines for targeted next generation sequencing analysis and interpretation. Association for Clinical Genetic Science, Goldman JS, Hahn SE, Catania JW, et al. Genetic counseling and testing for Alzheimer disease: joint practice guidelines of the American College of Medical Genetics and the National Society of Genetic Counselors. Genetics in Medicine 2011;13(6): Hickey SE, Curry CJ, Toriello HV. ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing. Genetics in Medicine 2013;15(2): Meikle PJ, Hopwood JJ, Clague AE, Carey WF. Prevalence of lysosomal storage disorders. JAMA 1999;281(3): Ferner RE, Huson SM, Thomas N, et al. Guidelines for the diagnosis and management of individuals with neurofibromatosis 1. Journal of Medical Genetics 2007;44:81-88.

60 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. Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Human Genetics Society of Australasia The Human Genetics Society of Australasia was formed in 1977 to provide a forum for the various disciplines collected under the title of Human Genetics. The HGSA is a full member of the International Federation of Human Genetics Societies and domestically we work closely with the Royal Australasian College of Physicians and Royal College of Pathologists of Australasia as well as other groups through the Pathology Associations Council. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

61 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Royal Australasian College of Surgeons General Surgeons Australia 1 Don t perform repair of minimally symptomatic or asymptomatic inguinal hernias without careful consideration, particularly in patients who have significant co-morbidities. The proportion of patients presenting with inguinal hernias who are suffering significant co-morbidities is increasing. In these populations and in the presence of multiple of co-morbidities, the importance of carefully assessing the risks and benefits of surgical intervention is vital. Studies have shown that adoption of a watch and wait approach does not heighten the risk of the patient developing more severe symptoms. In cases of minimally symptomatic and asymptomatic inguinal hernias, the patient s prognosis and long term health may be improved by non-surgical intervention. Ongoing surgical review is required to ensure that an individual s condition is monitored and that a re-evaluation of their surgical need is made should their symptoms increase in severity. 2 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. The role of ultrasound in the diagnosis and treatment of groin hernias is limited. When the clinical diagnosis of a groin hernia is uncertain, any sonographic findings should be interpreted in conjunction with clinical judgment and treated conservatively. The diagnostic accuracy of ultrasound is reduced in the absence of any clinically palpable hernia. 3 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. The limited blood resources available within the health system and the lack of evidence to support transfusing more blood than required necessitate the use of appropriate guidelines. Patients should be carefully evaluated (through use of applicable guidelines) when being assessed for blood transfusions and closely monitored.

62 4 Do not use endoscopy for investigation in gastric band patients with symptoms of reflux. The treatment of reflux in gastric band patients should be carefully considered. Endoscopy should not be used without consideration of alternative strategies. Reflux in gastric band patients is often related to the device. It is best managed by removal of fluid, in consultation with a Bariatric Surgeon or other appropriately qualified person. 5 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. Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is a good diagnostic tool that will reduce radiation exposure. Ultrasound is the preferred initial consideration for imaging examination in children and young adults. If the results of the ultrasound exam are equivocal, it may be followed by CT.

63 SUPPORTING EVIDENCE 1. Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M, et al. Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men. JAMA 2006;295(3): Turaga K, Fitzgibbons RJ, Puri V. Inguinal Hernias: Should We Repair? Surgical Clinics of North America 2008;88(1): Mayer F, Lechner M, Adolf D, Öfner D, Köhler G, Fortelny R, et al. Is the age of >65 years a risk factor for endoscopic treatment of primary inguinal hernia? Analysis of 24,571 patients from the Herniamed Registry. Surgical Endoscopy 2016;30(1): O Rourke MGE, O Rourke TR. Inguinal hernia: Aetiology, diagnosis, post-repair pain and compensation. ANZ Journal of Surgery 2012;82(4): Robinson A, Light D, Nice C. Meta-analysis of sonography in the diagnosis of inguinal hernias. Journal of Ultrasound in Medicine 2013;32(2): Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157(1): Goodnough LT, Shieh L, Hadhazy E, Cheng N, Khari P, Maggio P. Improved blood utilization using real-time clinical decision support. Transfusion 2014;54(5): Burton PR, Brown W, Laurie C, Lee M, Korin A, Anderson M, Hebbard G, O Brien PE. Outcomes, satiety, and adverse upper gastrointestinal symptoms following laparoscopic adjustable gastric banding. Obesity Surgery 2011;21(5): Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg 2011;98(10): Wan MJ, et al. Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis-a Markov decision analytic model. Radiology 2009;250(2): Doria AS, et al. US or CT for diagnosis of appendicitis in children? A meta-analysis. Radiology 2006;241(1): Krishnamoorthi R, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259(1):231-9.

64 HOW THIS LIST WAS MADE RACS and General Surgeons Australia (GSA) collaborated on the development of a list 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 Board of Directors (GSA) to develop a list of tests/treatments/procedures for general surgery. Last reviewed: March 2017 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Royal Australasian College of Surgeons RACS is the leading advocate for surgical standards, professionalism and surgical education in Australia and New Zealand. The College is a not-for-profit organisation that represents more than 7000 surgeons and 1300 surgical trainees and International Medical Graduates. RACS also supports healthcare and surgical education in the Asia-Pacific region and is a substantial funder of surgical research. About General Surgeons Australia General Surgeons Australia is a not-for-profit organisation founded in 1999, that is committed to promoting both high quality training and the continuing medical education of its members. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

65 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Royal Australasian College of Surgeons The Australian Society of Otolaryngology Head and Neck Surgery 1 Don t order computed tomography (CT) scan of the head/brain for sudden hearing loss Computed tomography scanning is expensive, exposes the patient to radiation and offers no useful information that would improve initial management. CT scanning may be appropriate in patients with focal neurologic findings, a history of trauma or chronic ear disease. Sudden hearing loss is distinct from progressive loss and chronic ear disease. Sudden sensorineural hearing loss (SSHL) can be described as at least 30dB sensorineural hearing loss (SNHL) in at least three consecutive frequencies within a three-day period. 2 Don t prescribe oral antibiotics for uncomplicated acute discharge from grommets Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections. A discharge is uncomplicated when it is not associated with any other symptom, for example fever, pain or swelling of the ear canal. 3 Don t prescribe oral antibiotics for uncomplicated acute otitis externa Oral antibiotics have significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes; in contrast, topically administered products do provide coverage for these organisms. Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

66 4 Don t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis Imaging of the paranasal sinuses, including plain film radiography, computed tomography (CT) and magnetic resonance imaging (MRI) is unnecessary in patients who meet the clinical diagnostic criteria for uncomplicated acute rhinosinusitis. Acute rhinosinusitis is defined as up to four weeks of purulent nasal drainage (anterior, posterior or both) accompanied by nasal obstruction, facial pain-pressure-fullness or both. Imaging is costly and exposes patients to radiation. Imaging may be appropriate in patients with a complication of acute rhinosinusitis, patients with comorbidities that predispose them to complications and patients in whom an alternative diagnosis is suspected. 5 Don t obtain computed tomography (CT) or magnetic resonance imaging (MRI) in patients with a primary complaint of hoarseness prior to examining the larynx Examination of the larynx with mirror or fibre optic scope is the primary method for evaluating patients with hoarseness. Imaging is unnecessary in most patients and is both costly and has potential for radiation exposure. After laryngoscopy, evidence supports the use of imaging to further evaluate 1) vocal fold paralysis, or 2) a mass or lesion of the larynx. It is essential to have the larynx examined by a specialist if the hoarseness has not resolved within 4 weeks.

67 SUPPORTING EVIDENCE 1. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: Sudden hearing loss. Otolaryngol Head Neck Surg 2012;146(IS):S1-35. Tarshish Y, Leschinski A, Kenna M. Pediatric sudden sensorineural hearing loss: Diagnosed causes and response to intervention. International Journal of Pediatric Otorhinolaryngology 2013;77(4): Goldblatt EL, Dohar J, Nozza RJ, et al. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Int J Pediatr Otorhinolaryngol 1998;46: Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical Practice Guideline: Tympanostomy tubes in children. Otolaryngol Head Neck Surg 2013;149(IS): S Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg 2014;150(IS):S1-24. Wipperman J. Otitis externa. Primary Care: Clinics in Office Practice 2014;41: Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015;152(2S):S1-39. Ebell MH, McKay B, Guilbault R, et al. Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy. British Journal of General Practice 2016;66(650):e Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1-31. Mau T. Diagnostic evaluation and management of hoarseness. Medical Clinics of North America 2010;94(5):

68 HOW THIS LIST WAS MADE RACS and The Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) collaborated on the development of a list 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 Board of Directors (ASOHNS) to develop a list of tests/treatments/procedures for head and neck surgery. Last reviewed: March 2017 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Royal Australasian College of Surgeons RACS is the leading advocate for surgical standards, professionalism and surgical education in Australia and New Zealand. The College is a not-for-profit organisation that represents more than 7000 surgeons and 1300 surgical trainees and International Medical Graduates. RACS also supports healthcare and surgical education in the Asia-Pacific region and is a substantial funder of surgical research. About the Australian Society of Otolaryngology Head and Neck Surgery ASOHNS is the representative organisation for Ear Nose and Throat Head and Neck Surgeons in Australia, and dates from ASOHNS, with the Royal Australasian College of Surgeons, provides a nationwide Training Program for future Otolaryngology Head and Neck Surgeons. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

69 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by The Australasian College of Dermatologists 1 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 Bilateral lower leg cellulitis is very rare. Most commonly the redness is due to an underlying inflammatory skin disorder such as venous eczema or a more deeply extending inflammation involving the subcutaneous fat known as lipodermatosclerosis. This condition, which occurs more frequently in patients with venous disease, who are overweight and immobile, may initially present as bilateral redness and swelling, and then progresses over time to produce scarring and hardening of the underlying tissues. A careful history and physical examination should be undertaken. An entry point for infection should be looked for, and swabs taken from open skin wounds. However, microbiological testing from intact overlying skin is usually of little value. 2 Do not routinely prescribe antibiotics for inflamed epidermoid cysts (formerly called sebaceous cysts) of the skin The inflammation is secondary to an intense foreign body reaction to the cyst contents leaking into adjacent tissues and will respond to incision and drainage. The use of intralesional corticosteroid injections has been suggested, but there are no formal studies to support this practice. Although oral antibiotics are often prescribed, there is no evidence on which to base recommendations for their routine use in this setting.

70 3 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 The individual weals of acute urticaria and angioedema can be widespread and variable in appearance, resolving in 24 hours leaving normal skin. In children, upper respiratory tract and viral infections are the most common cause of acute urticaria. Foods and medications such as antibiotics and nonsteroidal anti-inflammatory drugs are possible triggers in all age groups. Thus the cause of acute urticaria is usually suggested by a patient s history without the need for routine blood investigations. Do not prescribe topical 4 or systemic anti-fungal medication for patients with thickened, distorted toenails unless mycological confirmation of a dermatophyte infection has been obtained Fifty percent of thickened distorted toenails are caused by age, pressure from footwear (onychogryphosis) or other trauma, or associated with inflammatory disorders such as psoriasis or lichen planus, and are not due to a fungal infection. 5 Monotherapy for acne with either topical or systemic antibiotics should be avoided In light of concerns about antibiotic resistance, the treatment of acne with topical or oral antibiotics should be in combination with agents such as benzoyl peroxide or retinoids and prolonged use should be avoided.

71 SUPPORTING EVIDENCE 1. Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part I. Lower limb cellulitis. Journal of the American Academy of Dermatology 2012;67(2):163e1-163e12. Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. Journal of the American Academy of Dermatology 2012; 67(2):177.e1-177.e9. Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. British Journal of Dermatology 2011;164(6): Arakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatology 2014;150(10): Diven D, Dozier S, Meyer, D, Smith EB. Bacteriology of inflamed and uninflamed epidermal inclusion cysts. Archives of Dermatology 1998;134(1): Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol 2009;10(4): Schaefer P. Urticaria: evaluation and treatment. Am Fam Physician 2011;83(9): Grattan CEH, Humphreys F. and on behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for evaluation and management of urticaria in adults and children. British Journal of Dermatology 2007;157(6): de Berker D. Fungal nail disease. N Engl J Med 2009;360: Ameen M, Lear JT, Madan V, et al. British Association of Dermatologists guidelines for the management of onychomycosis 2014;171(5); Eisman S, Sinclair R. Fungal nail infection: diagnosis and management. BMJ 2014;348:g Eady EA, Gloor M, Leyden JJ. Propionibacterium acnes resistance: A worldwide problem. Dermatology 2003;206 (1):54-6. Earnshaw S, Mendez A, Monnet DL, et al. Global collaboration to encourage prudent antibiotic use. The Lancet Infectious Diseases 2013;13(12): Archer CB, Cohen SN, Baron SE and on behalf of British Association of Dermatologists and Royal College of General Practitioners. Guidance on the diagnosis and clinical management of acne. Clin Exp Dermatol 2012; 37(s1)1:1-6. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance the need for global solutions. The Lancet Infectious Diseases 2013;13(12): Zaenglein A, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2015;

72 HOW THIS LIST WAS MADE A long-standing College Fellow, in consultation with the Honorary Secretary prepared 5 recommendations. All ACD members were invited to choose three out of the five recommendations. Following an NPS Representatives meeting, it was noted that five recommendations are needed. Therefore the remaining two recommendations were selected. Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About The Australasian College of Dermatologists The Australasian College of Dermatologists was established in 1966 as the medical college responsible for the training and professional development of medical practitioners in the speciality of dermatology. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

73 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists 1 Recognise and stop the prescribing cascade A prescribing cascade occurs when a new medicine is prescribed to treat an adverse reaction to another drug in the mistaken belief that a new medical condition requiring treatment has developed. Prescribing cascades should be avoided because they are associated with adverse outcomes due to the second or additional drugs, which places the patient at risk. One example of a prescribing cascade is when a patient is prescribed a non-steroidal drug for pain, and is then prescribed proton pump inhibitors (PPIs) to reduce the risk of stomach side effects caused by the first prescribed drug. As prescribing cascades are precipitated by adverse drug reactions, they can be prevented by avoidance and early detection of the initial adverse drug reaction. For instance, many adverse drug reactions in the elderly are dose-related. It is advised that starting treatment at low doses and titrating to effect may reduce their risk. Most adverse drug reactions occur within a few months of starting a medicine. Clinicians should consider the potential for an adverse drug reaction to be the cause of any new symptoms, particularly if a drug has been recently started or changed. Patients should be asked about new symptoms, as many patients do not report adverse drug reactions. When such reactions occur, non-drug treatment strategies should be considered as the most appropriate first-line management, rather than starting a second medicine to counteract adverse effects. 2 Reduce the use of medicines when there is a safer or more effective nonpharmacological management strategy Pharmacological treatments should be avoided or minimised if safer or more effective nonpharmacological alternatives are available. Pharmacological treatments may become a panacea for chronic lifestyle-related problems, and may detract from behaviour management tools that have proven effective in managing these same problems. There is also a risk of adverse effects from particular pharmacological treatments which may be avoidable by using non-pharmacological management strategies. For instance, physiotherapy should be used instead of oxycodone for addressing non-cancer pain, because of the risk of adverse effects. Another example is the use of psychotropic medicines for behavioural and psychological symptoms of dementia when nonpharmacological management strategies are both more effective and safer.

74 3 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 Therapeutic dosage should be adjusted to optimise the benefit-to-risk ratio of the treatment. Dosage should be no higher or lower than needed to achieve the patient s therapeutic goals. As patients become more frail, potential harms usually increase and potential benefits usually decrease for a given dosage of pharmacological treatment. For example, carefully assessing the risk and benefits when initiating non-steroidal inflammatory drugs in elderly patients is important, because of the increased risk of stroke associated with NSAID therapy; and use of proton pump inhibitors in the elderly should be stepped down after an initial course of therapy. Related to this, high drug doses are not necessarily more effective than low doses. An example of this is the relationship between doses of a selective serotonin re-uptake inhibitor for patients with major depressive disorder and useful clinical improvements. 4 Stop medicines when no further benefit will be achieved or the potential harms outweigh the potential benefits for the individual patient Pharmacological treatments should cease when there are no further benefits to be achieved from the treatment, or when the potential harms from the treatment start to outweigh the potential benefits. This is particularly pertinent for elderly patients with a limited life expectancy where the treatments are unlikely to prevent disease events, and may in fact lead to adverse effects that reduce quality of life. These patients are at an increased risk of polypharmacy and increased drug events. For example, bisphosphonate treatment should not be administered to patients living in residential aged care facilities when these patients are already too frail to swallow drugs or have a life expectancy which is significantly less than 12 months. 5 Reduce use of multiple concurrent therapeutics (hyper-polypharmacy) Polypharmacy defined as five to nine medications taken regularly is common among elderly patients. However, patients who are prescribed with multiple, concurrent therapeutics (i.e. hyper-polypharmacy) may be on ten or more drugs at time. Research has confirmed a significant association between polypharmacy and adverse outcomes among older people living in the community because the toxicities and side effects associated with prescribed drugs are accrued over many years. Polypharmacy in older people is associated with decreased physical and social functioning; increased risk of falls, delirium and other geriatric syndromes; hospital admissions; and, death.

75 SUPPORTING EVIDENCE 1. Caughey GE, Roughead EE, Pratt N, et al. Increased risk of hip fracture in the elderly associated with prochlorperazine: is a prescribing cascade contributing? Pharmacoepidemiol Drug Saf 2010;19: Kalisch LM, Caughey GE, Roughead EE, Gilbert AL. The prescribing cascade. Australian Prescriber 2011;34; Martin JH, Coombes I. Mortality from common drug interactions systems, knowledge and clinical reasoning to optimise prescribing. Internal Medicine Journal 2014;44(7): Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013;3:CD NSW Therapeutic Advisory Group Inc. Preventing and managing problems with opioid prescribing for chronic non-cancer pain. NSW TAG: Sydney, Caughey GE, Roughead EE, Pratt N, et al. Stroke risk and NSAIDs: an Australian population-based study. Med J Aust 2011;195(9): Dimmitt SB, Stampfer HG. Low drug doses may improve outcomes in chronic disease. Med J Aust 2009;191(9): Raghunath AS, O Morain C, McLoughlin RC. Review article: the long-term use of proton-pump inhibitors. Aliment Pharmacol Ther 2005;22: Maddison AR, Fisher J, Johnston G. Preventive medication use among persons with limited life expectancy. Prog Palliat Care 2011;19(1): Reeve E, Shakib S, Hendrix I, et al. The benefits and harms of deprescribing. Med J Aust 2014;201(7): Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust 2014; 201(7): Davies EC, Green CF, Taylor S, et al. Adverse drug reactions in hospital in-patients: A prospective analysis of 3695 patientepisodes. PLoS ONE 4(2):e4439. Hubbard RE, Peel NM, Scott IA, et al. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015;202(7): Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust 2014; 201(7):390-2.

76 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 Last reviewed: August 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) The Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT) is the professional and independent society in Australia and New Zealand with expertise in the use and toxicity of medicines and chemicals. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

77 THINGS PHYSIOTHERAPISTS AND CONSUMERS SHOULD QUESTION Developed by the Australian Physiotherapy Association 1 Don t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain Trials have consistently shown that there is no advantage from routine imaging of non-specific low back pain, and there are some potential harms. Imaging is instead recommended for cases of low back pain where there is a suspicion of an underlying medically serious disease, like cancer or infection. In people who present to primary care with low back pain, medically serious disease is uncommon. Patients with a higher likelihood of medically serious disease as the cause of their low back pain can be identified by red flags, like a history of cancer. A recent Australian study revealed that most people experiencing acute low back pain expect imaging, believing it will identify the cause of their pain and so was considered a prerequisite for effective care. These views conflict with the available evidence on imaging. 2 Don t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. The Canadian C-Spine rule identifies patients who can safely be managed without imaging with high sensitivity. 3 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) Most clinically significant acute ankle injuries can be diagnosed with history, examination, and selective use of plain radiography. The Ottawa Ankle Rules dictate selective use of plain radiography in patients with acute ankle injury is useful in identifying patients who have sustained clinically important fracture, dislocation, and osteochondral injuries. However, acute ligamentous injuries involving the anterior talofibular ligament can be diagnosed clinically and treated symptomatically. When there are persistent symptoms, which raise suspicion of either instability or other internal derangement such as osteochondral injury, MRI can be used if the non-urgent weight bearing x-rays show no abnormality.

78 4 Don t routinely use incentive spirometry after upper abdominal and cardiac surgery. Postoperative pulmonary complications occur in ~40% of patients undergoing open coronary artery surgery and upper abdominal surgery. A Cochrane review of 592 open coronary artery surgery patients found no significant benefit of incentive spirometry over no treatment for atelectasis, pneumonia, or length of hospital stay. Another Cochrane review of 1834 upper abdominal surgery patients found no significant benefit on pulmonary complication risk of incentive spirometry over no treatment, deep breathing exercises, or other physiotherapy. Further research into incentive spirometry could be conducted, particularly in some subgroups such as high-risk patients. However, these Cochrane reviews identify a substantial pool of existing evidence that has not demonstrated any benefits of incentive spirometry. Other interventions, such as preoperative inspiratory muscle training do improve postoperative outcomes in these patients, when added to established standard care such as early mobilisation. Therefore, until evidence of a benefit from incentive spirometry becomes available, it is recommended that it not be routinely used in these surgical populations. 5 Avoid using electrotherapy modalities in the management of patients with low back pain Although used in clinical practice for many years, current evidence-based clinical practice guidelines do not endorse electrotherapy modalities (such as ultrasound, laser, interferential) in the management of low back pain, due to lack of evidence of effects on clinically relevant outcomes. Instead, patients with (sub)acute low back pain should be reassured of a favourable prognosis, advised to stay active, and be referred for prescribed analgesia if necessary. For chronic low back pain, helpful interventions include short-term use of medication/manipulation/acupuncture, supervised exercise therapy, cognitive behavioural therapy and multidisciplinary treatment. 6 Don t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder Adhesive capsulitis (also termed frozen shoulder) is a condition characterised by spontaneous onset of pain, progressive restriction of movement of the shoulder and disability that restricts activities of daily living, work and leisure. Most studies indicate that it is a self-limiting condition lasting up to two to three years, although 40% people may experience clinically detectable restriction of movement and disability beyond this time point without significant pain. Well-designed randomised trials have not demonstrated any worthwhile clinical benefits for ongoing physiotherapy beyond the benefits of a simple home exercise program.

79 SUPPORTING EVIDENCE 1. Karel YH, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. Eur J Intern Med 2015;26: Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015;313: Slade SC, Kent P, Bucknall T, Molloy E, Patel S, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies. BMJ Open 2015;5:e Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19: Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009;373: Chou R, Qaseem A, Owens DK and Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med 2011;154: Henschke N, Maher C, Refshauge K, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60: Downie A, Williams CM, Henschke N, Hancock MJ, OStelo RWJG, devet HCW, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347:f7095. Hoffmann, T.C., et al., Patients expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract 2013;14:7. Webster BS, Choi YS, Bauer AZ, Cifuentes M, Pransky G. The Cascade of Medical Services and Associated Longitudinal Costs Due to Nonadherent Magnetic Resonance Imaging for Low Back Pain Spine 2014;39: Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine 2013;38: Graves JM, Fulton-Kehoe D, Jarvik JG, Franklin GM. Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain. Health Serv Res 2014;49: Michaleff ZA, Maher CG, Verhagen A, Rebeck T, LIN CC. Accuracy of the Canadian C-Spine Rule and NEXUS for clinically important cervical spine injury in patients following blunt trauma: a systematic review. CMAJ 2012;184:E Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21: Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 2003;326: Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med 2009;16: Freitas ERFS, Soares BGO, Cardoso JR. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev 2012;9:CD Nascimento P, Modolo NSP, Guimaraes MMF, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev 2014;2:CD Mans CM, Reeve JC, Elkins MR. Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis. Clinical Rehabil 2015;29: Browning L, Denehy L, Scholes RL. The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Aust J Physiother 2007;53: Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomised clinical trial. BMJ 1996;312:148.

80 Haines KJ, Skinner EH, Berney S. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 2013;99: Parry SP, Denehy L, Berney. Clinical application of the Melbourne risk prediction tool in a high-risk upper abdominal surgical population: an observational cohort study. Physiotherapy 2014;100: Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19: Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev 2008;4:CD Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van Tulder MW. Therapeutic ultrasound for chronic low-back pain. Cochrane Database Syst Rev 2014;3:CD Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev 2008;2:CD Seco J, Kovacs FM, Urrutia G. The efficacy, safety, effectiveness, and cost-effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review. Spine J 2011;11: Chou R, Huffman LH, American Pain S, American College of P. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med 2007;147: Primary Care Management of Low Back Pain. August 2014 update Intermountain Health Care intermountainhealthcare.org/ext/dcmnt?ncid= The Norwegian Back Pain Network- The communication unit. Acute low back pain. Interdisciplinary clinical guidelines. Oslo, 2002:The Norwegian Back Pain Network. 6. Carette, S., H. Moffet, et al.. Intra-articular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis & Rheumatism 2003;48: Buchbinder R, Youd JM, Green S, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis & Rheumatism 2007;57: Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R. Manual therapy and exercise for adhesive capsulitis (frozen shoulder), Cochrane Database Syst Rev 2014;8:CD 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. Last reviewed: March 2016

81 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About Australian Physiotherapy Association (APA) The Australian Physiotherapy Association (APA) is the peak body representing the interests of Australian physiotherapists and their patients. The APA is a national organisation with non-autonomous state and territory branches and specialty subgroups. The organisation has more than 19,000 members and over 300 members in volunteer positions on committees or working parties. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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83 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Endocrine Society of Australia 1 Don t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland Thyroid ultrasound is used to identify and characterize thyroid nodules, and is not part of the routine evaluation of abnormal thyroid function tests (over- or underactive thyroid function) unless the patient also has a palpably large goitre or a nodular thyroid. Incidentally discovered thyroid nodules on ultrasound are common. Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction, may lead to further unnecessary investigation, unwarranted patient anxiety and increased costs. Imaging may be needed in thyrotoxic patients; when needed, a radionuclide thyroid scan, not an ultrasound, is used to assess the aetiology of the thyrotoxicosis and the possibility of focal autonomy in a thyroid nodule or nodules. 2 Don t prescribe testosterone therapy unless there is evidence of proven testosterone deficiency Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing. Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, for example, conditions in which sex hormone-binding globulin concentrations are altered, a calculated free or bioavailable testosterone may be of additional value. 3 Do not measure insulin concentration in the fasting state or during an oral glucose tolerance test to assess insulin sensitivity Measurement of insulin either in the fasting state or during an oral glucose tolerance test is not a clinically useful method (and may be costly because of the insulin assay) to estimate insulin sensitivity. The hyperinsulinemiceuglycemic (HIEG) clamp is the gold standard for assessing insulin sensitivity as it is possible to assess tissue specific sensitivity and can be used in all types of populations. This feature is important because a method of standardisation must be developed to control for various factors prior to any methods for measurement.

84 4 Avoid multiple daily glucose selfmonitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycaemia Once target control is achieved and the results of self-monitoring become quite predictable, there is little gained in most individuals from repeatedly confirming. There are many exceptions, such as for acute illness, when new medications are added, when weight fluctuates significantly, when A1c targets drift off course and in individuals who need monitoring to maintain targets. Self-monitoring is beneficial as long as one is learning and adjusting therapy based on the result of the monitoring. 5 Don t order a total or free T3 level when assessing thyroxine dose in hypothyroid patients T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of thyroid-stimulating hormone (TSH), as well as the effects of thyroid hormone in multiple organs; a normal TSH indicates an adequate T4 dose. Conversion of T4 to T3 at the cellular level may not be reflected in the T3 level in the blood. Compared to patients with intact thyroid glands, patients taking T4 may have higher blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be misleading (low normal or slightly low); in most patients a normal TSH indicates a correct dose of T4.

85 SUPPORTING EVIDENCE 1. Ahn HS. Korea s Thyroid-Cancer Epidemic Screening and Overdiagnosis. New England Journal of Medicine 2014;371: Brito JP. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. British Medical Journal 2013;347. Bahn CRS. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid 2011;21: Corona G. Cardiovascular risk associated with testosterone-boosting medications: a systematic review and meta-analysis. Expert Opin Drug Saf 2014;13: Finkle WD. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLoS One 2014;9(1):e Baillargeon J. Risk of myocardial infarction in older men receiving testosterone therapy. The Annals of Pharmacotherapy 2014;48: Vigen R. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels, JAMA 2013;310(17): Xu L. Testosterone therapy and cardiovascular events among men: a systematic review and meta-analysis of placebocontrolled randomized trials. BMC Medicine 2013;11:108. Shores MM. Testosterone treatment and mortality in men with low testosterone levels. Journal of Clinical Endocrinology Metabolism 2012;97: Bhasin S. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology Metabolism 2010;95: Fernández-Balsells MM. Clinical review 1: Adverse effects of testosterone therapy in adult men: a systematic review and meta-analysis, Journal of Clinical Endocrinology Metabolism 2010;95(6): Antuna-Puente R. How can we measure insulin sensitivity/resistance?, Diabetes & Metabolism 2011;37(3): Teede HJ. Assessment and management of polycystic ovary syndrome Medical Journal of Australia 2011;195(6). Borai A. Selection of the appropriate method for the assessment of insulin resistance. British Medical Journal 2011;11:158. Samaras K. Insulin levels in insulin resistance: phantom of the metabolic opera? Medical Journal of Australia 2006;185(3): Welschen LMC. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of Systematic Reviews 2012; Issue 1. Farmer AJ. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. British Medical Journal 2012;344:e486. Department of Health and Ageing and University of South Australia 2012, Pharmaceutical Benefits Scheme Products Used in the Treatment of Diabetes, Part 1: Blood Glucose Test Strips. Clar C. Self-monitoring of blood glucose in type 2 diabetes: systematic review. Health Technology Assessment. 2010;14(12): McIntosh B. Efficacy of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin: a systematic review and meta-analysis. Open Medicine 2010;4(2):e International Diabetes Federation 2009, Guideline: Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes. Allemann S. Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis. Current Medical Research & Opinion. 2009;25(12): Garber JR. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid 2012; 22(12):

86 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Endocrine Society of Australia (ESA) The Endocrine Society of Australia (ESA) is a national nonprofit organisation of scientists and clinicians who conduct research and practice in the field of Endocrinology. The society was founded in 1958 and incorporated in 1986 in the State of Victoria. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

87 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Royal Australian and New Zealand College of Ophthalmologists 1 In the absence of relevant history, symptoms and signs, routine automated visual fields and optical coherence tomography are not indicated When a patient s visual symptoms can be explained by simple refractive error and a comprehensive eye examination including slit lamp, extraocular movements, intraocular pressures, fundoscopy and confrontation visual fields is normal, there is no need for further tests. There are occasional exceptions eg if the patient is specifically being reviewed in relation to an inherited retinal or optic nerve disorder, or as screening or baseline for drug-related toxicity. When testing for driving eligibility, the confrontation method is acceptable to screen for visual field defects. Automated perimetry is only required when significant field defects are suspected. As in almost all branches of medicine, history and examination precede investigations and not the other way around. 2 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 The AREDS studies were randomised controlled trials which demonstrated benefit for specific combinations of supplements for certain subtypes of age-related macular degeneration (AMD). They did not show benefit for patients without AMD, and have not been tested for retinal conditions other than AMD. There is no high-level evidence to support the use of dietary supplements for the prevention or treatment of other retinal conditions, assuming a normal diet and the absence of specific vitamin or other nutrient deficiency. Despite this, there is widespread promotion and use of dietary supplements perceived to have benefits for other retinal diseases.

88 3 Don t prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery Alpha-1 adrenergic blockers such as tamsulosin nearly always affect the structural integrity of the iris and this can be permanent after only a few doses of the drug. As a result, intraoperative floppy-iris syndrome often results when intraocular surgery, especially cataract surgery, is performed. This can lead to iris damage and post-operative glare problems but also increase the risk of more serious complications such as posterior capsule rupture, vitreous loss, macular oedema and retinal detachment. This risk is up to ten times greater in some series. Surgeons can minimise the risk if they know a patient has taken the drug. Patients on long waiting lists can sometimes forget to tell the ophthalmologist they have been prescribed it whilst waiting for surgery. Better still, if the need for taking tamsulosin is not absolute and immediate, delaying its prescription until after any impending cataract surgery is performed would be in the patient s best interest. 4 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 Studies show that giving intravitreal injections, most commonly anti-vegf agents for wet macular degeneration, can be safely done in an outpatient setting if standard, well published protocols are followed. These protocols include the use of standard aseptic technique, topical antiseptic in the conjunctival sac, and a face mask. Performing these injections in a hospital or day surgery adds enormous cost to the procedure for no clinical benefit. This cost, initially borne by private health funds, clearly puts pressure on the sustainability of the private health system and contributes to the need to increase health insurance premiums and to reduce benefits for other procedures. 5 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 Lattice degeneration and related asymptomatic retinal conditions are frequently found in eyes with retinal detachment. Intuitively one would expect that prophylactic treatment of such visible areas of abnormality would reduce the risk of retinal detachment, and such treatments used to be commonplace. The available evidence has, however, failed to demonstrate any convincing benefit, and there are also significant potential side effects to such treatment. One reason for the absence of demonstrated benefit is the frequent occurrence of retinal breaks outside areas of visible abnormality. With occasional exceptions, there is no justification for such treatment in asymptomatic eyes, and it has been a recommendation of the American Academy of Ophthalmology for many years that such treatment is not indicated. Counselling and follow-up of at-risk patients is likely more effective, and far more cost-effective, in preventing loss of vision due to retinal detachment.

89 SUPPORTING EVIDENCE 1. American Academy of Ophthalmology. Choosing Wisely: Five Things Ophthalmologists and Patients Should Question. Recommendation 2: Imaging Tests 2013 [updated February 21, 2013] Available from: American Academy of Ophthalmology. Advisory Opinion: One Network: Clinical Education Spaeth GL. Glaucoma Testing: Too Much of a Good Thing. Review of Ophthalmology [Internet] Available from: Augsburger JJ. Unnecessary clinical tests in ophthalmology. Transactions of the American Ophthalmological Society 2005;103: Austroads, NTC Australia. Assessing fitness to drive for commercial and private vehicle drivers March Available from: American Academy of Ophthalmology. Preferred Practice Pattern: Comprehensive Adult Medical Eye Evaluation: Elsevier; Available from: Bussel II, Wollstein G, Schuman JS. OCT for glaucoma diagnosis, screening and detection of glaucoma progression. British Journal of Ophthalmology 2013;2013(98):ii15 - ii9. 2. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Archives of Ophthalmology 2001;119(10): Chew EY, Clemons TE, Agrón E, Sperduto RD, SanGiovanni JP, Kurinij N, et al. Long-Term Effects of Vitamins C and E, B-Carotene, and Zinc on Age-related Macular Degeneration. Ophthalmology 2013;120(8): e4. The Age-Related Eye Disease Study 2 Research Group. Lutein + Zeaxanthin and Omega-3 fatty acids for Age-Related Macular Degeneration: The Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. Journal of the American Planning Association 2013;309(19): Doss EL, Potter MB, Chang DF. Awareness of intraoperative floppy-iris syndrome among primary care physicians. Journal of Cataract & Refractive Surgery 2014;40(4): Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. Journal of Cataract & Refractive Surgery 2005;31(4): Ng DT, Rowe NA, Francis IC, Kappagoda MB, Haylen MJ, Schumacher RS, et al. Intraoperative complications of 1000 phacoemulsification procedures: a prospective study. Journal of Cataract & Refractive Surgery 1998;24(10): Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. Journal of Cataract & Refractive Surgery 2010;36(6): Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007;114(5): Manvikar S, Allen D. Cataract surgery management in patients taking tamsulosin staged approach. Journal of Cataract & Refractive Surgery 2006;32(10): Chang DF. Use of Malyugin pupil expansion device for intraoperative floppy-iris syndrome: results in 30 consecutive cases. Journal of Cataract & Refractive Surgery 2008;34(5): Shimada H, Hattori T, Mori R, Nakashizuka H, Fujita K, Yuzawa M. Minimizing the endophthalmitis rate following intravitreal injections using 0.25% povidone-iodine irrigation and surgical mask. Graefe s Archive for Clinical and Experimental Ophthalmology 2013;251(8): Tabandeh H, Boscia F, Sborgia A, Ciraci L, Dayani P, Mariotti C, et al. Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting. Retina 2014;34(1): Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. International Journal of Retina and Vitreous [Internet] 2015; 1(9). Available from: journalretinavitreous.biomedcentral.com/articles/ /s y. Fagan XJ, Al-Qureshi S. Intravitreal injections: a review of the evidence for best practice. Clinical & Experimental Ophthalmology 2013;41(5): The Royal Australian and New Zealand College of Ophthalmologists. Guidelines for performing intravitreal therapy 2006/2012. Available from:

90 5. Blindbaek S, Grauslund J. Prophylactic treatment of retinal breaks- a systematic review. Acta Ophthalmologica 2014;93(1):3-8. Wilkinson CP. Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration. Ophthalmology 2000;107(1):12-5; discussion 5-8. Chauhan DS, Downie JA, Eckstein M, Aylward GW. Failure of prophylactic retinopexy in fellow eyes without a posterior vitreous detachment. Archives of Ophthalmology 2006;124(7): Lewis H. Peripheral retinal degenerations and the risk of retinal detachment. American Journal of Ophthalmology 2003;136(1): Kazahaya M. Prophylaxis of retinal detachment. Seminars in Ophthalmology 1995;10(1): Folk JC, Bennett SR, Klugman MR, Arrindell EL, Boldt HC. Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment: analysis of failures and risks of treatment. Retina 1990;10(3): Folk JC, Arrindell EL, Klugman MR. The fellow eye of patients with phakic lattice retinal detachment. Ophthalmology 1989;96(1):72-9. Mastropasqua L, Carpineto P, Ciancaglini M, Falconio G, Gallenga PE. Treatment of retinal tears and lattice degenerations in fellow eyes in high risk patients suffering retinal detachment: a prospective study. British Journal of Ophthalmology 1999;83(9): American Academy of Ophthalmology Preferred Practice Pattern: Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration Available at:

91 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 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Royal Australian and New Zealand College of Ophthalmologists The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) is the leading medical eye specialist organisation in Australia and New Zealand. RANZCO s mission is to drive improvements in eye health care through continuing exceptional training, education, research and advocacy. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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93 things clinicians and consumers should question Developed by The Royal Australian and New Zealand College of Radiologists 1 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) Most clinically significant acute ankle injuries can be diagnosed with history, examination, and selective use of plain radiography. Extensive validation studies have shown that the Ottawa Ankle Rules can be safely applied to adult and paediatric populations. Selective use of plain radiography in patients with acute ankle injury is useful in identifying patients who have sustained clinically important fracture, dislocation, and osteochondral injuries. However, acute ligamentous injuries involving the anterior talofibular ligament can be diagnosed clinically and treated symptomatically. When there are persistent symptoms (such as pain and swelling) after an acute injury, which raise suspicion of either instability or other internal derangement, such as osteochondral injury, MRI can be used if the non-urgent (or delayed or elective or similar) weight bearing x-rays show no abnormality. Don t request duplex 2 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. The potential complications of untreated deep venous thrombosis (DVT) include thrombus propagation, pulmonary embolism (PE) and death from PE. A significant but underappreciated longer-term complication is post-thrombotic syndrome (PTS) and this can occur in up to 40% of patients with proximal DVT, as a result of venous incompetence and hypertension. Wells et al (2003) showed that ambulatory outpatients with suspected lower limb DVT and a DVT risk assessment score (Wells Score) of less than 2, can have DVT excluded by a negative result on D dimer assay, obviating the need to perform duplex compression ultrasound. The lower limit of the negative predictive value of the combination of a score <2 and negative D dimer was found to be The Wells Score has been extensively and externally validated since first publication.

94 3 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 Pulmonary embolism (PE) affects 2-3 per 1000 adults per year. It can be fatal if untreated, more often in hospitalised people than outpatients. The symptoms and signs of PE (chest pain, cough, dyspnoea, and tachycardia) are non specific and so imaging is required to make the diagnosis. PE is diagnosed by direct (CT pulmonary angiogram) or indirect (ventilation/perfusion or V/Q lung scanning) demonstration of the emboli within the pulmonary arterial tree. PE can be excluded in low risk patients by a negative result on whole blood D dimer. Some low risk patients ( Pulmonary Embolism Rule-out Criteria [PERC] negative ) are at such low risk they require no diagnostic testing, including D dimer. Clinical decision rules (CDRs) are more specific than clinical gestalt in determining which patients are unlikely to have PE, and thus can prevent unnecessary imaging in these groups. Validated risk assessment strategies are not applicable to pregnant women and D dimer is physiologically elevated early in pregnancy. Ventilation perfusion lung scanning is the test of choice in the presence of a normal chest radiograph in a pregnant woman with suspected PE as the radiation dose to the breast is much lower than for CT pulmonary angiography and the fetal dose is very small and comparable for both imaging tests. 4 Don t perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain Low back pain (LBP) is extremely common, being the third most common health complaint seen by Australian general practitioners. A simple classification places patients into one of three categories: LBP associated with sciatica or spinal canal stenosis Serious spinal pathology (such as cancer, infection, fracture, and cauda equina syndrome) comprises 1% of GP presentations with LBP Non-specific low back pain (90% of presentations) When evaluating patients with acute LBP, one of the key issues to be addressed is whether or not the patient should be investigated using imaging to confirm or refute the presence of an underlying/associated condition that would

95 change the subsequent medical treatment or investigation of the patient. Age over 70 years, trauma, corticosteroid therapy, and female gender are risk factors for fracture and previous or current cancer significantly increases the likelihood of cancer related back pain. At least one of fever, systemic symptoms, recent invasive procedure or sepsis, or elevated CRP are seen in most but not all patients with discitis or epidural abscess. New lower limb or bladder motor dysfunction increase the likelihood of cauda equina syndrome in a patient with LBP and are indications for emergency MRI. 5 Don t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule Cervical spine imaging of every trauma patient is costly and results in significant radiation exposure to a large number of patients, very few of whom will have a spinal column injury. Clinical decision rules have been developed that identify patients who can be safely managed without imaging. These rules include the Canadian C-Spine Rule or Nexus Low Risk Criteria. The Canadian C-Spine Rule provides higher specificity and lower imaging requirements, and should be used if possible. This is a joint recommendation with Australasian College for Emergency Medicine (ACEM) 6 Don t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule Most head injuries presenting to Emergency Departments will be minor and do not require immediate neurosurgical intervention or inpatient care. Mild head injury patients can be risk stratified into low or high risk groups based on the presence or absence of identified clinical risk factors. Current validated clinical decision rules include the Canadian CT Head Rule (for adults) or the PECARN Tool (for children). These rules can safely identify patients who can be discharged home, without CT scanning. This is a joint recommendation with Australasian College for Emergency Medicine (ACEM)

96 supporting evidence 1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21(4): Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003; 349(13): Oudega R, Moons KG, Hoes AW. Ruling out deep venous thrombosis in primary care. A simple diagnostic algorithm including D-dimer testing. Thromb Haemost. 2005; 94(1): Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: A meta-analysis. Ann Intern Med. 2011; 155(7): Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a Simple Clinical Model to Categorize Patients Probability of Pulmonary Embolism-Increasing the Models Utility with the SimpliRED D-dimer. Thromb Haemost. 2000; 83(3): Stuttgart. Gibson NS, Sohne M, Kruip MJ, Tick LW, Gerdes VE, Bossuyt PM, et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008; 99(1): Le Gal G, Righini M, Roy P, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: The Revised Geneva Score. Ann Intern Med. 2006; 144(3): Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the Revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008; 168(19): Douma RA, Gibson NS, Gerdes VE, Buller HR, Wells PS, Perrier A, et al. Validity and clinical utility of the Simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost. 2009; 101(1): Kline JA, Nelson RD, Jackson RE, Courtney DM. Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: A multicenter US study. Ann Emerg Med. 2002; 39(2): Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004; 2(8): Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, et al. Prospective multicenter evaluation of the Pulmonary Embolism Rule-out Criteria. J Thromb Haemost. 2008; 6(5): Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S. Diagnostic accuracy of Pulmonary Embolism Ruleout Criteria: A systematic review and meta-analysis. Ann Emerg Med. 2012; 59(6): e4. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol. 2012; 52(1): Douma RA, Mos IC, Erkens PM, Nizet TAC, Durian MF, Hovens MM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism - A prospective cohort study. Ann Intern Med. 2011; 154(11): Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS. Assessment of the Pulmonary Embolism Rule-out Criteria rule for evaluation of suspected pulmonary embolism in the emergency department. Am J Emerg Med. 2008; 26(2): Kline JA, Peterson CE, Steuerwald MT. Prospective evaluation of real time use of the Pulmonary Embolism Rule-out Criteria in an academic emergency department. Acad Emerg Med. 2010; 17(9): Penaloza A, Verschuren F, Dambrine S, Zech F, Thys F, Roy P-M. Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population. Thromb Res. 2012; 129(5): e Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ (Clinical Research Ed). 2008; 337: a171. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J and Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J Henschke N, Maher C, Refshauge K, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009; 60: Chou R, Qaseem A, Owens DK and Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011; 154: Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low back pain. Cochrane Database Syst Rev

97 Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P and Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev ; 2. Henschke N, Maher C and Refshauge K. Screening for malignancy in low back pain patients: a systematic review. Eur Spine J. 2007; 16: Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001; 286(15): Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998; 32(4): Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS lowrisk criteria in patients with trauma. N Engl J Med. 2003; 349(26): Miller P, Coffey F, Reid A-M, Stevenson K. Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation? Accid Emerg Nurs. 2006; 14(3): Vaillancourt C, Stiell IG, Beaudoin T, Maloney J, Anton AR, Bradford P, et al. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Ann Emerg Med. 2009; 54(5): e1. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000; 343(2): Mahler S, Pattani S, Caldito G. Use of a clinical sobriety assessment tool with the NEXUS low-risk cervical spine criteria to reduce cervical spine imaging in blunt trauma patients with acute alcohol or drug use: A pilot study. Ann Emerg Med. 2009; 54: S26-7. Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: Overutilization? AJR Am J Roentgenol. 2011; 197(2): Migliore S, Strelkauskas A, Matteucci M. The NEXUS criteria: Inter-rater reliability between residents versus attending physicians in the emergency department. Acad Emerg Med. 2011; 18: S Rethnam U, Yesupalan R, Gandham G. Does applying the Canadian Cervical Spine rule reduce cervical spine radiography rates in alert patients with blunt trauma to the neck? A retrospective analysis. BMC Med Imaging. 2008; 8: 12. Coffey F, Hewitt S, Stiell I, Howarth N, Miller P, Clement C, et al. Validation of the Canadian C-spine rule in the UK emergency department setting. Emerg Med J. 2011; 28(10): Duane TM, Wilson SP, Mayglothling J, Wolfe LG, Aboutanos MB, Whelan JF, et al. Canadian Cervical Spine rule compared with computed tomography: A prospective analysis. J Trauma. 2011; 71(2): Paediatric Specific: Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108(2): E Finkelstein E, Corso P, Miller T, Associates. The Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press; Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000; 343(2): Mower W, Hoffman J, Herbert M, Wolfson A, Pollack C, Zucker M, et al. Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: methodology of the NEXUS II investigation. Ann Emerg Med. 2002; 40(5): Mower WR, Hoffman JR, Herbert M, Wolfson AB, Pollack CV, Jr., Zucker MI. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005; 59(4): Stiell IG, Lesiuk H, Wells G, McKnight R, Brison R, Clement C, et al. The Canadian CT Head Rule Study for patients with minor head injury: Rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. 2001; 38(2): Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357(9266): Stiell IG, Lesiuk H, Wells GA, Coyle D, McKnight RD, Brison R, et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and economic analysis). Annals of emergency medicine. 2001; 38(3): Ro Y, Shin S, Holmes J, Song K, Park J, Cho J, et al. Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study. Academic emergency medicine. 2011; 18(6):

98 Bouida W, Marghli S, Souissi S, Ksibi H, Methammem M, Haguiga H, et al. Prediction Value of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter External Validation Study. Annals of emergency medicine. 2012; 61(5): Paediatric Specific References Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Jr., Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009; 374(9696): Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K. Derivation of the children s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006; 91(11): Osmond M, Klassen T, Wells G, Correll R, Jarvis A, Joubert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182(4): how this list WAS made 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. Updated: March 2017 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About The Royal Australian and New Zealand College of Radiologists (RANZCR) The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

99 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by the Royal Australian and New Zealand College of Radiologists Faculty of Radiation Oncology 1 Don t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age 50y with early-stage invasive breast cancer without considering shorter treatment schedules Whole-breast radiation therapy decreases local recurrence and improves survival of women with invasive breast cancer treated with breast conservation therapy. Most studies have utilised conventionally fractionated schedules that deliver therapy over 5-6 weeks, often followed by 1-2 weeks of boost therapy. Recent studies, however, have demonstrated equivalent tumor control and cosmetic outcome in specific patient populations with shorter courses of therapy (~4 weeks). Patients and their physicians should review these options to determine the most appropriate course of therapy. 2 Don t initiate management of low risk prostate cancer without discussing active surveillance Patients with prostate cancer have a number of reasonable management options. These include surgery and radiation, as well as conservative monitoring without therapy in appropriate patients. Shared decision making between the patient and the physician can lead to better alignment of patient goals with treatment and more efficient care delivery. ASTRO has published patient-directed written decision aids concerning prostate cancer and numerous other types of cancer. These types of instruments can give patients confidence about their choices, improving compliance with therapy. 3 Don t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8 Gy fraction. A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site. Strong consideration should be given to a single 8 Gy fraction for patients with a limited prognosis or with transportation difficulties.

100 4 Don t routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases Randomised studies have demonstrated no overall survival benefit from the addition of adjuvant whole-brain radiation therapy (WBRT) to stereotactic radiosurgery (SRS) in the management of selected patients with good performance status and brain metastases from solid tumors. The addition of WBRT to SRS is associated with diminished cognitive function and worse patient-reported fatigue and quality of life. These results are consistent with the worsened self-reported cognitive function and diminished verbal skills observed in randomised studies of prophylactic cranial irradiation for small cell or non-small cell lung cancer Patients treated with radiosurgery for brain metastases are at higher risk of developing metastases elsewhere in the brain. Careful surveillance and the judicious use of salvage therapy at the time of brain relapse allow appropriate patients to enjoy the highest quality of life without a detriment in overall survival. Radiation oncologists should discuss these options with patients, including participation in appropriate clinical trials. 5 Don t routinely use extensive locoregional therapy in most cancer situations where there is metastatic disease and minimal symptoms attributable to the primary tumour In the past, extensive local regional therapies (e.g., surgery) were often provided in patients with metastatic disease, regardless of the symptomatology of the primary tumour. However, recent evidence has suggested that in many cases these therapies do not improve outcome and, at times, delay the more important treatment of metastatic disease (e.g., chemotherapy). In general, patients with metastatic disease from solid organ malignancies and a relatively asymptomatic primary tumour should be considered for systemic therapy as a priority; the delay in systemic therapy and potential additional morbidity arising from extensive locoregional therapies should be avoided in these patients.

101 SUPPORTING EVIDENCE 1. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 366: Smith BD, Bentzen SM, Correa CR, et al. Fractionation for Whole Breast Irradiation: An American Society for Radiation Oncology (ASTRO) Evidence-Based Guideline. Int J Radiation Oncology Biol Phys 2011;81(1): Early Breast Cancer Trialists Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011;378: Haviland JS, Owen JR, Dewar JA, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013;14(11): Dahabreh IJ, Chung M, Balk EM, et al. Active surveillance in men with localized prostate cancer: a systematic review. Ann Intern Med 2012;156(8): Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367(3): Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011;364(18): Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer. J Urol 2007;177(6): Klotz L, Zhang L, Lam A, et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J Clin Oncol 2010;28(1): Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions (Review). Cochrane Database Syst Rev 2011;10:CD CD Chen RC, Rumble B, Loblaw DA, at el. Active surveillance for the management of localized prostate cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 2016; DOI: /JCO Tosoian JT, Mamawala M, Epstein JI, et al. Intermediate and longer-term outcomes from a prospective active-surveillance program for favourable-risk prostate cancer. J Clin Oncol 2015;33(30): Preston MA, Feldman AS, Coen JJ, et al. Active surveillance for low-risk prostate cancer: need for intervention and survival at 10 years. Urologic Oncology: Seminars and Original Investigations 2015; 33(9):383.e9-16. Morash C, Tey R, Agbassi C, et al. Active surveillance for the management of localized prostate cancer: Guideline recommendations. Can Urol Assoc J 2015;9(5-6): Bul M, Zhu X, Valdagni R, et al. Active surveillance for low-risk prostate cancer worldwide: The PRIAS study. Eur Urol 2013;63: Weerakoon M, Papa N, Lawrentschuk N, et al. The current use of active surveillance in an Australian cohort of men: a pattern of care analysis from the Victorian Prostate Cancer Registry. BJU Int 2015 Apr;115,Suppl 5: Lutz S, Berk L, Chang E, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys 2011;79(4): Expert Panel on Radiation Oncology-Bone Metastases: Lutz ST, Lo SSM, Chang EL, et al. ACR Appropriateness Criteria non-spine bone metastases. J Palliat Med 2012;15(5): Chow E, Zheng L, Salvo N et al. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol 2012;24(2): Soffietti R, Kocher M, Abacioqlu UM, et al. A European organisation for research and treatment of cancer phase III trial of adjuvant whole-brain radiotherapy versus observation in patients with one to three brain metastases from solid tumors after surgical resection or radiosurgery: quality-of-life results. J Clin Oncol 2013;31(1): Chang EL, Wefel JS, Hess KR, et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomized controlled trial. Lancet Oncol 2009;10(11): Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 2006;295(21):

102 Kocher M, Soffietti R, Abacioglu U, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC study. J Clin Oncol 2011;29: Gondi V, Paulus R, Bruner DW, et al. Decline in tested and self-reported cognitive functioning after prophylactic cranial irradiation for lung cancer: pooled secondary analysis of Radiation Therapy Oncology Group randomized trials 0212 and Int J Radiat Oncol Biol Phys 2013;86(4): Brown PD, Asher AL, Ballman KV, et al. NCCTG N0574 (Alliance): A phase III randomized trial of whole brain radiation therapy (WBRT) in addition to radiosurgery (SRS) in patients with 1 to 3 brain metastases. J Clin Oncol 2015;33(18): suppl LBA4. 5. Kleespies A, Füessl KE, Seeliger H, et al. Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer. Int J Colorectal Dis 2009;24(9): National Comprehensive Cancer Network. NCCN Guidelines for Colon Cancer Version 3 [Internet] [cited 2014 April]. Available from: Badwe R, Parmar V, Hawaldar R, et al. Surgical removal of primary tumor and axillary lymph nodes in women with metastatic breast cancer at first presentation: A randomized controlled trial. Cancer Res 2013;73(24 Suppl): Abstract nr S2-02. Choosing Wisely Canada. Oncology: Ten things physicians and patients should question. [Internet] [cited 2016 March]. Available from:

103 HOW THIS LIST WAS MADE 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 Committee and the Economics and Workforce Committee, 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 1-4 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 5 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. Current as at: October 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About the Royal Australian and New Zealand College of Radiologists The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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105 things ClInICIAns AnD ConsUmers should question Developed by The Royal Australian College of General Practitioners 1 Don t use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing PPIs are very effective and widely used medications for treating gastroesophageal reflux disease (GORD) and peptic ulcer disease. However, there is evidence of inappropriate prescribing, with a high proportion of patients kept on maximal doses long term. After initial symptom control, the lowest dose and frequency that provides ongoing symptom control should be reached by stepping down, and the medication ceased when no longer required. This reduces the risk of possible adverse effects to the individual, and the costs of long term treatment. Adverse effects of long term use include increased risk of GI infection (incl. clostridium difficile), community acquired pneumonia, osteoporotic fractures, interstitial nephritis, and nutritional deficiencies (B12, Fe, Mg), particularly in the elderly or immunocompromised. Exceptions, for which prolonged treatment may be necessary, include Barrett s oesophagus, high grade oesophagitis, and GI bleeding. The cost of anti-acid medication was $450 million in , with prescription volume increasing 9% annually. 2 Don t commence therapy for hypertension or hyperlipidaemia without first assessing the absolute risk of a cardiovascular event The benefit gained from treating elevated blood pressure or lipids is proportional to a patient s baseline risk of a cardiovascular event. Patients with multiple risk factors who are at high risk of an event will gain the most benefit from treatment. Patients with elevated blood pressure or lipids but who are low risk (< 10% 5-year risk according to the current National Vascular Disease Prevention Alliance (NVDPA) absolute CVD risk guidelines) do not require medication. The NVDPA guidelines also recommend treatment of blood pressure persistently greater than 160/100 mmhg regardless of baseline risk, and for other patients with conditions considered high risk, or with existing cardiovascular disease (see guidelines). Ideally, patients should share in the decision to commence medication, with an understanding of the potential benefits and harms. Lipid-modifying drugs cost the PBS $1.1 billion in , more than any other class of medication.

106 3 Don t advocate routine self-monitoring of blood glucose for people with type 2 diabetes who are on oral medication only There is no evidence that self-monitoring of blood glucose (SMBG) affects patient satisfaction, general well-being or general health-related quality of life. A 2012 Australian review found SMBG may possibly reduce HbA1c levels by %, considered clinically insignificant. SMBG actually increased hypoglycaemia risk, although causation was uncertain. This recommendation aligns with the 2015 draft NICE guidelines for selfmonitoring of blood glucose, the Canadian CADTH recommendations and the Scottish Intercollegiate Guidelines Network. Therefore, use HbA1c levels to guide therapy, and promote lifestyle interventions regardless of diabetes control. Exceptions (i.e. not routine ) may include: symptomatic hypoglycaemia; heavy machinery operators on a sulfonylurea; elderly people with renal failure; pregnancy; and possibly short-term education about diet influencing blood sugar. Australian government spending on test strips was $143 million in Diabetics not on insulin who used SMBG, averaged 300 test strips annually. 4 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 Major risk factors for vascular disease include older age, male sex, hypertension, smoking, dyslipidaemia and diabetes. Calculators using cardiovascular risk factors are widely available to determine a patient s individual risk for a vascular event. The additional information obtained by screening asymptomatic adults at low risk for a vascular event, via a resting ECG or stress test, is very unlikely to alter risk stratification or reduce overall events related to coronary artery disease. The potential harms of these tests have been found to equal or exceed the potential benefits in this population. In the absence of clinical trial data demonstrating an overall benefit, coronary artery calcium score is also not recommended in this population. (NVDPA guidelines) Similarly, screening with carotid duplex ultrasound in low-risk patients results in many more false-positive than true-positive results. This in turn leads to a significant number of unnecessary angiographies or surgical procedures, with the attendant risks of stroke, myocardial infarction and death.

107 5 Avoid prescribing benzodiazepines to patients with a history of substance misuse (including alcohol) or multiple psychoactive drug use Based on epidemiological data, the prevalence of benzodiazepine (BZD) abuse is generally low in the therapeutic setting. However, the incidence of BZD misuse and abuse is much higher in people who abuse alcohol and other drugs, either currently or in their past history. When BZDs are combined with other CNS depressants (e.g., alcohol, antidepressants, antipsychotics, opioids), patients are at risk of respiratory depression, heavy sedation, coma and death. Alcohol and BZDs can produce cross-tolerance, and regular use of both can make withdrawal more severe and/or protracted. Patients who use two or more psychoactive drugs in combination (polydrug use) and those with a history of significant mental illness may be more vulnerable to major harms. When treating polydrug users, avoid initiating BZDs, and for patients already taking them, reduce and cease prescription of BZDs in a supervised manner.

108 supporting evidence 1. Hughes JD1, Tanpurekul W, Keen NC, Ee HC. Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care. 2009;17(1): A. S. Raghunath, C. O Morain & R. C. McLoughlin. Review article: the long-term use of proton-pump inhibitors. Aliment Pharmacol Ther 2005; 22 (Suppl. 1): T Ali, DN Roberts, WM Tierney. Long-term safety concerns with proton pump inhibitors. The American journal of medicine, October 2009 Vol 122, Issue 10, Pages Reimer C. Safety of long-term PPI therapy. Best practice & research Clinical gastroenterology. 2013;27(3): Cholesterol Treatment Trialists (CTT) Collaborators, Mihaylova B, Emberson J, Blackwell L, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet Aug 11;380(9841): doi: /S (12) Epub 2012 May 17. Blood Pressure Lowering Treatment Trialists Collaboration, Sundström J, Arima H, Woodward M, et al. Blood pressurelowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet Aug 16;384(9943): NVDPA Absolute cardiovascular risk guidelines pdf 3. Malanda UL, Welschen LMC, Riphagen II, et al. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin, Cochrane Database Syst Rev Jan 18: 1 Farmer AJ, Perera R, Ward A et al. Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ 2012;344:e486 National Institute for Health and Care Excellence (NICE); Type 2 diabetes in adults, Clinical Guideline Update, 2015 draft. Department of Health and Ageing and University of South Australia. Pharmaceutical Benefits Scheme products used in the treatment of diabetes CADTH Recommendations on Self-Monitoring of Blood Glucose Using Test Strips, Canada Chou R, Arora B, Dana T, et al. Screening asymptomatic adults for coronary heart disease with resting or exercise electrocardiography: systematic review to update the 2004 U.S. Preventive Services Task Force recommendation. Evidence Synthesis No. 88. AHRQ Publication No EF-1. Rockville, MD: Agency for Healthcare Research and Quality; Desai CS, Blumenthal RS, Greenland P. Screening low-risk individuals for coronary artery disease. Curr Atherosclerosis Rep 2014: Apr;16(4):402. Jonas DE, Feltner C, Amick HR, et al. Screening for asymptomatic carotid artery stenosis: a systematic review and metaanalysis for the U.S. Preventive Services Task Force. Ann Intern Med Sep 2;161(5): NVDPA Absolute cardiovascular risk guidelines pdf 5. Dell osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. European Psychiatry 28 (2013) 7 20 Sheehan D, Raj A. Benzodiazepines. In: Shatzberg A, Nemeroff C, editors. The American Psychiatric Publishing Textbook of Psychopharmacology Fourth edition. Arlington, VA.: American Psychiatric Publishing; p Mills K, Deady M, Proudfoot H, et al. Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings. Sydney: National Drug and Alcohol Research Centre, University of New South Wales. Lingford-Hughes AR, Welch S, British Association for Psychopharmacology ERG, et al. BAP updated guidelines: evidencebased guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol. 2012;26(7):

109 how this list WAs made 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. last printed: April 2015 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About racgp The Royal Australian College of General Practitioners (RACGP) is Australia s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 29,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia. About nps medicinewise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit

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111 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by The Royal Australian College of General Practitioners 1 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 This recommendation does not apply to people with a bowel symptom such as bleeding. Approximately 98% of Australians are at average or slightly above average risk (e.g. one relative with bowel cancer diagnosed at 55yo). RACGP guidelines recommend two-yearly faecal occult blood testing (FOBT) from years of age. The best available data to 2011 suggests 13% of this group were instead over-screened using colonoscopy. National Bowel Cancer Screening Program (NBCSP) data shows that, per 10,000 people in this group followed up for an average 18 months, 6 will die from bowel cancer if unscreened. If screened with colonoscopy, 2.3 will die (1.5 from bowel cancer plus 0.8 from colonoscopy complications), compared to just 1.9 deaths for FOBT. A colonoscopy also risks bowel perforation (7 per 10,000), involves bowel preparation, and costs around $3000. NBCSP monitoring shows that a negative FOBT is 99.9% specific in ruling out bowel cancer. 2 Don t order chest x-rays in patients with uncomplicated acute bronchitis Acute bronchitis is the commonest cause of cough presenting to GPs. It is usually viral (>90%) and self-limiting, and antibiotics should not routinely be used. Chest x-rays (CXRs) are the imaging tests most frequently ordered by Australian GPs, and the most common indication is acute bronchitis/ bronchiolitis (140,000 annually, data combined for both conditions). Uncomplicated bronchitis refers to cough and sputum lasting less than three weeks in immunocompetent patients without underlying respiratory disease, and no clinical features suggesting pneumonia (heart rate >100, resp rate >24, temp >38.0C, haemoptysis, signs of consolidation). A Cochrane review found routine CXR did not affect outcomes in adults or children presenting to hospital with acute chest infection. Note that purulent (green) sputum is not predictive of bacterial infection and is not in itself an indication for CXR. CXRs may also lead to false positives, further investigation and unnecessary radiation. The threshold for CXR should be lower in patients over 60.

112 3 Don t routinely do a pelvic examination with a Pap smear During a routine cervical smear for screening (i.e. no symptoms), a bimanual pelvic examination has no proven benefit, as it has not been shown to improve the detection of ovarian cancer or to benefit other outcomes. In a large study of Australian women undergoing routine screening pelvic examination, no ovarian malignancies were found, and the high prevalence of benign abnormalities (bulky/fibroid uterus in 13%, abnormal adnexal findings in 2%) often led to further investigation. A recent US review concluded that no data supports the effectiveness of speculum or bimanual pelvic examinations in the asymptomatic, average-risk woman. The procedure causes pain, fear, anxiety, and/or embarrassment in a third of women and can lead to unnecessary, invasive, and potentially harmful diagnostic procedures. Pelvic examinations require additional clinician time and, for consultations not otherwise requiring intimate examination, the consideration of a chaperone. Therefore, unnecessary examinations lead to resource and opportunity costs. 4 Don t treat otitis media with antibiotics, in non-indigenous children aged 2-12 years, where reassessment is a reasonable option Avoid the routine use of antibiotics in acute otitis media, except in a child with acute systemic features such as high fever, vomiting or lethargy. Clinical review at hours is good practice, if available. Regardless of whether one or both eardrums are red or bulging, antibiotics do not reduce pain at 24 hours, and up to 20 children must be treated to prevent pain in one child at 2 to 7 days. Routine antibiotic use slightly reduces tympanic membrane perforation (NNT = 33) but has no effect on tympanic membrane findings at 3 months, nor on severe complications. One in 14 children will develop antibiotic side effects, particularly rash, diarrhoea, or vomiting. Antibiotic use promotes bacterial resistance, both in the individual and community. Aboriginal and Torres Strait Islander children are at higher risk of complications and should be treated early. Guidelines vary about the value of antibiotic treatment in children aged 6-23 months, but support antibiotics for infants under 6 months.

113 5 Don t test thyroid function as population screening for asymptomatic patients This screening recommendation does not apply to people with symptoms suggestive of thyroid disease. The prevalence in adults of subclinical hypothyroidism is about 4.3% (0.7% for subclinical hyperthyroidism), and prevalence is higher in older adults and women. About 2-5 percent of people with subclinical hypothyroidism and 1-2 percent with subclinical hyperthyroidism will develop overt thyroid disease per year. However, many patients with subclinical thyroid dysfunction revert to normal when followed over time. A 2014 systematic review of screening for thyroid dysfunction found that clear evidence on the benefits and harms of screening is unavailable, and recommended against population-based screening. In the absence of evidence that early treatment reduces symptoms, lipid levels, or the risk of cardiovascular disease in patients with mild thyroid dysfunction detected by screening, the RACGP Guidelines for preventive activities in general practice does not recommend screening for thyroid disease in asymptomatic populations.

114 SUPPORTING EVIDENCE 1. RACGP, Red Book Taskforce. Guidelines for preventive activities in general practice. Royal Australian College of General Practitioners: Melbourne (2012). Available from: Ouakrim DA et al. Screening practices of Australian men and women categorized as at or slightly above average risk of colorectal cancer. Cancer Causes Control 2012;23: (The 13% figure taken from the latest, unpublished data, received via correspondence from the primary author, Oct 2015). Emery J. NHMRC Centre for Research Excellence for Optimising Colorectal Cancer Screening at the University of Melbourne. AIHW data, National Bowel Cancer Screening Program. Viiala CH, et al. Complication rates of colonoscopy in an Australian teaching hospital environment. Internal Medicine Journal 2003;33: Australian Institute of Health and Welfare. Analysis of bowel cancer outcomes for the National Bowel Cancer Screening Program Canberra: AIHW cat. no. CAN 87. Available from: aspx?id= Gordon J, Miller G, Pan Y. Ordering chest X-rays in Australian general practice. Aust Fam Physician 2015;44: Michigan Quality Improvement Consortium. Management of uncomplicated acute bronchitis in adults. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Sep. 1. Metlay J, Kapoor W, Fine M. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17): Cao A, Choy J, Mohanakrishnan L, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.:CD Albert A. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010;1:82(11). 3. Grover SR, Quinn MA. Is there any value in bimanual pelvic examination as a screening test? Med J Aust 1995;162(8): Ebell MH, Culp M, Lastinger K, Dasigi T. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med 2015;48(3): Simms I, Warburton F, Weström L. Diagnosis of pelvic inflammatory disease: time for a rethink. Sex Transm Infect 2003;79(6): Bloomfield HE, Olson A, Cantor A, et al. Screening Pelvic Examinations in Asymptomatic Average Risk Adult Women [Internet]. Washington (DC): Department of Veterans Affairs; 2013 Sep Venekamp R, Sanders S, Glasziou P, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015;1:CD Avail from: Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; Indigenous and Rural Health division, Department of Health. Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. Avail from: gov/ / Rovers M, Glasziou P, Appelman C, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006;368: Avail from: fcgi?cmd=retrieve&db=pubmed&dopt=citation&list_uids= Hoberman A, Paradise J, Rockette H, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med Jan 13;364(2): Avail from:

115 5. RACGP, Red Book Taskforce. Guidelines for preventive activities in general practice. Royal Australian College of General Practitioners: Melbourne (2012). Available from: Rugge JB, Bougatsos C, Chou R. Screening for and Treatment of Thyroid Dysfunction: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No AHRQ Publication No EF-1. Rockville, MD: Agency for Healthcare Research and Quality; Ochs N, Auer R, Bauer DC. Meta-analysis: subclinical thyroid dysfunction and the risk for coronary heart disease and mortality. Ann Intern Med 2008;148(11): HOW THIS LIST WAS MADE 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About The Royal Australian College of General Practitioners The Royal Australian College of General Practitioners (RACGP) is Australia s largest professional general practice organisation and represents urban and rural general practitioners. We represent more than 30,000 members working in or towards a career in general practice. There are more than 125 million general practice consultations taking place annually in Australia. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

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117 THINGS CLINICIANS AND CONSUMERS SHOULD QUESTION Developed by The Royal College of Pathologists of Australasia 1 Do not perform surveillance urine cultures or treat bacteriuria in elderly patients in the absence of symptoms or signs of infection Asymptomatic bacteriuria is a common finding in all ages and in association with other comorbidities. Treatment of asymptomatic bacteriuria is recommended in pregnancy but not in other clinical situations. Prophylaxis against development of symptoms prior to simple cystoscopy and prosthetic joint replacement is not recommended. Extensive guidelines from the Infectious Diseases Society of America (IDSA) are available for this condition and asymptomatic bacteriuria in catheterised patients. The use of chemical screening strips in asymptomatic patients may lead to unnecessary urine cultures when positive results are obtained. Increasing antibiotic resistance in urinary pathogens may be a consequence of unnecessary treatment. 2 Do not perform PSA testing for prostate cancer screening in men with no symptoms and whose life expectancy is less than 7 years Prostate cancer causes significant mortality and morbidity and all patients with concerns about their risks of having the disease and/or their prognosis if diagnosed, including the role of prostate specific antigen (PSA) testing, should discuss these with their doctor. Since any mortality benefit from early diagnosis of prostate cancer due to PSA testing is not seen within less than 6 7 years from testing, PSA testing is not recommended for men who are unlikely to live another 7 years. 3 Do not perform population based screening for Vitamin D deficiency The quality of the evidence for the health benefits of an adequate vitamin D status is highly variable. As the main source of vitamin D is UVB sunlight exposure, vitamin D status as assessed by the measurement of 25 hydroxyvitamin D (25OH-D) is correlated with time spent outdoors, exercise and other aspects of a healthy lifestyle including body weight. Vitamin D insufficiency is associated with low levels of exercise, obesity and/or reduced sun light exposure, such as occur more commonly in the elderly, the overweight, the frail and unwell or institutionalised and where there are occupational, racial or cultural reasons. In individuals at risk of vitamin D deficiency, measurement of 25OH-D is an appropriate, case-finding strategy. Routine screening of healthy infants, children and adults (including pregnant women) for vitamin D deficiency is currently not recommended.

118 4 Restrict the use of serum tumour marker tests to the monitoring of a cancer known to produce these markers or where there is a strong known underlying predisposition or suspicion The measurement of levels of certain tumour biomarkers is known to be helpful in monitoring the progress of specific cancers in response to treatment or in detecting changes in cancer activity or secondary or recurring cancer. In some circumstances they are helpful adjuncts in detecting specific cancers, where there is a strong known underlying predisposition or suspicion, such as in detecting liver cancer in patients with chronic hepatitis C and cirrhosis. However, the testing for a broad range of biomarkers in patients with non-specific symptoms in the hope of finding an undetected cancer is not supported by the evidence from numerous systematic reviews. Tumour markers generally should not be used in the initial diagnostic pathway and are rarely diagnostic due to low sensitivity and specificity. 5 Do not routinely test and treat hyperlipidemia in those with a limited life expectancy Measurement of lipid levels is part of absolute risk assessment for the prevention of cardiovascular disease. Age is a predominant risk factor in the elderly, so absolute risk calculators accommodate this by fixing 75 years as the maximum age that can be included in the calculation. Clinicians need to consider whether or not the assessment and treatment of risk factors beyond this age in the very elderly is likely to yield clinical benefit within the patient s remaining life expectancy. On rare occasions lipid testing may provide relevant information in other life threatening diseases, such as pancreatitis, but in most critical illnesses lipid measurement for prevention of chronic disease will no longer be a priority.

119 SUPPORTING EVIDENCE 1. Nicolle LE. Asymptomatic bacteriuria. Current Opinion in Infectious Diseases 2014;27(1):90-6. Nicolle LE, Bradley S, Colgan S, et al. Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases 2005;40(5): Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases 2011;52(5):e Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;50(5): Bergdahl AG, Holmberg E, Moss S, et al. Incidence of prostate cancer after termination of screening in a populationbased randomised screening trial. Eur Urol 2013;64(5): Hugosson J, Carlsson S, Aus G et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11(8): Roobol MJ, Kranse R, Bangma CH et al. Screening for prostate cancer: Results of the Rotterdam section of the European randomized study of screening for prostate cancer. Eur Urol 2013;64(4): Schroder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012;366(11): Ajuria-Morentin I, Mar-Medina C, Bereciartua-Urbieta E et al. Lack of transferability between different immunoassays and LC-MS/MS for total 25-hydroxyvitamin D measurement and disagreement defining deficiency. Scand J Clin Lab Invest 2013;73(1):82-6. Autier P, Boniol M, Pizot C, et al. Vitamin D status and ill health: a systematic review. The Lancet Diabetes & Endocrinology 2014;(2): Bolland MJ, Grey A, Gamble GD et al. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis. The Lancet Diabetes & Endocrinology 2014;2(4): Cavalier E, Lukas P, Crine Y, et al. Evaluation of automated immunoassays for 25(OH)-vitamin D determination in different critical populations before and after standardization of the assays. Clin Chim Acta 2014;(431):60-5. Glendenning P, Chew GT. Controversies and consensus regarding vitamin D deficiency in 2014: whom to test and whom to treat? Med J Aust 2015;202(9): Meyer HE, Holvik K, Lips P. Should vitamin D supplements be recommended to prevent chronic diseases. BMJ 2015;(350):321. Schleicher RL, Sternberg MR, Lacher DA, et al. The vitamin D status of the US population from 1988 to 2010 using standardized serum concentrations of 25-hydroxyvitamin D shows recent modest increases. Am J Clin Nutr 2016;104(2): Theodoratou E, Tzoulaki I, Zgaga L, et al. Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials. BMJ 2014;348:g Association for Clinical Biochemistry & Laboratory Medicine. Recommendations as a result of the ACB national audit on tumour marker service provision Recommendation Document. Available at Duffy MJ, McGing P. Guidelines for the use of tumour markers. Association of Clinical Biochemists in Ireland Available at: National Institute of Health and Care Excellence. Diagnosis and management of metastatic malignant disease of unknown primary origin. NICE Clinical Guideline 104. National Collaborating Centre for Cancer Available at guidance/cg104. Sturgeon CM, Duffy MJ, Stenman UH, et al. National Academy of Clinical Biochemistry laboratory medicine practice guidelines for use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancers. Clin Chem 2008;54(12):e Sturgeon CM, Hoffman BR, Chan DW, et al. Laboratory Medicine Practice Guidelines for use of tumor markers in clinical practice: quality requirements. National Academy of Clinical Biochemistry Available at science-and-research/practice-guidelines/tumor-markers-quality-requirements. 5. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk

120 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. Updated: February 2017 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges, societies and associations and is facilitated by NPS MedicineWise. About The Royal College of Pathologists of Australasia The RCPA is the leading organisation representing pathologists and senior laboratory scientists in Australasia. Its mission is to train and support pathologists and to improve the use of pathology testing to achieve better healthcare. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at

121 THINGS PHARMACISTS AND CONSUMERS SHOULD QUESTION Developed by The Society of Hospital Pharmacists of Australia 1 Don t initiate and continue medicines for primary prevention in individuals who have a limited life expectancy Frail, elderly patients are more susceptible to the adverse effects of medicines. There is limited evidence to support the use of many medicines in elderly patients as they are typically excluded from clinical trials. One study has estimated cost to the PBS of potentially inappropriate medication in older patients is between $240 and $450 million each year. The use of medicines used to prevent a condition, or disease, or those with a long time to benefit profile may not be consistent with the life expectancy of the patient and their goals of care. The proactive de-prescribing of medicines that no longer provide a benefit to the patient is integral to end-of-life care and advance care planning. Patients or their carer, or designated guardian, should be involved in the decision to review treatment and the ongoing need for each medicine. 2 Don t initiate an antibiotic without an identified indication and a predetermined length of treatment or review date Antibiotics may be prophylactic, empirical or targeted against a known organism. Prolonged duration of antibiotics is associated with: an increased risk of adverse reactions, Clostridium difficile infection, candidiasis, selection of antibiotic resistant organisms as well as unnecessary cost. Therefore the shortest possible duration of therapy should be used. For the majority of infections treatment should not exceed 7 days. The most appropriate duration of therapy may be difficult to identify in some circumstances. In these instances treatment duration must be individualised for the patient on the basis of clinical, microbiological or radiological parameters. If ongoing treatment is required a date for review should be identified. Patients should be advised that using antibiotics when they don t need them can contribute to the problem of antibiotic resistance. They should be advised, when the antibiotic is prescribed and dispensed, when the antibiotic is to finish, or the date to be reviewed.

122 3 Don t initiate and continue antipsychotic medicines for behavioural and psychological symptoms of dementia for more than 3 months Behavioural and psychological symptoms of dementia (BPSD) are often temporary. The mainstay treatment of BPSD is non-pharmacological. Antipsychotic medicines should only be considered when nonpharmacological interventions have failed and the patient has symptoms that are distressing for them, their family or co-residents. Patients or their carer, or designated guardian, should be involved in the decision to begin treatment with an antipsychotic medicine. Consideration needs to be given to the patient s ability to appreciate the consequences of refusing or agreeing to treatment. If used, the dose of the antipsychotic medicine should be increased as slowly as necessary with the goal of using the lowest effective dose for the shortest possible time. The effectiveness of the medicine and the occurrence of delirium, sedation, or anti-cholinergic side effects should be assessed at least weekly. Treatment should be reviewed after no more than 3 months and the dose should be reduced and then stopped wherever possible. 4 Don t recommend the regular use of oral non-steroidal anti-inflammatory medicines (NSAIDs) in older people Non-steroidal anti-inflammatory medicines (NSAIDs) are frequently used in the short term to treat moderate acute pain. They are not usually required after the cause of the acute pain has been addressed. Treatment should be re-assessed if the acute pain is ongoing and not resolved within 2 weeks. Oral NSAIDs have considerable cardiovascular, gastrointestinal and kidney function risks. They should not be recommended without consideration of the patient s additional diseases or conditions; in particular older people, people with kidney disease, a history of peptic ulcer disease, hypertension or heart failure. Older people should use the lowest possible dose of an oral NSAID, for the shortest duration possible and multiple NSAIDs should not be taken at the same time. The effectiveness of long-term oral NSAID treatment should be routinely assessed against the individual patient s management plan. If possible the total dose should be reduced or ceased.

123 5 Don t recommend the use of medicines with sub-therapeutic doses of codeine (<30mg for adults) for mild to moderate pain Products containing low dose (<12mg) codeine per tablet combined with another analgesic medicine are available without a prescription and are commonly recommended for the treatment of mild to moderate pain. Codeine is converted to morphine in the body to work. The extent of this metabolism depends on each individual s pharmacogenetics, which are not readily known and this is highly variable between individuals. There is evidence that doses of codeine less than 30 mg every 6 hours, are no more effective than paracetamol or an NSAID alone. Therefore, combination products that contain low dose codeine should not be recommended for mild to moderate pain. If used, their effectiveness should be assessed within 48 hours. If symptoms persist the product should be ceased and the patient referred for further assessment. Codeine can lead to constipation, nausea, vomiting, bloating and abdominal pain, any of these symptoms can impact on quality of life.

124 SUPPORTING EVIDENCE 1. Hardy JE, Hilmer SN. Deprescribing in the last year of life. J Pharm Pract Res 2011; 41(2): Elliott RA, Stehlik P. Identifying inappropriate prescribing for older people. J Pharm Pract Res 2013;43(4): Scott IA, Le Couteur DG. Physicians need to take the lead in deprescribing. Intern Med J 2015;45(3): Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D et al. Reducing inappropriate polypharmacy. JAMA Internal Medicine 2015;175(5): File TM Jr. Duration and cessation of antimicrobial treatment. J Hosp Med 2012;7(1) suppl 1:S22-S33. Havey TC, Fowler RA, Daneman N. Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis. Crit Care 2011;15:R267. Brown K, Valenta K, Fisman D, Simor A, Daneman N. Hospital ward antibiotic prescribing and the risks of Clostridium difficile infection. JAMA Internal Medicine 2015;175(4): Stuart RL, Wilson J, Bellaard-Smith E, Brown R, Wright L, Vandergraaf S et al. Antibiotic use and misuse in residential aged care facilities. Intern Med J 2012;42(10): Australian Commission on Safety and Quality in Health Care. Antimicrobial prescribing practice in Australian hospitals: results of the 2014 National Antimicrobial Prescribing Survey. Sydney: ACSQHC; Antibiotics Expert Groups. Therapeutic guidelines: antibiotics. Version 15. Melbourne: Therapeutic Guidelines Limited; Britton ME. Drugs, delirium and older people. J Pharm Pract Res 2011;41(3): Westbury J, Beld K, Jackson S, Peterson GM. Review of psychotropic medication in Tasmanian residential aged care facilities. Australasian Journal on Ageing 2010;29(2):72-6. Snowdon J, Galanos D, Vaswani D. Patterns of psychotropic medication use in nursing homes: surveys in Sydney, allowing comparisons over time and between countries. International Psychogeriatrics 2011;23(9): Ballard CG, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer s disease. Cochrane Database of Syst Rev. 2006, Issue 1 CD Liperoti R, Pedone C, Corsonello A. Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Curr Neuropharmacol 2008; 6(2): Gareri P, De Fazio P, Graziella V, Manfredi L, De Sarro G. Use and safety of antipsychotics in behavioral disorders in elderly people with dementia. J Clin Psychopharmacol 2014;34: Psychotropic Expert Groups. Therapeutic guidelines: psychotropic. Version 7. Melbourne: Therapeutic Guidelines Limited; Ong CKS, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med Res 2007;5(1): Marcum ZA, Hanlon JT. Recognizing the risks of chronic nonsteroidal anti-inflammatory drug use in older adults. Ann Longterm Care 2010;18(9):24-7. Barkin RL, Beckerman M, Blum SL, Clark FM, Koh E,DS Wu. Should Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) be Prescribed to the Older Adult? Drugs Aging 2010;27(10): Analgesics Expert Groups. Therapeutic guidelines: analgesic. Version 6. Melbourne: Therapeutic Guidelines Limited; Murnion BP. Combination analgesics in adults. Australian Prescriber 2010;32(4): Ledema J. Cautions with codeine. Australian Prescriber. 2011;34(5): Derry S, Moore RA, McQuay HJ. Single dose oral codeine, as a single agent, for acute postoperative pain in adults. Cochrane Database Syst Rev Apr 14; (4): CD Signal Investigation Unit. Codeine use in children and ultra-rapid metabolisers: Pharmacovigilance and Special Access Branch Safety Review. Version 1.0. Canberra: Therapeutic Goods Administration; Analgesics Expert Groups. Therapeutic guidelines: analgesic. Version 6. Melbourne: Therapeutic Guidelines Limited; 2012.

125 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. Last reviewed: March 2016 About Choosing Wisely Australia Choosing Wisely Australia is enabling clinicians, consumers and healthcare stakeholders to start important conversations about tests, treatments and procedures where evidence shows they provide no benefit and in some cases, lead to harm. This initiative is being led by Australia s medical colleges and societies and is facilitated by NPS MedicineWise. About the Society of Hospital Pharmacists Australia (SHPA) The Society of Hospital Pharmacists of Australia (SHPA) is the national professional organisation for more than 3,000 pharmacists, pharmacists in training, pharmacy technicians and associates working across Australia s health system. About NPS MedicineWise Independent, not-for-profit and evidence based, NPS MedicineWise enables better decisions about medicines and medical tests. Visit Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. Choosing Wisely Australia disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read the full disclaimer at