17 May 2019 | Health Quality & Safety Commission
Associate Professor Sue Crengle says the Choosing Wisely approach has the potential to reduce, maintain or increase inequities – and deliberate consideration of equity is needed across all Choosing Wisely activities.
‘We need to consider unintended consequences all the time and use available evidence to help us do this or obtain that evidence. I would really like to see us expand Choosing Wisely to include more equity-focused recommendations.’
Prof Crengle was a keynote speaker at the Choosing Wisely forum held in Wellington on 10 May, and focused on how equity could be embedded into the programme.
The importance of equity
She first outlined why equity was so important in Aotearoa.
‘Life expectancy at birth is about seven years less for Māori, for both men and women. Mortality rates for many conditions are higher for Māori as are rates of hospitalisation for those conditions. Conversely, the provision of preventative service such as mammography or cervical screening to Māori and Pacific peoples is lower than to the provision to non-Māori non-Pacific women.
‘Ricci Harris and her colleagues have done excellent work looking at the prevalence of ethnic discrimination in a range of sectors, including in the health sector. They have clearly demonstrated that Māori and Pacific people are more likely to report experiencing ethnic discrimination in the health system and that this experience is associated with adverse health outcomes across a range of conditions.
‘We need to be very mindful of this and think carefully about cultural competence and how we are communicating with people who are may not necessarily have had positive health system experiences. However, while good communication and high health literacy is essential, it is a limited subset of the actions that are needed to address equity in Choosing Wisely programmes. A broader range of actions are needed to ensure Choosing Wisely does not increase inequities and ideally reduces inequities. The health system and health professionals also play important roles in determining outcomes.’
An equity focus must be explicit
Prof Crengle says programmes that do not consider equity in their design and implementation can inadvertently increase inequities or maintain them.
‘There are unintended consequences that arise from this failure to consider equity. For example, in the 1990s the back-to-sleep health promotion campaign to reduce sudden infant deaths was implemented in ways that were more effective for non-Māori. In addition, the messages around where baby slept were more effective in a non-Māori population. As a result, there was greater uptake of the messages by non-Māori resulting in a rapid reduction of non-Māori SIDS and no real change in Māori SIDS. We saw a massive blow out of inequity.
‘Subsequently, the Māori SIDS prevention programme was implemented and undertook a range of activities including providing culturally appropriate recommendations around where babies sleep. As a result, Māori SIDS rates have fallen. So even though in the 90s SIDS was more common in the Māori community, the original back-to-sleep programme was not designed or implemented in ways that were appropriate or effective for Māori and had the unintended consequence of increasing inequities.’
She says another example of where wise choices might increase inequities is the messaging that antibiotic prescribing for upper respiratory tract infections and sore throats is inappropriate as these are usually viral infections.
‘In Māori children and young people or adults who have had previous rheumatic fever, this universal message may lead to harm if there is untreated group A strep throat and therefore the risk of an episode of rheumatic fever.
‘The messaging needed to be more nuanced, should have taken into account differences in rheumatic fever risk and should have recommended different approaches to managing sore throats.’
Equity focus lacking in Choosing Wisely Aotearoa
Prof Crengle noted that the New Zealand Choosing Wisely Mission statement, like most international Choosing Wisely programmes, does not explicitly consider equity. In addition, of the 32 organisations in New Zealand and Australasia that have Choosing Wisely recommendations, the NZ College of Public Health Medicine was the only one to specifically consider equity in its recommendations and supporting documentation.
‘This is an example of great leadership from that college. Their first recommendation is specifically about health equity, two others explicitly include equity in the recommendation, and a fourth recommendation includes consideration of the impacts of programmes on equity.
‘It may be that other colleges considered equity in their recommendations, however this wasn’t apparent from the text.’
She challenged health professional groups to include at least one equity-focused recommendation, including increasing the use of high-value investigations or treatments for Māori and other groups that currently have low access to these.
‘To do this, colleges need to have good data about inequity in their area and this includes information about epidemiology, outcomes and inequities across the investigation and treatment pathways. Once these data are known, equity focused specific ‘do less’ or ‘do more’ recommendations can be formulated.’
Prof Crengle says she was pleased to find a document on the Choosing Wisely New Zealand website that specifically addresses equity considerations.
‘In this document Choosing Wisely notes the need for partnership with Māori in governance and design of the campaign, and monitoring for equity and evaluation of programme impacts. It recommends New Zealand colleges take equity into account when developing lists of recommendations and provide clear guidance when the recommendations should not be applied to all population groups.
‘It also notes the need for health professionals to practice in culturally competent ways to make sure they are able to understand patient and whānau values and preferences, and recognises the need for patient resources to incorporate and reflect the views and needs of Māori and other groups.’
‘Do less’ and ‘do more’ approaches
Prof Crengle talked about the importance of have a ‘do more’ as well as a ‘do less’ approach.
‘Gout provides an interesting example of both a ‘do more’ and ‘do less’ recommendation. The prevalence of gout is two or three times higher in Māori and Pacific populations, and the hospitalisation rates for gout are four times higher for Māori and nine times higher in Pacific populations when compared to non-Māori, non-Pacific.
‘Use of urate lowering therapy is recommended for people who have recurrent gout. However, although Māori and Pacific peoples are more affected by gout, fewer receive urate-lowering therapy. A ‘do more’ recommendation around the use of urate-lowering therapy in Māori and Pacific populations could assist with reducing this inequity.
‘Conversely, the use of non-steroidals could be a ‘do less’ recommendation. Non-steroidal anti-inflammatories can be used to manage an acute gout flare, but they can have significant drawbacks, particularly in relation to kidney injury and cardiovascular disease.
‘Doing more urate lowering and prescribing fewer non-steroidals could reduce inequities in gout prevalence and hospitalisation.’
Addressing equity in Choosing Wisely
She had a number of recommendations on how Choosing Wisely Aotearoa could embed equity within its programmes and activities and therefore avoid unintended adverse consequences.
‘It would be helpful for Choosing Wisely to explicitly embed equity practices across the programme, strengthening the current capacity and capability of Choosing Wisely governance and operational groups to consider and address issues of equity.
‘I also recommend Choosing Wisely considers expanding the programme focus from reducing and avoiding low value and inappropriate interventions to include promoting high value and appropriate interventions being provided to groups that are currently under represented.’
She says ensuring that at least one of the five recommendations made by colleges specifically focuses on reducing a known inequity in an investigation or treatment has the potential to make an important contribution to equity.
‘Another strategy to address inequity is to eliminate instances where people are giving high value treatment or investigations inappropriately. That is, they might not meet the criteria for these investigations or treatments but they receive them anyway.
‘It is also important to ensure information about addressing inequities in Choosing Wisely campaigns and interventions is included in the guidance documents on the website. The level of experience, capability and confidence to consider and address inequities varies across the health sector, and stronger guidance will be valuable for those with less experience, capability and confidence.’
She encouraged the Choosing Wisely programme to consider whether a low-value investigation or treatment is low value for all populations.
‘For example, throat swabs might be a low value test for New Zealand European young people but be a higher value test for Māori and Pacific young people because of the risk of rheumatic fever.
‘Also consider who is receiving the low value test? Are Māori more likely to receive low value tests or treatments. If access to low value tests or treatments is reduced will they then receive greater access to high value tests and treatments? If not, the impact of reducing low value testing might be to increase inequities, assuming that low value tests and treatments have a net positive benefit greater than doing nothing.’
Prof Crengle’s presentation is available on the Choosing Wisely website.
Choosing Wisely New Zealand is partnering with Te Ohu Rata o Aotearoa – Maori Medical Practitioners Association (Te ORA) – to do a research project to improve shared decision making between health professionals and Māori consumers and their whānau, with the goal of supporting more equitable health outcomes for Māori.
The project outputs will include practical and cost-effective strategies (eg, tools and/or resources and/or approaches) to improve shared decision making for use by all health professionals and/or providers.