Choosing wisely? Quantifying the extent of three low value psychotropic prescribing practices in Australia

BACKGROUND:The global Choosing Wisely campaign has identified the following psychotropic prescribing as low-value (harmful or wasteful): (1) benzodiazepine use in the elderly, (2) antipsychotic use in dementia and (3) prescribing two or more antipsychotics concurrently. We aimed to quantify the extent of these prescribing practices in the Australian population. METHODS:We applied indicators to dispensing claims of a 10% random sample of Australian Pharmaceutical Benefits Scheme beneficiaries to quantify annual rates of each low-value practice from 2013 to 2016. We also assessed patient factors and direct medicine costs (extrapolated to the entire Australian population) associated with each practice in 2016. RESULTS:We observed little change in the rates of the three practices between 2013 and 2016. In 2016, 15.3% of people aged ≥65 years were prescribed a benzodiazepine, 0.5% were prescribed antipsychotics in the context of dementia and 0.2% of people aged ≥18 years received two or more antipsychotics concurrently. The likelihood of elderly people receiving benzodiazepines or antipsychotics in the context of dementia increased with age and the likelihood of receiving all three practices increased with comorbidity burden. In 2016, direct medicine costs to the government of all three practices combined, extrapolated to national figures, were > $21 million AUD. CONCLUSIONS:Our indicators suggest that the frequency of these three practices has not changed appreciably in recent years and that they incur significant costs. Worryingly, people with the greatest risk of harm from these prescribing practices are often the most likely to receive them.Jonathan Brett, Helga Zoega, Nicholas A. Buckley, Benjamin J. Daniels, Adam G. Elshaug and Sallie-Anne Pearso

Low-value care in Australian public hospitals: prevalence and trends over time

Objective: To examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals. Design: Analysis of admitted patient data for financial years 2010–2011 to 2016–2017. Main outcome measures: Number and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017. Results: For 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to$A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends. Conclusions: Low-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.Tim Badgery-Parker, Sallie-Anne Pearson, Kelsey Chalmers, Jonathan Brett, Ian A Scott, Susan Dunn, Neville Onley, Adam G Elshau

Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010-2014)

OBJECTIVE:To examine the prevalence, costs and trends (2010-2014) for 21 low-value inpatient procedures in a privately insured Australian patient cohort. DESIGN:We developed indicators for 21 low-value procedures from evidence-based lists such as Choosing Wisely, and applied them to a claims data set of hospital admissions. We used narrow and broad indicators where multiple low-value procedure definitions exist. SETTING AND PARTICIPANTS:A cohort of 376 354 patients who claimed for an inpatient service from any of 13 insurance funds in calendar years 2010-2014; approximately 7% of the privately insured Australian population. MAIN OUTCOME MEASURES:Counts and proportions of low-value procedures in 2014, and relative change between 2010 and 2014. We also report both the Medicare (Australian government) and the private insurance financial contributions to these low-value admissions. RESULTS:Of the 14 662 patients with admissions for at least 1 of the 21 procedures in 2014, 20.8%-32.0% were low-value using the narrow and broad indicators, respectively. Of the 21 procedures, admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value (1607-2956; 44.4%-81.7%).Seven low-value procedures decreased in use between 2010 and 2014, while admissions for low-value percutaneous coronary interventions and inpatient intravitreal injections increased (51% and 8%, respectively).For this sample, we estimated 2014 Medicare contributions for admissions with low-value procedures to be between $A1.8 and$A2.9 million, and total charges between $A12.4 and$A22.7 million. CONCLUSIONS:The Australian federal government is currently reviewing low-value healthcare covered by Medicare and private health insurers. Estimates from this study can provide crucial baseline data and inform design and assessment of policy strategies within the Australian private healthcare sector aimed at curtailing the high volume and/or proportions of low-value procedures.Kelsey Chalmers, Sallie-Anne Pearson, Tim Badgery-Parker, Jonathan Brett, Ian A Scott, Adam G Elshaug ... et al

Acid suppressants for managing gastro-oesophageal reflux and gastro-oesophageal reflux disease in infants: a national survey

Objectives: To evaluate the diagnosis and management of reflux and gastro-oesophageal reflux disease (GORD) in infants aged <1 year presenting to general practitioners (GPs). Design, setting and participants: A nationally representative, prospective, cross-sectional survey of GP activity in Australia, 2006–2016 (Bettering the Evaluation And Care of Health Study). Annually, a random sample of around 1000 GPs recorded details for 100 consecutive visits with consenting, unidentified patients. Outcome measures: Diagnoses of reflux and GORD and their management including prescribing of acid-suppressant medicines (proton pump inhibitors (PPIs) and histamine receptor antagonists (H2RAs)) and counselling, advice or education. Results: Of all infants’ visits, 512 (2.7%) included a diagnosis of reflux (n=413, 2.2%) or GORD (n=99, 0.5%). From 2006 to 2016, diagnostic rates decreased for reflux and increased for GORD. Prescribing of acid suppressants occurred in 43.6% visits for reflux and 48.5% visits for GORD, similar to rates of counselling, advice or education (reflux: 38.5%, GORD: 43.4% of visits). Prescribing of PPIs increased (statistically significant only for visits for reflux), while prescribing of H2RAs decreased. Conclusions: Overprescribing of acid suppressants to infants may be occurring. In infants, acid-suppressant medicines are no better than placebo and may have significant negative side effects; however, guidelines are inconsistent. Clear, concise and consistent guidance is needed. GPs and parents need to understand what is normal and limitations of medical therapy. We need a greater understanding of the influences on GP prescribing practices, of parents’ knowledge and attitudes and of the pressures on parents of infants with these conditions.Jane C Bell, Francisco J Schneuer, Christopher Harrison, Lyndal Trevena, Harriet Hiscock, Adam G Elshaug, Natasha Nassa

Setting a research agenda for medical overuse

Although overuse in medicine is gaining increased attention, many questions remain unanswered. Dan Morgan and colleagues propose an agenda for coordinated research to improve our understanding of the problemDaniel J Morgan, Shannon Brownlee, Aaron L Leppin, Nancy Kressin, Sanket S Dhruva, Les Levin, Bruce E Landon, Mark A Zezza, Harald Schmidt, Vikas Saini, Adam G Elshau