Richard King: What not to do

EARLIER this year, articles appeared in the New York Times and the Australian Financial Review on low-value health care and the response from doctors.

These articles reflect to the public the worldwide drive by health care organisations, governments and doctors towards disinvestment in ineffective or inappropriately applied practices in health care. It has been described as a growing priority for health care systems to improve the quality of care and sustainability of resource allocation.

Identification of procedures and practices for disinvestment has increased, particularly in the past 4 years, with the UK National Institute for Health and Care Excellence introducing “do not do” recommendations, followed by the American Board of Internal Medicine’s “Choosing Wisely” campaign.

Choosing Wisely, an initiative that is about to be introduced in Australia, was developed after about 60 medical colleges and societies in the US put together an evidence-based list of five investigations or procedures in each specialty that had little or no value, and that should not be done.

In Australia, a list of 156 practices that had questionable benefit or low value was published in the MJA in 2012.

A second way to identify inappropriate procedures is to find articles in high-impact journals that produce solid evidence showing current procedures should not be done. One team of US researchers identified 146 articles published over a 10-year period to 2010 that reversed established practice.

A third way is to identify the procedures or devices that will be replaced or substituted when a new technology is introduced. Examples of this were identified at the 2013 National Workshop on Disinvestment and outlined in the final report of the Health Policy Advisory Committee on Technology, including endobronchial ultrasound to biopsy and diagnose mediastinal lung tumours, which resulted in significant disinvestment in its pre-existing surgical comparator, mediastinoscopy, saving millions of dollars.

However, implementation of disinvestment in low-value health care is not well developed. We need action at federal, state and hospital levels.

At a federal level, the Medical Services Advisory Committee (MSAC) has the power to review procedures on the Medicare Benefits Schedule (MBS) and recommend their removal if they are not effective. This did happen in 2006 when MSAC recommended the introduction of magnetic resonance cholangiopancreatography and removed the general use of diagnostic endoscopic retrograde cholangiopancreatography. However, there have been no other recommendations since.

The federal Department of Health and Ageing did report at the 2013 Workshop on Disinvestment that it was looking at 20 items on the MBS being considered for removal.

At a state level, the Queensland Health Clinical Senate in 2013 devoted a lot of time to disinvestment, which it regarded as a priority in Queensland.

In Victoria, the Department of Health’s Victorian Policy Advisory Committee on Technology is looking at how a coordinated approach in hospitals might be achieved through cooperation across the sector. This is still in early days.

Monash Health has a disinvestment subcommittee as part of its New Technology Committee which has been active since 2009. It has recommended the cessation of various procedures such as vertebroplasty for osteoporotic vertebral body fractures and stenting of artherosclorotic renal arteries for hypertension, based on a similar method to identifying articles in high-impact journals that show current procedures should not be done.

There are many impediments to stopping existing practices. It has been said that to get a technology onto a schedule such as the MBS requires the same level of evidence as for civil trials — the balance of probabilities.

To take something off a schedule requires the same level of evidences as for a criminal conviction — beyond reasonable doubt.

If our health system is to remain sustainable, disinvestment must become part of the health care process.

As Dr Lowell Shipper, chair of a task force on value in cancer care at the American Society of Clinical Oncology, told the New York Times: “We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room.”

Associate Professor Richard King is the medical director of medicine at Monash Health and chair of the Victorian Policy Advisory Committee on Technology.