For consumers

The Council of Medical Colleges (CMC) previously facilitated the Choosing Wisely campaign in New Zealand, as part of its commitment to improving the quality of care for all consumers.

This information is not being actively updated. For information on the history of the campaign please contact enquiries@cmc.org.nz

Unnecessary tests do not add value to you or your whānau

Just because tests and treatments are available, doesn’t mean we should always use them.

Tests, treatments and procedures have side-effects and some may even cause harm. For example, CT scans and x-rays expose you to radiation; overuse of antibiotics leads to them becoming less effective; a false positive test may lead to painful and stressful further investigation.

In this section you will find lists and questions relating to specific problems and concerns – and the questions to ask before agreeing to a medical intervention or test.

As each situation is unique, health care professionals and patients should have a conversation to work out an appropriate health care plan together.

Four questions for patients to ask

Some tests, treatments and procedures provide little benefit. And in some cases, they may even cause harm. These questions can help you make sure you end up with the right amount of care — not too much and not too little. As each situation is unique, a discussion with your health professional can help you develop a healthcare plan for you.

1. Do I really need this test or procedure?

Tests may help you and your doctor or other healthcare professionals determine the problem. Procedures may help to treat it. Understanding why your doctor is considering a test -and weighing up the benefits and risks – is always advisable, and is every patient’s right and responsibility.

2. What are the risks?

If you have – or don’t have – the test or procedure, what is likely to happen? Are there potential side effects? What are the chances of getting results that aren’t accurate? Could that lead to more testing or another procedure?

3. Are there simpler, safer options?

Sometimes all you need to do is make lifestyle changes, such as eating healthier foods or exercising more. Or an alternative test or treatment that might deliver useful information, while reducing any potential negative impacts for you.

4. What happens if I don't do anything?

Ask if your condition might get worse – or better – if you don’t have the test or procedure right away.

Patient & consumer resources

Allergies

Allergic reaction - severe

Don’t use antihistamines to treat anaphylaxis — prompt administration of adrenaline is the only treatment for anaphylaxis.

Anaphylaxis is a potentially life threatening, severe allergic reaction and should always be treated as a medical emergency.

Infant feeding and allergy prevention

Introducing solids to infants

Don’t delay introduction of solids to infants – start around 4-6 months.

Allergy prevention for children FAQ

Alzheimer's disease

Alzheimer's disease and other forms of dementia - disruptive behaviour

Antipsychotic drugs are usually not the best choice

People with Alzheimer’s disease and other forms of dementia can become restless, aggressive, or disruptive. They may believe things that are not true. They may see or hear things that are not there. These symptoms can cause even more distress than the loss of memory.
Doctors often prescribe powerful antipsychotic drugs to treat these behaviours:

Olanzapine (Zyprexa and generic)
Quetiapine (Seroquel and generic)
Risperidone (Risperdal and generic)

If you are uncertain if your loved one is taking one of these medications please ask their health care team. In most cases, antipsychotics should not be the first choice for treatment. Here’s why:

Antipsychotic drugs don’t help much. Studies have compared these drugs to sugar pills or placebos. These studies showed that antipsychotics usually don’t reduce disruptive behaviour in older dementia patients.

Antipsychotic drugs can cause serious side effects. Doctors can prescribe these drugs for dementia for behavioural symptoms, but they cause serious side effects.

Side effects include:

Drowsiness and confusion—which can reduce social contact and mental skills, and increase falls
Weight gain
Diabetes
Shaking or tremors (which can be permanent)
Pneumonia
Sudden death.

Other approaches often work better. It is almost always best to try other approaches first, such as the suggestions listed below.

Make sure the patient has a thorough exam and medicine review.
The cause of the behaviour may be a common condition, such as constipation, infection, vision or hearing problems, sleep problems, or pain.
Many drugs and drug combinations can cause confusion and agitation in older people.

Talk to an aged care health professional

This person can help you find non-drug ways to deal with the problem. For example, when someone is startled, they may become agitated. It may help to warn the person before you touch them. For more tips, see below.

Consider other drugs first

Talk to your doctor about the following drugs that have been approved for treatment of disruptive behaviours:

Drugs that slow mental decline in dementia.
Antidepressants for people who have a history of depression or who are depressed as well as anxious.

Consider antipsychotic drugs if:

Other steps have failed.
Patients are severely distressed.
Patients could hurt themselves or others.

Start the drug at the lowest possible dose. Caregivers and health professionals should watch the patient carefully to make sure that symptoms improve and that there are no serious side effects. The drugs should be stopped if they are not helping or are no longer needed.

Tips to help with disruptive behaviours

Keep a daily routine. People with dementia often become restless or irritable around dinner time.

Do activities that use more energy earlier in the day, such as bathing.
Eat the biggest meal at midday.
Set a quiet mood in the evening, with lower lights, less noise, and soothing music.

Help the person exercise every day. Physical activity helps use nervous energy. It improves mood and sleep.

Don’t argue with a person who’s distressed.

Distract the person with music, singing, or dancing.
Ask the person to help with a simple task, such as setting the table or folding clothes.
Take the person to another room or for a short walk.

Plan simple activities and social time. Boredom and loneliness can increase anxiety. Adult daycare programmes can provide activities for older people. They also give caregivers a break.

It’s OK to ask questions. If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from Choosing Wisely Canada (2014), Treating disruptive behaviour in people with dementia. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Alzheimer’s disease – feeding tubes – when you need them and when you don’t

Most people in the last stage of Alzheimer’s disease have difficulty eating and drinking. At this time, families/whānau may wonder if a patient needs a feeding tube. Families/whānau want to do everything possible for someone who is ill. But they often get little information about feeding tubes. And they may feel pressure from doctors or nursing home staff, because feeding is simpler with a feeding tube. But feeding tubes sometimes do more harm than good. Here’s why:

Feeding tubes usually aren’t helpful for severe Alzheimer’s disease

People with severe Alzheimer’s disease can no longer communicate or do basic things. Chewing and swallowing is often hard. This can cause serious problems, such as weight loss, weakness, and pressure sores. Or food can get into the lungs, and cause pneumonia. So people often need help to eat.

In many cases, a decision is made to use a feeding tube. The tube may be put down the throat. Or it may be put through a small cut in the abdominal wall, into the stomach. The patient is then given liquid nutrition through the tube. But tube feeding is not better than careful hand feeding—and it may be worse. It does not help people live longer, gain more weight, become stronger, or regain skills. And it may increase the risk of pneumonia and pressure sores. Hand feeding gives human contact and the pleasure of tasting favourite foods.

When death is near and patients can no longer be fed by hand, families/whānau often worry that the patient will “starve to death.” In fact, refusing food and water is a natural, non-painful part of the dying process. There is no good evidence that tube feeding helps these patients live longer.

Feeding tubes can have risks

Tube feeding has many risks.
It can cause bleeding, infection, skin irritation, or leaking around the tube.
It can cause nausea, vomiting, and diarrhoea.
The tube can get blocked or fall out, and must be replaced in a hospital.
Many people with Alzheimer’s disease are bothered by the tube and try to pull it out. To prevent that, they are often tied down or given drugs.
Tube-fed patients are more likely to get pressure sores.
Tube-fed patients are more likely to spit up food, which may lead to pneumonia, a term called “aspiration pneumonia”.
At the end of life, fluids can fill the patient’s lungs, and cause breathing problems.

So when are feeding tubes a good idea?

Feeding tubes can be helpful when the main cause of the eating problem is likely to get better. For example, they can help people who are recovering from a stroke, brain injury, or surgery. The tubes also make sense for people who have problems swallowing and are not in the last stage of an illness that can’t be cured. For example, they can help people with Parkinson’s disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Caring for a person with severe Alzheimer's disease

When caring for a person with severe Alzheimer’s disease, these steps can help with eating problems and other end-of-life concerns:

Treat conditions that cause appetite loss, such as constipation, depression, or infection.
Feed by hand. Ask a health professional about the best kinds of foods to offer and the best ways to feed by hand.
Stop unneeded medicines. Some drugs can make eating problems worse, including:
- antipsychotics such as quetiapine (Seroquel and generic)
- sleeping pills or anti-anxiety drugs such as lorazepam or zopiclone
- bladder-control drugs such as oxybutynin
- some drugs for osteoporosis such as alendronate (Fosamax and generic)
- drugs for Alzheimer’s disease such as donepezil (Aricept and generic).

Schedule dental care. Badly fitting dentures, sore gums, and toothaches can make eating hard or painful.

Plan ahead. Every adult should have an advance directive. It lets you say what kind of care you want and who can make decisions for you if you cannot speak for yourself.

It’s OK to ask questions. If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

© 2013 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2013) and Choosing Wisely Canada (2014), Feeding tubes for people with Alzheimer’s disease, developed in cooperation with the Canadian Geriatrics Society.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Blood tests

Anaemia in hospital – blood transfusions

What is a blood transfusion?

A blood transfusion is a treatment arranged by your doctor. It involves giving you blood, or blood components, into a vein.

Where does blood come from?

In New Zealand, blood is obtained only from unpaid and voluntary donors.

How much blood do you need?

Getting a blood transfusion in the hospital can save your life. You may need a lot of blood if you are bleeding heavily because of an injury or illness.

But anaemia is usually not urgent. And usually you don’t need a lot of blood. You may only need one unit of blood while you are in the hospital. Or you may not need any blood at all. Here’s why:

What is anaemia?

If you have anaemia, your blood doesn’t have enough red blood cells, or they don’t work properly. Red blood cells carry haemoglobin. This is an iron-rich protein that helps bring oxygen to the body. Anaemia is measured in haemoglobin levels.

There are a number of reasons you may become anaemic while you are in the hospital, including:

Bleeding
Liver and kidney disease
A chronic condition or disease
Medications
Kidney disease
Chronic infections
Cancer

Extra Units of blood are not helpful

In New Zealand, haemoglobin is measured in grams per litre of blood (g/L).

The normal haemoglobin range for a man is between 130–170 g/L
The normal haemoglobin range for a woman is between 120–160 g/L.

Some doctors believe that hospital patients whose haemoglobin falls below 100 g/dL should get a blood transfusion.

But recent research found that:

Many patients with levels over 70g/L may not need a blood transfusion.
One unit of blood is usually as good as two, and it may even be safer.
Some patients in intensive care may do better when they receive less blood.

Using more blood units may increase risks

In New Zealand, the blood is generally very safe. The risks when you get blood are very small. They include:

A minor allergic reaction (fever or rash) occurs in 1% to 2% of transfusions.
A major reaction may cause kidney failure, breathing difficulties, and sometimes other life threatening complications. This is rare – there is roughly 1 case per year in NZ.
Transfusion of blood products can sometimes cause an infection:
- Minor virus infections that are common in the community may sometimes be passed on.
- Infection with viruses such as Hepatitis B and C, and HIV/AIDS are very rare, but these infections are sometimes life-threatening. Tests on blood donations minimise the risk for these infections.
  - For hepatitis B the risk is estimated as 1 in 300,000 transfusions (1 case every 2-3 years).
  - The risks of acquiring hepatitis C, or HIV/AIDS is even lower (less than 1 in every 1,000,000 transfusions in New Zealand).

These problems can happen with any transfusion. But the risks are higher if you get more blood.

The supply of blood relies on donations

If you only use the blood you need, you are helping to keep a blood supply for other people.

Do patients ever need more than one unit of blood?

Most patients do well with just one unit of blood, if the transfusion is not for an emergency. But some people may need more blood. Discuss this with your doctor.

You may need more than one unit if:

You have bleeding that is not well controlled, such as bleeding that continues during surgery.
You have severe anaemia and unstable chest pain ('unstable' means that your symptoms keep changing).

Why was this resource developed?

This Choosing Wisely resource is based on the top five anaesthetic-related practices that, based on clinical evidence, may have limited benefit, no benefit or may potentially cause harm to patients, according to the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Surgeons, the Australian and New Zealand Intensive Care Society, and College of Intensive Care Medicine of Australia and New Zealand.

Choosing Wisely is a campaign to help health professionals and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high quality care.

Supporting evidence for the issues discussed in this resource

For a list of supporting evidence for the issues discussed in this resource, please see:

Having them every day may not be necessary

If you stay in a hospital overnight or longer, you may have many blood tests. Sometimes you need all the tests, especially if you are very sick. But sometimes you get more tests than you need. Here’s what you should know about blood tests in the hospital.

Common blood tests

When you’re in the hospital, you may have blood taken for two common tests:

A full blood count (FBC) checks your blood for signs of infection, immune system problems, bleeding problems, and anaemia (low iron)
A blood chemistry panel gives your doctor information about your muscles, bones, heart, and other organs. It also checks your blood sugar, calcium, and other minerals.

These tests can help your doctor identify a problem and learn if a treatment is working.

More testing doesn’t help you

If your test results stay the same after a day or two, you may not need them again. More tests won’t tell your doctor anything new, unless you’re in intensive care or your treatment changes.

Less testing doesn't hurt you

There’s no harm in having fewer tests. One study showed that reducing common tests at the hospital did not affect patient health or safety.

Getting too many blood tests has risks

Blood tests are very safe. But they can cause other problems if you have them every day.

Anaemia. This can happen if you lose too much blood. With anaemia, your blood cells can’t carry enough oxygen to the rest of your body. Anaemia can make it harder for you to heal. It is especially dangerous for people with heart or lung problems.
Increased risk of infection. Blood tests have a low risk of infection. But the more tests you have, the more risk you have.
Less sleep. Nurses often wake patients up to get blood tests. Poor sleep can affect how you heal.

You may need a blood test every day if:

you are in intensive care
the doctors don’t know what’s wrong with you
you are trying a new treatment
your doctor thinks you may have internal bleeding, especially if you’re having surgery.

Other tests you may need

If you’re scheduled to have surgery, your doctor may want you to have certain tests. These are usually done before the day of your surgery. Consider the tests below only if you have certain problems or need some kinds of surgery:

Blood coagulation test. May be needed if you’re having brain, cancer, heart, or spinal surgery. You may also need it if you have certain medical conditions or take blood thinners.
Breathing test. Recommended if you’re having lung, chest, or upper abdominal surgery. You may also need it if you have lung disease or are short of breath.
Cardiac stress test. May be needed if you have heart disease, especially if you are having major surgery.
Chest X-ray. May be needed if you smoke, have symptoms of lung or heart disease, or are older than 70, especially if you’re having major surgery.

Download this resource

© 2015 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2015), Blood tests when you’re in the hospital, developed in co-operation with the Society of Hospital Medicine.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Imaging and diagnostics

Bone density (DEXA) scans

A bone-density test is a way to measure the strength of your bones. The test, called a DEXA scan, is a kind of X-ray. The main reason to have the test is to find and treat serious bone loss, called osteoporosis, and prevent fractures and disability.

A DEXA scan measures the mineral density of the bone, usually in the hip and spine. Results are given as a “T-score”, which is your bone density compared to a normal young adult of the same sex.

Most men and women under age 65 probably don’t need the test because:

Most people do not have serious bone loss

Most people have no bone loss or have mild bone loss (called osteopenia). Their risk of breaking a bone is low so they do not need the test. They should exercise regularly and get plenty of calcium and vitamin D. This is the best way to prevent bone loss.

The bone-density scan has risks

A bone-density test gives out a small amount of radiation, but radiation exposure can add up. The effects can add up in your body over your life, so it is best to avoid it if you can.

Who should get a bone-density scan?

Women should get a DEXA scan at age 65, and men age 70 and up. They may want to talk with their health care providers about the risks and benefits before deciding. Younger women and men ages 50 to 69 should consider the test if they have risk factors for serious bone loss. Common risk factors include:

breaking a bone in a minor accident
having rheumatoid arthritis
having a parent who broke a hip
smoking or drinking excess alcohol
having a low body weight
using corticosteroid drugs for three months or more.

You may need a follow-up bone-density test after several years

Most changes in bone density do not happen quickly. There is often no benefit having a follow-up DEXA scan for at least 5 years. If your T score from your first scan was 2.00 or more, you do not need another scan for 5 years. You may need a follow-up scan sooner if you have risk factors for bone loss, such as:

hyperparathyroidism (where your parathyroid gland is over-active)
taking certain medicines, such as steroids, or hormones for treating breast or prostate cancer
Low levels of vitamin D.

How can you keep your bones strong?

The following steps can help you build bone:

The best exercise for your bones is exercise that makes your bones carry weight. When you walk, your bones carry the weight of your whole body. You can also lift weights. Aim for at least 30 minutes of weight-bearing exercise a day
Get enough calcium and vitamin D. They help keep your bones strong. Aim for at least 1,200 mg of calcium a day. Eat foods high in calcium, such as dairy products, leafy green vegetables, and canned sardines and salmon. You may need a calcium pill each day. Consider taking vitamin D if you are a woman in menopause or you get little sun. Take 800 IU a day.
Avoid smoking and limit alcohol. Among other things, smoking and drinking alcohol can speed up bone loss. Quitting smoking can be difficult, but there are many treatments that can help you do it. Ask your health care provider or contact Quitline on 0800 778 778. For alcohol, limit yourself to one drink a day for women, and two drinks a day for men.
Try to avoid certain medicines. Some medicines can damage bones. These include proton pump inhibitors (such as omeprazole, lansoprazole, and pantoprazole), used to treat heartburn; corticosteroids; and some of the newer antidepressants. If you take one of these medicines, ask your health care provider about whether these medications are right for you.

Why was this resource developed?

This Choosing Wisely resource is based on the top five practices that, based on clinical evidence, may have limited benefit, no benefit or may potentially cause harm, according to the New Zealand Association of Rheumatologists[1].

Supporting evidence for the issues discussed in this resource

For a list of supporting evidence for the issues discussed in this resource, please see: https://www.hqsc.govt.nz/our-programmes/other-topics/choosing-wisely/recommendations-and-resources/for-clinicians/new-zealand-rheumatology-association-nzra

Ask these questions

Do I really need to have this test, treatment or procedure?

The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.

What are the risks (of having or not having it)?

Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.

Are there simpler, safer options?

Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing?

Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada and Choosing Wisely USA/Consumer Reports (2016) “Bone density tests: when you need them and when you don’t” and BPAC New Zealand (2008) “Prevention of Osteoporosis”. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Back pain - imaging tests

The exact cause of your acute low back pain may be difficult to identify but in most cases it is related to things like muscle strain rather than conditions like nerve or bone damage, infection or cancer. Talk to your health professional about how to manage your low back pain.

The problem

Getting an X-ray, CT scan or MRI may seem like a good idea. But back pain usually subsides in about a month, with or without testing. For example, one study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didn’t recover faster.

The risks

X-rays and CT scans expose you to radiation, which can increase cancer risk. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain, but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes even including surgery.

When to consider the tests

X-ray and CT scans often make sense if you have nerve damage, or signs of a serious underlying condition such as cancer or a spinal infection. “Red flags” that can alert your health professional that imaging may be worthwhile include a history of cancer, unexplained weight loss, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.

Ask these questions

Do I really need to have this test, treatment or procedure?

What are the risks (of having or not having it)?

Are there simpler safer options?

Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing?

Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.

Download this resource

© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Ankle and knee imaging

About medical imaging

The ankle and knee are joints located in the lower leg. Injuries to these joints are very common reasons why people visit their GP or physiotherapist. Injuries that frequently affect these joints include ligament sprains, muscle and tendon strains, and damage to the meniscus (cartilage) in the knee.

Although these injuries are often painful and uncomfortable, they can usually be managed with rest, ice, support and a gradual return to physical activity.

In some cases, such as when the cause of the injury is unclear or the damage to the joint is complex, an imaging test, such as an X-ray, ultrasound or magnetic resonance imaging (MRI), may be recommended. However, research shows that in most cases of acute ankle and knee sprain/strain, having an X-ray or MRI does not change the treatment you receive or how fast you recover. In addition, having an X-ray you don’t need may expose you to unnecessary radiation.
In fact, for many sprains affecting the ankles and knees, taking a history and examining the joint is all that your health professional will need to do to determine the diagnosis and guide management.

Factsheets

Ankle sprains: 10 things to know

Read 10 things you should know about ankle sprains on the NPS MedicineWise website to help you get back moving as usual.

Your knee joint injury, explained

The knee is a commonly injured part of the body. In fact, in sport it’s the most commonly injured part, with research finding that up to one in four of all sport injuries affect the knee.

Different types of medical imaging

There are several types of medical imaging tests, each with its own advantages and disadvantages. Read Know your imaging options on the NPS MedicineWise website to be informed about your medical imaging test and talk to your health professional about any questions or concerns you may have.

Questions you can ask about medical imaging

Imaging can be very useful in helping to diagnose the cause of your symptoms, but is not always necessary. Read Talking to your health professional about imaging on the NPS MedicineWise website to be well informed about your imaging and ask your doctor any questions you may have.

For more information: Health Navigator.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Adapted from NPS MedicineWise (2016), Ankle and knee imaging. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Electrocardiogram (ECGs)

The problem

An ECG records the electrical activity of your heart at rest. It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous heart attack (myocardial infarction).

The risks

The ECG will not harm you. However, it can sometimes show mild nonspecific abnormalities that are not due to underlying heart disease, but cause worry and lead to follow-up tests and treatments that you do not need.

When to consider the tests

You may need an ECG test if you have risk factors for heart disease such as high blood pressure, or symptoms such as palpitations or chest pain. Or you may need it if you already have heart disease.

Ask these questions:

Do I really need to have this test, treatment or procedure?

What are the risks (of having or not having it)?

Are there simpler, safer options?

Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing?

Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.

Download this resource

Choosing Wisely do not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Headaches

CT and MRI examinations are called imaging tests because they take pictures, or images, of the inside of the body. Many people who have headaches want a CT scan or an MRI to find out if their headaches are caused by a serious problem, such as a brain tumor. Most of the time these tests are not needed. Here’s why:

Imaging tests rarely help

Health professionals see many patients for headaches and most of them have migraines or headaches caused by tension. Both kinds of headaches can be very painful, but a CT scan or an MRI rarely shows why the headache occurs. Having a CT scan or MRI also does not help ease the pain.

A health professional can diagnose most headaches during an office visit. They ask you questions about your health and your symptoms. This is called a medical history. Then they may do what is called a neurological exam, which includes a test of your reflexes. If your medical history and exam are normal, usually imaging tests will not show a serious problem.

Imaging tests have risks

The results of your CT scan or an MRI may also be unclear. This can lead to more tests and even treatment that you do not need.

When should you have an imaging test for headaches?

In some cases you might need a CT scan or an MRI. You might need one if your health professional cannot diagnose your headache based on your neurological exam and medical history. Or you might need one if the exam finds something that is not normal.

You may also need a CT scan or an MRI if you have unusual headaches. See your health professional right away if:

You suddenly develop a very severe headache which feels like something is bursting inside your head.
Your headaches are different from other headaches you’ve had, especially if you are age 50 or older.
Your headaches happen after you have been physically active.
You have headaches with other serious symptoms, such as a loss of control, a seizure or fit, or a change in speech or alertness.

How to treat a headache

Your health professional can advise you on how best to treat your headache. You can help most headaches by taking these steps:

Avoid triggers. Triggers are events that can cause headaches. These tips can help you avoid triggers:

If you have migraines:

Wear tinted glasses in bright light
Do not skip meals
Avoid alcohol, meat with added nitrates (such as cold cuts), and aged cheeses (hard, dry cheeses such as parmesan).

If you have tension headaches:

Avoid getting over tired
Hold your back and neck straight when you sit or stand
Keep your jaw relaxed (not clenched).

Quit smoking. Smoking can bring on either kind of headache.

Manage stress. Try meditation, yoga, stretching, or other activities that can help you relax.

Get plenty of sleep. Aim for six to eight hours of sleep each night. Set a regular time to go to bed and to wake up. Avoid watching TV or using a computer just before you go to bed.

Get plenty of exercise. Regular exercise, such as swimming, brisk walking, or cycling, can reduce stress and ease both kinds of headaches.

Non-prescription pain medicines such as the following can help:

paracetamol
ibuprofen
naproxen

You can buy all of these without a prescription. Try not to take any of these pills more than once or twice a week. Overuse can make headaches worse and cause side effects.

If your headaches are severe or happen often, there are medications which your health professional can prescribe to help lower the pain level and/or reduce how frequently you get them.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2016) and Choosing Wisely Canada (2014), Imaging tests for headaches, developed in cooperation with the Canadian Association of Radiologists. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Antibiotics

Antibiotics - coughs, colds & sore throats

Manage symptoms without antibiotics

If you have a viral infection of the ear, nose, throat, sinuses or chest, antibiotics won’t make you feel better or recover faster. Talk to your health professional about why you probably don’t need antibiotics.

Do you need a medicine?

Coughs, colds, earaches, sinus congestion problems and sore throats are usually caused by a virus. Antibiotics kill bacteria, not viruses. Colds usually get better in 7 to 10 days, although a cough can last up to 3 weeks.

Taking antibiotics when you don’t need them can have unwanted results. When antibiotics are necessary, the benefits far outweigh the risks, but when they are not needed, you are taking an unnecessary risk. People taking an antibiotic may experience side effects such as diarrhoea, nausea or vomiting.

Unnecessary use of antibiotics can also lead to antibiotic resistance. This means that antibiotics are no longer effective against the bacteria they once killed. If you have an antibiotic-resistant infection you:

will have the infection for longer
may be more likely to have complications of the infection
could remain infectious for longer and pass your infection to other people.

What can you do?

Rest
Allow your immune system to fight off the virus

Use home remedies
Inhale steam from a bath or shower in a closed room to help relieve a blocked nose. Don’t inhale steam from a bowl of hot water due to the risk of burns. Soothe your sore throat by gargling warm salty water, sucking ice cubes or throat lozenges as needed or drinking warm water with honey and lemon.

Use symptom-relieving medicines
Take over-the-counter (non-prescription) medicines such as paracetamol or ibuprofen to relieve your pain or fever.

Use a nasal or oral decongestant to relieve a blocked nose. Cough and cold medicines should not be given to children under 6 years of age and should only be given to children aged 6 to 11 years on the advice of a health professional. Saline nasal spray or drops may be used in children. For more information on symptom-relieving medicines see the Choosing Wisely resource on medicines and treatments for bronchitis.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Further information

Antibiotics: Health Navigator

Antibiotic resistance: Health Navigator, Ministry of Health

Download this resource

Adapted from NPS MedicineWise (2016), Coughs, colds & sore throats. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Antibiotics for sinusitis

The problem

People with sinusitis (congestion combined with nasal discharge and facial pain) are often prescribed antibiotics. But most people don’t need them. That’s because the problem almost always stems from a viral infection, not a bacterial one—and antibiotics don’t work against viruses.

The risks

About one in four people who take antibiotics report side effects, such as a rash, dizziness and stomach problems. In rare cases, they can cause severe allergic reactions. Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.

When to consider antibiotics

Antibiotics should usually only be considered when symptoms last longer than a week, start to improve but then worsen again, or are very severe. Worrisome symptoms that can warrant immediate antibiotic treatment include a fever over 38.6°C, extreme pain and tenderness over your sinuses, or signs of a skin infection, such as a hot, red rash that spreads quickly.

Ask these questions

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.

What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.

Are there simpler safer options?
Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing?
Ask your health professional if your condition might worsen — or get better — if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a healthy conversation with your health professional today.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Further information

Antibiotics: Health Navigator

Antibiotic resistance: Health Navigator, Ministry of Health

Download this resource

© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Antibiotics for your skin

When you need them and when you don't

Sometimes rashes and surgical wounds become infected with bacteria. Doctors treat these infections with antibiotics, which are medicines that can kill bacteria.However, doctors may prescribe antibiotics even when there is no infection. Most of the time, that’s not useful, and it can do more harm than good. Here’s why:

Antibiotics usually don't help if your skin is not infected

Eczema causes dry, itchy, red skin. People with eczema often have high amounts of bacteria on their skin, but that doesn’t mean they have an infection. Even so, some doctors treat eczema with oral antibiotics, in pill or liquid form. Antibiotics do not help the itching, redness, or severity of eczema. And the skin bacteria usually come back in a month or two. You can control eczema better with moisturisers and the other steps below. To relieve itching and swelling, ask your doctor about creams or ointments containing a steroid (also called a corticosteroid) or other medicines.

Most surgical wounds don’t need antibiotics

Some doctors use antibiotic creams or ointments to prevent infection in surgical wounds. However, most surgical wounds have a very low risk of infection. Antibiotics don’t make the risk any lower. In fact, petroleum jelly (Vaseline and generic) is cheaper and less likely to irritate the wound.

Antibiotics have risks

Oral antibiotics for eczema can have side effects, including upset stomach, vomiting, diarrhoea, and vaginal yeast infections. They can also cause allergic reactions such as rashes, swelling, itching, and trouble breathing.

Antibiotic creams and ointments can actually slow down the healing of wounds. And they can cause redness, swelling, blistering, draining, and itching. Using antibiotics when you don’t need them helps drug-resistant bacteria grow. These bacteria are harder to kill. They can cause illnesses that are harder to cure. This increases the risk of complications and side effects. The resistant bacteria can also be passed on to others.

When do you need antibiotics?

Antibiotics should be prescribed for eczema when there are signs of a bacterial infection, such as:

Pus-filled bumps, or cracks and sores that ooze pus
Honey-colored crusting
Very red or unusually warm skin
Possibly fever

Antibiotics should be prescribed for surgical wounds:

when the wound shows signs of a bacterial infection, such as redness, pain, swelling, warmth, pus, oozing, and yellow crusting
sometimes when a patient has a fever, sweats, or chills
when the wound is in an area of the body that is more likely to get infected (such as the groin).

Safeguard your skin

Eczema

Moisturise often during the day.
Use mild unscented skin cleansers and moisturisers. Avoid products with alcohol or dyes.
Short, cooler baths and showers are better than long hot soaks.
After washing, pat the skin partly dry. Then apply moisturiser right away on your damp skin.
Avoid things that make your skin worse. These can include scratchy fabrics, cigarette smoke, strong soaps, detergents and cleaning products.
Try to prevent scratching. It can lead to infection. Cut your fingernails short. Light cotton gloves can help prevent scratching at night.

Surgical wounds

Before you leave the hospital or doctor’s office, make sure you know how to care for your wound. Ask where to call if you have questions.
Always clean your hands before and after caring for your wound.
Don’t scratch the wound. That can slow the healing. Talk to your health professional if itching is a problem.
Avoid activities that could cause your wound to pull apart, such as lifting and straining.
Eat well to heal well. A healthy diet helps wounds heal.

Further information

Antibiotics: Health Navigator

Antibiotic resistance: Health Navigator, Ministry of Health

This report is for you to use when talking with your health professional.

Download this resource

© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2016), Antibiotics for your skin. When you need them — and when you don’t, developed in co-operation with the American Academy of Dermatology.Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Ear infection - treatments

A middle ear infection (otitis media) will often get better by itself in a few days as the body’s immune system can take care of the infection without any treatment.

Children with a middle ear infection

Most children older than 2 years won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days. However, many children younger than 2 years may need antibiotics to treat the infection. Antibiotics won’t help relieve your child’s ear pain. Whilst a child’s ear pain will be of concern to their parents or carers, studies show that 6 out of 10 children will have no ear pain after the first 24 hours without any treatment (antibiotics or pain relief). Pain relief medicines (such as paracetamol or ibuprofen) can help to relieve the symptoms of an ear infection, and will usually only be needed for a short time.

If your child’s symptoms don’t improve after a few days, or their symptoms get worse, see your doctor.

Antibiotics for middle ear infections in children

Antibiotics are recommended for children with middle ear infections who:

are younger than 6 months
are younger than 2 years old with an infection in both ears or fluid leaking out of their ear (called ‘otorrhoea’)
have a fever (a temperature of 38.5°C or higher) and are vomiting.

Babies and infants younger than 6 months old
Infants younger than 6 months old who have ear infections (with or without fever or vomiting) will usually be prescribed an antibiotic. Your doctor will usually ask to see your baby again in 24 hours.

Children aged 6 months to 2 years
Your doctor will advise you on how to relieve the symptoms of a middle ear infection.. Your doctor may ask to see your child after 24 hours, or contact you to ask how they are. If your child’s symptoms don’t improve after 24 hours, your doctor may prescribe antibiotics.

Children aged 2 years or older
Your doctor will advise you on how to relieve the symptoms of a middle ear infection.. If your child’s symptoms don’t improve in 2 days, your doctor will usually examine your child again and may prescribe antibiotics if necessary.

Adults with a middle ear infection

Most adults won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days.

Your doctor can provide advice about how to relieve your symptoms. If your symptoms don’t improve in 2 days, your doctor will usually examine you again and may prescribe antibiotics.

Paracetamol, ibuprofen or aspirin can help relieve the pain caused by an ear infection.

For more information: Health Navigator.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2016), Medicines and treatments for a middle ear infection. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Bronchitis

What causes bronchitis?

The viruses that cause the common cold or flu (influenza viruses A and B) usually cause bronchitis, but bacteria (e.g. Mycoplasma pneumoniae) can sometimes also cause it.

Other viruses that cause bronchitis include the parainfluenza viruses (which can also cause croup and bronchiolitis), the respiratory syncytial virus (which can also cause bronchiolitis), the coronaviruses (which can also cause colds) and the adenoviruses (which can also cause colds, pneumonia and croup).

The viruses that cause respiratory tract infections such as bronchitis are usually spread when someone infected with the virus sneezes or coughs, releasing droplets that contain the virus into the air. These droplets can be breathed in by others, or transferred to anyone who touches a surface contaminated with droplets containing the virus.

Some people are at more risk of getting bronchitis and of having more severe symptoms including people who:

are older
smoke
have a weakened immune system (e.g. due to HIV or some medicines)
are exposed to chemicals that can irritate the lung tissue (e.g. in their workplace).

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2012), What causes bronchitis? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

How is bronchitis diagnosed?

Your health professional will ask you questions about your health, for example:

if you have recently had a cold
what your symptoms are
what medicines you are taking
details of your medical history
any other medical conditions you may have e.g. asthma or chronic obstructive pulmonary disease (COPD).

Your health professional may examine you, and listen to your breathing using a stethoscope (a device used to listen to your breathing and heart beat). In bronchitis, the airways become inflamed and lots of mucus is produced.

Laboratory tests

Throat swabs

If you have a fever (a temperature of 38.5°C or higher), a sore throat and a cough, your health professional may also take a sample from your throat and nose using a sterile cotton swab, which will be sent off for laboratory tests to find out what is causing the infection.

Chest x-ray

Your health professional may recommend a chest X-ray if your symptoms get worse, as pneumonia is a common complication of bronchitis.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2012), How is bronchitis diagnosed? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Medicines and treatments

Most people with acute bronchitis have infections that can be dealt with by their immune system. They will usually only need treatment for the symptoms of bronchitis. Bronchitis is most often caused by a virus, so antibiotics won’t help, particularly if you are otherwise healthy with a normal immune system. Antibiotics do not kill viruses. There are ways you can relieve the symptoms of bronchitis (e.g. headache, aches, pains and fever), and some over-the-counter medicines that you can take. See your health professional if your symptoms change or become worse, as pneumonia is a common complication of bronchitis.

What can I do to relieve my symptoms?

You can relieve your symptoms by:

resting
drinking plenty of water and non-alcoholic fluids
avoiding exposure to cigarette smoke
inhaling steam; this can help relieve a blocked nose. Supervise your child while they breathe in steam from a hot bath or shower in a closed room.

You can help soothe a sore throat by:

gargling with warm salty water
sucking on an ice cube or a throat lozenge
drinking hot water with honey and lemon; this can also be a simple and effective home remedy.

Medicines to manage the symptoms of bronchitis

There are over-the-counter medicines you can take to help manage the symptoms of bronchitis. These include:

paracetamol, ibuprofen and aspirin for relieving pain and fever
decongestants and saline nasal sprays or drops for relieving a blocked nose.

Medicines for relieving pain and fever

Adults and children older than 1 month can take paracetamol.
Adults and children older than 3 months can take ibuprofen.
The correct dose of paracetamol or ibuprofen for children who have pain or fever is worked out according to how much your child weighs.
Do not give aspirin for pain or fever to children younger than 12 years as it may cause serious side effects (e.g. Reye’s syndrome, see below).
Do not give aspirin for fever to children 12 to 16 years old. This is because Reye’s syndrome, which can affect brain function and cause liver damage, has been associated with aspirin use in children (this is rare, i.e. fewer than 1 in 1000 people will experience the side effect).

Fevers are common in young children, especially if they have a chest infection or after a vaccination. A fever (a temperature of 38.5°C or higher) doesn’t necessarily mean you or your child has a serious illness. In fact, a fever helps the body’s immune system to fight infection.

Tips for using pain and fever medicines safely

Paracetamol and ibuprofen are common ingredients in some cold and flu medicines, so it’s important to check the active ingredients on the label of your medicine to avoid ‘doubling up’ and taking other medicines that also contain paracetamol or ibuprofen.
It’s important to tell your health professional about all the medicines you or anyone in your care is taking, including prescription, over-the-counter and complementary medicines (‘herbal’ or ‘natural’ medicines and vitamin or mineral supplements). This is because all medicines, including herbal and natural medicines, can cause side effects and may interact with other medicines.
Some medicines cannot be taken by people with particular medical conditions, by people who are also taking certain other medicines, by young children, during pregnancy or when breastfeeding.

Ask your pharmacist or doctor for advice about the safest medicine for you or your child, and always read the label on your medicine.

Medicines to relieve a blocked nose (nasal congestion)

Intranasal decongestants can help to relieve a blocked nose, but should not be used for more than 4 or 5 consecutive days to avoid rebound nasal congestion.

Medicated nasal decongestants must not be used in babies younger than 6 months, as rebound congestion may cause breathing difficulty. Decongestants containing pseudoephedrine, phenylephrine, oxymetazoline or xylometazoline must not be used in children younger than 6 years.

Use salt water (saline) nasal sprays or drops instead of a nasal decongestant for these children.

Before using any medicine, check with a doctor or pharmacist about the safest one for you or your child. Always read the information on the label and the consumer medicine information (CMI) leaflet for your medicine if available.

See your health professional if you notice a change in your symptoms or they become worse, as pneumonia is a common complication of bronchitis.

'Cough and cold' medicines

Cough, and combination ‘cough and cold’, medicines are available and may relieve your symptoms, but there is not enough information from good quality clinical trials proving their effectiveness, particularly in children. Cough medicines can also sometimes cause unwanted side effects such as drowsiness, nausea, vomiting and constipation. They are not recommended for use in children under 2 years. Before using any medicine, check with a doctor or pharmacist about the safest one for you or your child. Always read the information on the label and the consumer medicine information (CMI) for your medicine (if available).

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2012), Medicines and treatments for bronchitis. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

What are the symptoms of bronchitis?

If you have bronchitis, you will usually have a cough and one or more of the following symptoms:

a sore throat
tiredness
headaches
blocked nose and sinuses
difficulty breathing
a tight feeling in your chest
wheeziness
fever (a temperature of 38.5°C or higher) and chills
aches and pains

How long will the symptoms of bronchitis last?

Your cough can last for a few weeks after the other symptoms of bronchitis have gone. This is called acute bronchitis.

If you have a cough and are producing sputum (mucus or phlegm) for more than 2 months, this is called chronic bronchitis.

Most of the symptoms of acute bronchitis are not severe, and you may not need to see your health professional. However, some symptoms of bronchitis can be similar to those of pneumonia (an infection that causes inflammation in your lungs), so it is important to look out for any changes in your symptoms.

See your health professional if you notice a change in your symptoms or they become worse.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2012), What are the symptoms of Bronchitis? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

General

Common tests, treatments and procedures you may think you need

Let's think again

ECGs (electrocardiograms)

The problem

The risks

When to consider the tests

You may need an ECG test if you have risk factors for heart disease such as high blood pressure, or symptoms such as palpitations or chest pain. Or you may need it if you already have heart disease.

Imaging tests for lower-back pain

The problem

The risks

When to consider the tests

CT scans and MRIs for headaches

The problem

Many people who have headaches want a CT scan or MRI to find out if their headaches are caused by a brain tumour or other serious illness and health professionals often comply to provide reassurance. But all that’s usually needed is a careful medical history and neurological exam. Adding a CT scan or MRI rarely helps.

The risks

A CT scan of the head uses a low radiation dose. This may slightly increase the risk of harmful effects such as cancer. Risks from radiation exposure may add up, so it is best to avoid unnecessary radiation. The results of your CT scan or an MRI may also be unclear. This can lead to more tests and even treatment that you do not need.

When to consider the tests

They are often warranted if you have an abnormal result on a neurological exam, or if your health professional can’t diagnose the problem based on your symptoms and medical exam. See a health professional if you have head pain that is sudden or explosive; different from headaches you’ve had in the past; brought on by exertion; or accompanied by fever, a seizure, vomiting, loss of coordination, or a change in vision, speech or alertness.

Bone-density (DEXA) scans

The problem

Many people are routinely screened for weak bones with an imaging test called a DEXA scan. If it detects osteoporosis, the results can help patients and their health professional decide how to treat the problem. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.

The risks

A bone-density test gives out a small amount of radiation, but radiation exposure can add up. A diagnosis of osteopenia often leads to treatment with such drugs as alendronate (Fosamax), which poses risks. But there is little evidence that people with osteopenia benefit from these drugs.

When to consider the tests

Health professionals decide on who to refer for a DEXA scan based on risk factors such as age, a fracture from minor trauma, low body weight, and long-term use of corticosteroid drugs. Whether follow-up tests are needed depends on the results of the initial scan.

Ask these questions:

Do I really need to have this test, treatment or procedure?

What are the risks (of having or not having it)?

Are there simpler, safer options?

Sometimes lifestyle changes will provide all the relief you need.

What happens if I do nothing?

Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.

Download this resource

© 2014 Consumers Union of United States, Inc., (101 Truman Ave., Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again. Choosing Wisely do not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Communicating with your health professional

Before your appointment

Make a longer appointment if the problem you want to discuss is complex, or you need to discuss several issues.

Prepare a summary of your health problems, prioritise the issues you want to discuss, and make a list of questions as you think of them.

Let your health professional know if you need an interpreter or other assistance with communicating.

During your appointment

You should expect to be listened to – and be given clear and adequate explanations of your condition, any recommended tests, treatment options and the expected results.

When you describe your problems, be as accurate, complete and honest as possible.

If your health professional recommends a test, treatment or procedure and you are not clear of its purpose or benefits, you may want to discuss this.

Asking the following questions around potential tests or procedures

Do I really need to have this test, treatment or procedure?
What are the risks?
Are there simpler safer options?
What happens if I do nothing?

If you don’t understand anything, tell your health professional – and ask them to repeat or clarify the information until you do understand.

If you don’t feel confident about your appointment, take a family/whānau member or friend with you. Take notes if you think you may have trouble remembering important details (or ask your health professional or support person to take notes for you).

If you want to know more, ask your health professional for some written information, or suggestions of where you might find it.

After your appointment

You may want to make a follow-up appointment to ask further questions, discuss continuing issues or talk to your health professional about your decisions after you’ve had time to consider the options.

If you want to discuss the issues with another health professional, don’t hesitate to get another opinion.

If you have any feedback please let us know here.

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Health checks - when you need them - and when you don't

Like many people, you may schedule a yearly checkup or “annual physical” with your health professional. It usually includes a health history, physical exam and tests. It is important to have a regular health professional who helps make sure you receive the medical care that is best for your individual needs. But healthy people often don’t necessarily need annual physicals, and those checkups can do more harm than good. Here’s why:

Annual physicals usually don’t make you healthier

There have been many studies of the effects of annual checkups. In general, they probably won’t help you stay well and live longer. And usually they don’t help you avoid hospital stays or keep you from dying of cancer or heart disease.

Tests and screenings can cause problems

Most people should only have a test or exam if they have symptoms or risks factors.

One problem is getting a false-positive result. These false alarms can cause anxiety, and unnecessary follow-up tests and treatments. For example, a false-positive blood test can result in a biopsy. An electrocardiogram (ECG) that is not interpreted correctly may lead to another test that exposes you to radiation. Or you might get a procedure to show arteries in the heart that has a risk of heart attack or death in two patients for every 100 who get the test.

Set a schedule with your health professional

Your health professional best knows your health history. You can discuss with him/her the best time for any exams or tests, which you may need.

If your health professional wants to schedule an annual physical, you can ask if it is necessary. Or ask if you can wait until you have a problem or are due for a test (such as a cervical smear or blood pressure check).

So when do adults need a checkup?

You may need a checkup:

When you are sick
When you have a symptom that could mean illness
To manage chronic or ongoing conditions
To check on the effects of a new medicine
To help with risk factors like smoking or obesity
For antenatal care, if you are pregnant
For lifestyle issues like family planning
For other reasons that are based on your individual needs

People in their twenties often do not see a health professional for several years without risking their health, while older people who have developed risks for certain diseases may see a health professional more often. It is best to have a trusted health professional you see regularly who has access to your health records.

What about preventive care?

Preventive care is important. Having a regular health professional helps you get preventive care. Everyone should get the recommended immunisations and screening tests at the times and frequencies recommended by the Ministry of Health.

Download this resource

© 2014 Consumers Union of United States, Inc., (101 Truman Ave., Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Health checkups: when you need them – and when you don’t, developed in cooperation with the Canadian Medical Association’s Forum on General and Family Practice Issues and College of Family Physicians of Canada. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Complementary medicines - ensure the benefits outweigh the risk

Coughs, colds & sore throats - manage symptoms without antibiotics

Do you need a medicine?

Taking antibiotics when you don’t need them can have unwanted results.

When antibiotics are necessary, the benefits far outweigh the risks, but when they are not needed, you are taking an unnecessary risk. People taking an antibiotic may experience side effects such as diarrhoea, nausea or vomiting.

will have the infection for longer
may be more likely to have complications of the infection
could remain infectious for longer and pass your infection to other people.

When does a sore throat need an antibiotic?

In some people, especially Māori and Pacific children, sore throats can have very serious complications and do need antibiotics.

All sore throats in Māori and Pacific children and young people (aged 4–19 years) who are living in some parts of the North Island need to be checked straight away by a doctor or nurse.

Call Healthline 0800 611 116 if you are unsure what you should do.

This is because they are at risk of a serious preventable illness called rheumatic fever. Sometimes a sore throat is caused by Streptococcus bacteria (strep throat). A strep throat can lead to rheumatic fever if it is not treated quickly with antibiotics. Rheumatic fever is a serious illness because it can cause heart damage.

What can you do to manage symptoms?

Rest
Allow your immune system to fight off the virus

Use home remedies

Inhale steam from a bath or shower in a closed room to help relieve a blocked nose. Don’t inhale steam from a bowl of hot water due to the risk of burns.

Soothe your sore throat by gargling warm salty water, sucking ice cubes or throat lozenges as needed or drinking warm water with honey and lemon.

Use symptom-relieving medicines

Take over-the-counter (non-prescription) medicines such as paracetamol or ibuprofen to relieve your pain or fever.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Why was this resource developed?

This Choosing Wisely resource is based on the top five low-value practices that, based on clinical evidence, may have limited benefit, no benefit or may potentially cause harm to patients, according to the Australasian Society for Infectious Diseases.

Supporting evidence for the issues discussed in this resource

Antibiotics:
https://www.healthnavigator.org.nz/medicines/a/antibiotics/

Antibiotic resistance:
https://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/antibiotic-resistance

Sore throats & rheumatic fever:

https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/rheumatic-fever

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Developed by Choosing Wisely New Zealand, 2018. Adapted from NPS MedicineWise (2016), Coughs, colds & sore throats and New Zealand Ministry of Health webpages on “Sore throat” and “Rheumatic fever” (accessed December 2018). 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Last updated: 16 December 2018

Ear infection - treatments

A middle ear infection (otitis media) will often get better by itself in a few days as the body’s immune system can take care of the infection without any treatment.

Children with a middle ear infection

Most children older than 2 years won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days. However, many children younger than 2 years may need antibiotics to treat the infection. Antibiotics won’t help relieve your child’s ear pain. Whilst a child’s ear pain will be of concern to their parents or carers, studies show that 6 out of 10 children will have no ear pain after the first 24 hours without any treatment (antibiotics or pain relief). Pain relief medicines (such as paracetamol or ibuprofen) can help to relieve the symptoms of an ear infection, and will usually only be needed for a short time.

If your child’s symptoms don’t improve after a few days, or their symptoms get worse, see your doctor.

Antibiotics for middle ear infections in children

Antibiotics are recommended for children with middle ear infections who:

are younger than 6 months
are younger than 2 years old with an infection in both ears or fluid leaking out of their ear (called ‘otorrhoea’)
have a fever (a temperature of 38.5°C or higher) and are vomiting.

Adults with a middle ear infection

Most adults won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days.

Your doctor can provide advice about how to relieve your symptoms. If your symptoms don’t improve in 2 days, your doctor will usually examine you again and may prescribe antibiotics.

Paracetamol, ibuprofen or aspirin can help relieve the pain caused by an ear infection.

For more information: Health Navigator.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

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Fatigue – are there tests for fatigue?

Facts about fatigue

There is no test specific for fatigue.
Undiagnosed medical problems are not a common cause of fatigue.
In some cases of fatigue further tests may be appropriate.

Fatigue is a symptom that can have many causes, and research into fatigue has shown that most of them are not related to a medical condition. Your health professional will use information from your medical history and from any examinations they conduct to decide what further steps may need to be taken to help treat or manage your fatigue.

Medical tests may help identify a physical cause

There is no test specific for fatigue, only tests that may help identify a physical cause. The decision about whether to have a test and what type of test to have will depend on your individual situation.

Studies have shown that a medical explanation is found in only about 4% of people with fatigue who go on to have some form of testing. So, for every 100 people who are recommended for some form of test by their health professional to help find out why they are experiencing fatigue, a medical condition will be identified in only about four cases.

It is important to understand that medical tests are not always accurate in their diagnosis. Sometimes they pick up a problem when there isn’t one (this is called a false positive), and sometimes they can miss a diagnosis (this is called a false negative).

So you may want to discuss the pros and cons of medical tests with your health professional. For further information: Health Navigator New Zealand.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

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Adapted from NPS MedicineWise, Are there medical tests for fatigue? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Gout - what medicines to use

Heartburn and reflux

Manage your medicine

Prescription medicine for heartburn and reflux, called a proton pump inhibitor, is often only needed for 4 to 8 weeks. If your symptoms are well managed, talk to your health professional about reviewing your medicine.

Do you need a medicine?

Acid reflux – also described as heartburn – is a condition where acid from the stomach moves up into your oesophagus (food pipe). Acid reflux is very common. Many people can control their symptoms by making lifestyle changes or by taking over-the-counter (non-prescription) medicines as needed. Some people with more regular or severe symptoms – people with gastro-oesophageal reflux disease (GORD) – may need a prescription medicine known as a proton pump inhibitor (PPI).

PPI medicines work by reducing the amount of acid made by the stomach and are very effective at controlling symptoms of reflux and heartburn. However, PPIs should not be taken long term when not needed, because of the cost and possible side effects.

If you’ve been taking a PPI for more than 4 to 8 weeks, and your symptoms seem to be well managed, talk to your health professional about reviewing your medicine. Your health professional may recommend stepping down your treatment, which can include any of the following:

reduce your daily dose of medicine
limit your treatment so that you take medicine only when you experience the symptoms of heartburn and reflux (also known as on-demand therapy)
stop treatment completely as your symptoms may not return

What can you do?

Making changes to your lifestyle may help control your symptoms and reduce the need for medicine.

Quit smoking

Discuss ways to quit smoking with your health professional, such as nicotine replacement therapies, or call Quitline on 0800 778 778.

Other lifestyle changes

Identify and avoid foods and drinks that make your symptoms worse (e.g. fatty foods, spicy foods, chocolate, coffee, cola drinks, orange juice and alcohol).
Avoid eating large or late meals and avoid lying down immediately after meals.
If you experience symptoms that are worse at night and disrupt your sleep, try raising the head of your bed.
If you are overweight, try losing some weight.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2016), Heartburn and reflux. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Hives or urticaria

What is urticaria?

Urticaria is a skin condition commonly known as hives. It produces an itchy rash that tends to come and go and can last for a variable period of time. The condition can be acute (lasting less than 6 weeks) or chronic (lasting longer than 6 weeks). Most cases of urticaria have no known cause.

What causes urticaria?

Urticaria occurs when certain substances such as histamine are released from specific cells in the skin. This process is usually triggered by various immunologic mechanisms, most commonly involving the presence of circulating “IgE” antibodies, although other pathways may also be involved.

The cause of this “immunologic triggering” is unknown in the majority of cases, but can sometimes be associated with various types of infections, chronic immunologic diseases or allergy to foods or medications. The use of intravenous dyes during some radiological tests can sometimes trigger urticaria as well.

Physical urticaria is a type of urticaria that may be caused by exposure of the skin to cold, heat, pressure or rubbing.

What does urticaria look like?

Urticaria typically looks like a raised rash that may be a normal skin colour or pinkish or red in colour. The rash may occur anywhere on the body and often starts off as small round spots that quickly enlarge and spread.

The rash can be very itchy but it usually only lasts for a few hours before settling, and eventually resolving completely within 24 to 48 hours.

What problems may occur with urticaria?

A viral illness can occur before urticaria develops, especially in children.

Image reproduced with permission Department of Dermatology, St Vincent’s Hospital MelbourneSome chronic medical conditions such as systemic lupus erythematosus or rheumatoid arthritis may occur with chronic urticaria.

Swelling of deeper tissues in the lips and throat may occur in some cases of urticaria and is called angioedema.

How is urticaria diagnosed?

For acute urticaria no specific tests are required as the condition is often expected to resolve completely. Allergy testing may be required if a specific food trigger is suspected.

For chronic urticaria tests involving blood, urine and stool specimens may be required to identify any infection or underlying chronic immune disorder that may be causing the condition.

How is urticaria treated?

The specific triggers that have been identified (such as a food or medication) should be avoided.

Chronic urticaria is usually treated with antihistamine medication. Antihistamines are commonly available as over-the-counter medications. They can often be effective in stopping itch and preventing future outbreaks of urticaria. Medication usually needs to be continued for many weeks and long term treatment may be required in some cases to keep the condition under control.

In cases where antihistamines fail to control symptoms, stronger immunosuppressive medications may be needed.

Acute urticaria usually resolves completely within 6 weeks.

Chronic urticaria can last for many weeks or months and the long term success of any treatment may depend on the presence of any underlying associated diseases.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

2016 © Australasian College of Dermatologists. This information has been written by Dr Nicholas Aspres. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Insomnia

Trouble sleeping or staying asleep for long enough, insomnia is a common problem and can be caused by many factors.

Migraines

What is a migraine?

Migraine is a very common type of headache, which can cause a lot of distress. Migraine attacks can last for hours—or even days. They can cause intense pain, nausea and vomiting. They can make you sensitive to light or noise and they can affect your life and work.

What is the problem?

Medicines specifically for migraines, and non-prescription painkillers, are the most effective migraine treatments. However many patients with migraine continue to be offered strong painkillers, called opioids, to treat migraines. Examples of opioid painkillers available in New Zealand include codeine, tramadol, morphine, oxycodone, fentanyl and pethidine.

Why should I ask questions if I am prescribed an opioid for my migraine?

There are three main problems with using these types of medicines for migraine:

a. They can make headaches worse

Using opioids for migraines can cause more headaches and chronic migraines than you had to begin with. This is called “medication overuse headache”. It is possible with all pain medications, but is more likely with opioids.

b. They are not as effective as other migraine medicines

There are other medicines that can reduce the number of migraines you have and how severe they are—better than opioids. This includes medicines called triptans, which work directly on the blood vessels in your head to relieve the pain from migraine.

c. They can be harmful

Opioids are strong medications which may cause you harm, including dependence and addiction. Opioids can cause serious withdrawal symptoms if you stop taking them suddenly. People who use high doses for a long time may need to be in the hospital in order to stop using them.

Opioids, even at low doses, can make you feel sleepy or dizzy. Other side effects include constipation and nausea. Using them for a long time can lower your sex drive and cause depression and sleep problems.

Which medicines are good for migraines?

The type of medication you need depends on many things, including how frequent and severe your migraines are. Your doctor will advise you on the best treatment, based on your symptoms and experience.

A usual approach is:

Step 1: Non-prescription pain relievers such as paracetamol and NSAIDs (such as ibuprofen, diclofenac, naproxen).
Step 2: Triptans (such as sumatriptan, rizatriptan or zomitriptan).
Step 3: Combination treatment with a triptan and an NSAID.

All of these options work best if you use them when the migraine is just beginning.

Anti-sickness medicines may also be used to relieve nausea associated with migraine. Examples include metoclopramide, domperidone and prochlorperazine.

If you have migraines often, or if they are very severe, ask your doctor about other medicines to prevent headaches.

When might I need an opioid for migraine?

If you have certain medical conditions, such as some heart diseases or you are pregnant, you may not be able to take the migraine-specific medicine. Talk to your doctor if this applies to you.

In some people, the migraine-specific medicines don’t work. Opioid painkillers may be a short-term “rescue” option for these people. In this situation, you should not take opioids more than 9 days per month. At the same time, you and your doctor should continue to focus on other strategies to help you prevent and manage your migraines. Long-term follow-up is needed to make sure you do not develop complications from taking opioids.

How can I manage without medicines?

Some migraines can be managed without medication. Talk to your doctor about how to:

Avoid triggers. These are things that bring on your headaches. Common food triggers are chocolate, cheese, alcohol, foods with MSG, and meats with nitrates (such as some processed meats). Other common triggers are strong smells, bright light, skipping meals, and smoking.
Reduce stress. Stress can bring on migraines. Try doing activities to help you relax, such as meditation, walking or swimming, yoga, tai chi, or stretching exercises. If you feel anxious or depressed, ask your doctor to help you treat these conditions or refer you to a psychiatrist for treatment.
Get regular sleep and exercise. Too much or too little sleep can lead to migraines. Aim for seven to eight hours a night, with a regular bedtime and wake-up time. Physical activity, such as walking or swimming, can also help prevent obesity, a risk factor for migraines.
Control symptoms. When you get a migraine, lie down in a quiet, dark room if you can. Put a cold cloth or compress over your forehead, massage your scalp, or press on your temples. Drink plenty of water, especially if you have vomited. It is helpful to take medications as early as possible.
Keep a headache diary. This can help you figure out what your triggers are and keep track of the medicines you use. Write down:
- when the pain began
- what you were doing before the pain began
- what you ate and drank in the 24 hours before the headache
- the medicine and dose you used to treat the pain and when you took it
- how well your headache attack responded to the medication.

For more information about migraines visit: https://www.healthnavigator.org.nz/health-a-z/m/migraine-severe-headache/#Overview

Why was this resource developed?

This Choosing Wisely resource is based on the top five clinical practices in neurology which may be overused, inappropriate or of limited effectiveness, according to the Australian and New Zealand Association of Neurologists in 2016.

Supporting evidence for the issues discussed in this resource

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):1157-68.
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):968-81.
Tepper SJ. Opioids should not be used in migraine. Headache 2012;52; S1:30-4.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada (2015), “Treating migraine headaches: some drugs should rarely be used” and Health Navigator (2017) “Migraine (severe headache)”. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Tennis elbow

Tennis elbow, also known as lateral epicondylitis, is a condition that causes pain around the outside of the elbow. It is commonly triggered by overuse of the muscles and tendons of the forearm, such as repetitive hand and wrist movements, or repeatedly bending the elbow. Resting the arm and avoiding doing things that make it worse is the best way to recover. Pain from tennis elbow usually lasts for 6 to 12 weeks, but can vary. Steroid injections are not recommended, as while they can provide some relief in the short term, over the longer term they can hold back recovery. If pain persists talk to your doctor or physiotherapist.

For more information about tennis elbow and things you can do to help, see: http://www.healthnavigator.org.nz/health-a-z/t/tennis-elbow/

Type 2 Diabetes

Self-monitoring your blood glucose levels is not routinely recommended if you have type 2 diabetes and are not taking insulin or a sulfonylurea. Talk to your health professional about reviewing your self-monitoring of blood glucose levels.

Do you need to test?

Type 2 diabetes is a condition where the body either cannot respond to insulin or cannot produce enough insulin to control glucose levels in the blood. Type 2 diabetes is associated with genetics and lifestyle factors (e.g. poor diet, obesity, physical inactivity). Blood glucose levels in people with diabetes are usually checked by your doctor four times per year, using a laboratory test called HbA1c, or a ‘finger prick’ test and a blood glucose monitor. Self-monitoring is when you check your blood glucose levels at home using the ‘finger prick’ test.

If you have type 2 diabetes and are not taking insulin or a sulfonylurea, self-monitoring of your blood glucose levels is not routinely recommended.

Research shows self-monitoring of blood glucose provides only slight improvement in control of type 2 diabetes, however general well-being or general health-related quality of life is not improved. Talk to your health professional about when self-monitoring might be of benefit, such as assessing low blood sugar.

Whether you self-monitor your blood glucose or not, the following advice will help manage your diabetes.

What can you do?

Manage your weight

Know your healthy weight and, if needed, develop a healthy eating and exercise plan to achieve those goals.

Eat a healthy diet

Maintain a balanced diet that includes a wide range of vegetables, moderate amounts of high-fibre carbohydrates that have a low glycaemic index (GI), lean cuts of meat and fish, low-fat dairy products, and small amounts of high fat and sugary foods. Low GI foods release glucose into the blood slowly, which helps blood glucose levels rise steadily and avoid a glucose high.

Exercise regularly

Regularly exercising improves blood glucose control and overall health and wellbeing. Aim for at least 150 minutes per week of moderate-intensity exercise (e.g. brisk walking, aqua aerobics) or 75 minutes of vigorous activity (e.g. jogging, swimming).

Take your medicines correctly

If you have been prescribed medicines to control your blood glucose levels, it is important to take your medicines at the correct dose and times.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2016), Type 2 diabetes. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Vitamin D - tests and deficiency

Vitamin D is a hormone that helps your body absorb the calcium it needs to keep your bones and muscles strong and healthy. We can get some of our vitamin D requirement from food, but it is very difficult to get enough vitamin D from diet alone. We are usually able to make most of the vitamin D we need ourselves, when our bare skin is exposed to ultraviolet (UV) radiation from sunlight.

Why do I need vitamin D?

We know that vitamin D is essential for bone and muscle health. Moderate to severe vitamin D deficiency can lead to rickets (soft bones) in infants and children. In adults over the age of 50, low vitamin D levels can lead to osteoporosis (brittle bones) and increase the risk of falls and fractures (broken bones).

Many health conditions, including diabetes, heart disease and some cancers, have been linked to low vitamin D levels, but whether low levels of vitamin D cause these conditions is unclear. The benefits of increasing vitamin D intake for these health problems —through sun exposure, diet or supplements — are unknown.

Am I at high risk of vitamin D deficiency?

You may be at risk of vitamin D deficiency if you:

are confined indoors because of age, illness or disability — particularly residents of aged-care facilities
are Māori, Pacific, African or Indian
wear clothing that covers most of your body most of the time (e.g. for religious or cultural reasons)
cover your skin or avoid the sun because of a condition that places you at higher risk of skin cancer (e.g. if you have a suppressed immune system, such as after an organ transplant)
have a health condition that affects vitamin D absorption from your diet (e.g. cystic fibrosis, coeliac disease, Crohn’s disease)
take medicines that cause vitamin D to break down (e.g. some epilepsy medicines).

People with very low levels (moderate to severe deficiency) are most at risk of health problems.

Women need to maintain healthy vitamin D levels during pregnancy, as their unborn baby needs vitamin D to help bone and tooth development. Some pregnant women may be at risk of low vitamin D — this is most likely if you also have one or more of the risk factors listed above.

Breastfed babies who fall into the risk categories above or have mothers with low vitamin D may also be at risk of vitamin D deficiency. Infant formula in New Zealand is fortified with vitamin D.

How do I get vitamin D?

Sun exposure

For most people, the simplest way to increase vitamin D levels is through sensible sun exposure on bare skin. The ideal amount of sun will vary depending on:

where you live — UV levels are higher in northern New Zealand (e.g. Auckland)
what season it is — UV levels are higher in summer than winter
the time of day — UV levels peak during the middle of the day
your skin colour — if you have dark skin, you need 3 to 6 times more sun exposure to produce the vitamin D your body needs.

During summer, most fair-skinned people can probably get enough vitamin D from a few minutes of exposure to sunlight on their face, arms and hands (or the equivalent area of skin) on either side of the peak UV periods on most days. In winter, in southern New Zealand, more sun exposure may be needed. The table below provides an approximate guide to sensible sun exposure for a person with fair skin.

Most children and teenagers can maintain healthy vitamin D levels if they play outdoor games or sport during the day. Children need sun protection — such as sunscreen, a hat, clothing, sunglasses and shading during summer.

Recommended daily sun exposure for vitamin D production for people with fair skin*

Region	Dec-Jan (summer) 10am or 2pm	July-Aug (winter) 10am or 2pm	July-Aug (winter) Midday
Auckland	6-8 min	30-47 min	24 min
Christchurch	6-9 min	49-97 min	40 min

Diet

The natural food sources of vitamin D include liver, eggs and fatty fish such as salmon, herring and mackerel. In New Zealand, milk and other products such as margarine and cereals may be fortified with vitamin D, but if you are low in vitamin D you will not be able to correct the problem through diet alone.

Supplements

Some New Zealanders find it difficult to get enough sun to ensure adequate levels of vitamin D, especially those people identified at high risk of deficiency. In these situations, vitamin D supplements may be required. If your health professional recommends a supplement, it’s important to take it exactly as advised.

Do I need a vitamin D test?

Studies have found that many New Zealanders have lower than recommended vitamin D levels. Whether this has any negative health effects remains to be seen.

People at low risk of deficiency do not need to be tested for vitamin D. People who are at higher risk of deficiency, such as those with darker skin, or those who wear modest dress, may need to get tested, as well as:

older people who have been diagnosed with osteoporosis and/or are at increased risk of falls and bone fractures
pregnant women and breastfeeding mothers with vitamin D risk factors, as vitamin D deficiency could affect their baby’s bone and tooth development
babies, children and adolescents who are at high risk of vitamin D deficiency, as their bones are still growing.

A vitamin D test is not required before a health professional prescribes a vitamin D supplement, unless severe deficiency is suspected.*

If you’re healthy but are worried your lifestyle is putting you at risk of low vitamin D, try to follow the safe sun exposure guidelines mentioned above and look after your bone and muscle health by:

Eating a calcium-rich diet — many people don’t consume enough calcium in their diet. The best food sources of calcium include dairy products, tinned bony fish, calcium-set tofu, nuts and some green vegetables.
Keeping physically active — weight-bearing and muscle-strengthening exercises such as tennis, jogging and Tai Chi are best. The exercise may also help guard against obesity, another risk factor for low vitamin D.

What does a vitamin D blood test involve?

A vitamin D test is a simple blood test that measures a form of vitamin D in the blood called 25-hydroxyvitamin D (25-OHD). In general, health experts agree that a vitamin D level of 50 nanomoles per litre (nmol/L) or above is adequate for bone health.
Vitamin D tests are best performed at the end of winter or in early spring when your body’s vitamin D levels are at their lowest. Ideally, your vitamin D level should be 50 nmol/L or above at this time, and somewhat higher in summer.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

*Source: Best Practice Journal (2011), Vitamin D supplementation: navigating the debate.

Adapted from NPS MedicineWise (2014), Vitamin D tests and deficiency. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Opioids

Managing non-cancer pain with opioid medicines

Opioids are a type of pain medicine (oxycodone, morphine, pethidine, fentanyl and methadone are examples of strong opioids, while tramadol and codeine are relatively weak opioids).

These medicines work well for some types of short-term pain but don’t always get rid of pain completely. They have significant side effects, become less effective over time and can be addictive.

It’s important to only use opioids for the shortest time and at the lowest dose possible.

Important questions to ask your health professional:

How long will the pain last?
How much will this medicine reduce the pain?
What to do if the medicine does not help my pain?
What are the side effects of the medicine?
When should I seek urgent medical attention?
When should I next see my doctor?

Pain relief in hospital

Pain is a common experience when you are in hospital. Talk to hospital staff about how pain is affecting you, so that they can help keep you as comfortable as possible.

There are many ways to treat pain. This often includes medicines such as paracetamol, anti-inflammatory medication, and opioids, but other strategies are also important and are mentioned below.

Questions to ask before leaving hospital

Before you leave hospital, make sure you ask your health professional these 5 questions and any other questions you may have.

a. What is causing the pain?

The cause of the pain and how long it is expected to last depends on your situation.

b. What are the possible benefits and potential risks of this medicine?

Opioids reduce pain – they won’t take the pain away completely. Any benefit needs to be weighed against potential harms, and benefits are not guaranteed in everyone. Opioids can have major side effects, including the possibility of addiction/dependence and overdose (including even death). Other side effects can include drowsiness and constipation.

c. How long should I take this medicine?

Opioids should only be used for the shortest time and at the lowest dose possible. Discuss with your doctor or pharmacist when you can lower your dose or stop the medicine altogether. Your doctor or pharmacist can also advise how to safely lower your dose, to reduce problems.

d. Are there other ways to manage the pain?

There are lots of effective and safer ways to help manage pain, such as building activity slowly, gentle exercises, mindfulness and relaxation. Most people need to use a combination of strategies.

e. What is my pain management plan?

Work with your health professional to develop a plan that works for you. You can use the pain management plan below as a guide.

Will I become addicted?

If opioids are used for short-term pain relief, addiction is not usually a problem, but it is important that you only use them for pain relief.

If you have to take opioids for a long period of time (a week or two) your body will get used to it. This means that instead of stopping the opioid medicine suddenly, you are likely to have to reduce the amount you take slowly to prevent having a withdrawal reaction. This is not the same as being addicted to it.

Top tips to keep you and others around you safe while you are taking opioids:

Do not share your medicines with others.
Keep the medication securely out of reach of children as even small doses can be extremely harmful. This is also true of pets.
Opioids can cause sedation. Do not drive or operate heavy machinery without first discussing with your doctor.
Let your doctor know if you are taking other medicines or supplements – sleepiness and other interactions can sometimes occur.
Take all leftover medicines to your pharmacy for disposal.
Opioids mixed with alcohol are very likely make you feel drowsy – this combination can be harmful and should be avoided.

Make a pain management plan

There are many ways you can manage pain and speed recovery. Work with your health professional to create your personal pain management plan.

Use the following tips to help create your personal plan.

a. Write down your pain management goal

E.g. getting off pain medication, getting back to work or hobbies, reducing the pain to a certain level, getting on with a normal life.

b. Physical (body) factors to consider to help with the pain

Build physical activity appropriately
Physiotherapy
Yoga or other gentle exercises
Massage
Heat or cold pack

c. Psychological (mind) factors to consider to help with the pain

Relaxation
Mindfulness
Distraction
Cognitive behavioural therapy (CBT)

d. Social (lifestyle) factors to consider to help with the pain

Stop smoking
Healthy eating
Reduce alcohol
Better sleep habits
Stay socially active

e. Write down what pain medicines you will trial and use, and how you will take them to gain the most benefit

E.g. paracetamol, anti-inflammatory medicine, opioid, other medicines for pain.

f. Write down any other notes you may have

Further information on opioids is also available at: https://www.healthnavigator.org.nz/medicines/o/opioid-painkillers/

This resource covers a number of areas including – which opioid is best for you, side effects, how to take opioids safely, advice about driving while taking opioids, using alcohol while taking opioids and how to safely stop opioids. There are also links to other resources, resources in several languages and a video on opioid advice.

Download these tips

Adapted from the NPS MedicineWise advice on “Managing pain and opioid medicines” 2019. Choosing Wisely Australia is an initiative of NPS MedicineWise.

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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Palliative care

Support at any time during a serious illness

Palliative care is an added layer of support to help you and your loved ones live with a serious illness.

With palliative care, you can get physical, emotional, and spiritual support

You can get help to relieve pain, fatigue, anxiety, shortness of breath, nausea, and depression. This helps you learn what to expect from your illness and decide on a treatment plan. Palliative care also supports your family/whānau. Sometimes your doctor can provide palliative support. Other times a trained palliative care team works with you and your doctor to provide specialist care and the services you need.

Palliative care can help you at any stage of a serious illness

Examples include congestive heart failure, kidney disease, multiple sclerosis, and cancer. Doctors often wait too long or they simply don’t refer patients for added palliative care supports. Many patients who are seriously ill miss out on the benefits of palliative care.

Palliative care improves your quality of life and may help you live longer

In a study of people with advanced cancer, those who got palliative care early reported better control of pain and other symptoms. People who got palliative care had a better quality of life and less depression. They also lived longer and spent less time in the hospital than those receiving only standard treatments.

Studies suggest that there are similar benefits for people with other life-limiting illnesses.

Palliative care is not “end-of-life” care or hospice

Palliative care can be useful no matter how long you are expected to live. You don’t have to give up other treatments for your illness.

Start palliative care early for best results

Palliative care is most helpful if you start it early during a life-limiting illness. You should request it, no need to wait for your doctor to bring it up. It will affect your quality of care and treatment decisions.

Plan ahead! Don’t wait until you are sick to start advance care planning conversations

Advance care planning helps you think about, talk about and document wishes for health care in the event that you become incapable of consenting to or refusing medical treatments or other care.

Choose a loved one, family/whānau member or friend to communicate your wishes for you, should you become too unwell to make decisions for yourself. Talking to that person as well as your doctor and the rest of your family/whānau will help ensure your wishes are known and will help your loved ones make treatment decisions on your behalf.

Put your plans in writing.

Some people and their doctors put off talking about their wishes and values for health care. This puts you at risk of being too ill to guide your doctors and may increase the uncertainty and burden that your loved ones feel.
For more information: http://www.advancecareplanning.org.nz/

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada (2014) “Palliative care” and the New Zealand Ministry of Health (2014) “About palliative care”[1]. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Last updated: 29th March 2018

[1] www.health.govt.nz/our-work/life-stages/palliative-care/about-palliative-care

End of life care for advanced cancer patients

When to stop cancer treatment?

When you have cancer and you have tried many treatments without success, it can be very hard to know when to stop treatment. Sometimes, even with the best care, cancer continues to spread. It is hard to accept, but the best thing for you at that point may be to stop the cancer treatment. Instead, you could focus on getting care to keep you comfortable and out of pain.

This fact sheet explains how to know when it is time to stop treatment and focus on end-of-life care. You can use this information to talk with your doctor about your options and choose the best care for you.

Cancer responds best to treatment the first time

When you treat a tumour for the first time, there is hope that the treatment will destroy the cancer cells and keep them from returning. If your tumour keeps growing, even with treatment, there is a lower chance that more treatment will help.

This is especially true for solid tumour cancers, like breast, colon, and lung cancer, and sarcoma. Doctors know a lot about how these cancers grow or shrink over time and how they respond to treatment. They have found that treatment after treatment often offers little or no benefit.

When is it time to stop thinking about stopping cancer treatment?

If you have had three different treatments and your cancer has grown or spread, more treatment usually will not help you feel better or increase your chance of living longer. Instead, more treatment could cause serious side effects that shorten your life and reduce the quality of the time you have left.

Still, many people with advanced cancer keep getting chemotherapy—even when it has almost no chance of helping them. They end up suffering when they should not have to.

How do you know when to stop treatment?

It can be hard for the patient, caregivers and the doctor to talk about stopping treatment for the cancer and focus on end-of-life care. Your doctor may bring it up, but sometimes you may need to start the discussion. Your doctor should give you clear answers to any questions you ask.

You need to understand how advanced your cancer is. Ask your doctor about the stage of your cancer and how much it has spread. Ask about your prognosis, or how long you have to live. No one can know exactly, but your doctor usually should be able to tell you a range of months or years.

You need to know if more treatment for cancer will help you live longer. Ask your doctor to explain the risks and benefits of any treatment. Fighting the cancer may no longer be the best thing for you.

Sometimes, if there are no more known treatments and you want to continue other options, you can join a clinical trial. Clinical trials offer new, experimental treatments. Ask your doctor if you are eligible for a clinical trial.

At any time during your treatment you can get help to relieve your symptoms and improve your quality of life. This is called palliative care and it is often important while going through cancer treatment. If you decide that you don’t want more cancer treatment, then it’s time to focus even more on palliative care.

Palliative care improves your quality of life

Palliative care is an added layer of support to help you and your loved ones live with cancer. It does not treat your cancer, but it helps reduce your pain and other symptoms. It helps you and your loved ones get the most out of the time you have left together.

With palliative care, you can get physical, emotional, and spiritual support. You can get help to relieve pain, fatigue, anxiety, shortness of breath, nausea, and depression. Sometimes your doctor can provide palliative support. Other times a trained palliative care team works with you and your doctor to provide specialist care and the services you need. For example, palliative radiation may be appropriate even when a non-active treatment approach has been adopted to treat symptoms such as pain. Ask your oncologist or palliative care team if that may be an option for you.

Palliative care services may be available in your home, in a hospice facility, or at a hospital.

Services include:

doctor and nursing care
pain management
medical equipment and medicines to ease symptoms
grief counselling for family/whānau and friends
social worker services
respite care, to give your caregivers a break.

Questions to ask your doctor

Let your doctor know how much additional information you want to know about your cancer, and when you are ready to talk about end-of-life care.

Ask your doctor:

How long do I have to live if I have more treatment?
What will happen if I do not have more treatment?
What is the goal of more treatment?
Will treatment stop or slow my cancer, or will it help with the symptoms?
What is the best way to manage my symptoms and side effects?
What can I do to make my quality of life better?
Should I meet with someone who knows about palliative care?

If you would like to know more about palliative care:

Ask your doctor for a referral to palliative care services available in your area.

Click here for more information.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2016) and Choosing Wisely Canada (2014), Care at the end of life for advanced cancer patients, developed in cooperation with the Canadian Association of Medical Oncologists, Canadian Association of Radiation Oncology, Canadian Society for Surgical Oncology and Canadian Partnership Against Cancer.

Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Pediatrics

Fever in children: does my child need medicine?

Fevers are common in young children, especially if they have a chest infection or after a vaccination. A fever (a temperature of 37.8°C or higher) doesn’t necessarily mean you or your child has a serious illness. In fact, a fever helps the body’s immune system to fight infection.

Should I give my child painkillers for their fever?

People often want to give their child medicine, such a paracetamol or ibuprofen, to bring down the fever. This is not necessary, unless your child is distressed.

A fever is the body’s normal response to an infection, and fever can help slow the growth and spread of bacteria. So fever is a sign that your child’s immune system is doing its job – there is no need to try and bring down the fever.

If your child is in pain or is distressed, then painkillers can help them feel better. So if your child has a fever but is playing and happy, there is no need to give them paracetamol or ibuprofen. If your child has a fever and is miserable, paracetamol or ibuprofen can help.

Children older than 1 month can take paracetamol.
Children older than 3 months can take ibuprofen.
The correct dose of paracetamol or ibuprofen for children who have pain or fever is worked out according to how much your child weighs.
Paracetamol and ibuprofen should not be given at the same time.
Do not give aspirin for pain or fever to children younger than 16. This can lead to Reye’s syndrome, which is very rare but can cause serious brain and liver damage.

Too much paracetamol can be dangerous

If you give your child paracetamol, you need to make sure you give the right dose. Too much paracetamol can damage your child’s liver. The right dose depends on:

your child’s weight
the strength of paracetamol you are using. There are two strengths available in NZ (120mg/5mL and 250mg/5mL).

You can use the dosing table below to work out how much you should give your child:

Your child's weight	120mg per 5mL	250mg per 5mL
5 kg or less	Ask doctor	Ask doctor
6.5kg	4mL	2mL
8kg	5mL	2.5mL
10kg	6mL	3mL
15kg	9mL	4.5mL
20kg	12mL	6mL
30kg	18mL	9mL
40kg	25mL	12mL

Don’t give your child more than 4 doses in any 24 hours, and make sure you wait at least 4 hours between doses.

For more information about using paracetamol safely, please see: https://www.kidshealth.org.nz/safe-use-paracetamol-children

An online calculator to work out the right dose can be found: https://www.healthnavigator.org.nz/tools/p/paracetamol-dose-calculator/

Does a fever mean my child needs antibiotics?

A fever does not mean your child needs antibiotics.

Antibiotics only work to kill bacteria. Most children with fever do not have a bacterial infection, so antibiotics will not help them.
Antibiotics have side-effects and shouldn’t be taken unless you really need them.
Using too many antibiotics causes bacteria in the community to become resistant, making them harder to kill, which is a serious problem for all of us.

For these reasons, antibiotics shouldn’t be given unless your child has a bacterial infection.

Does treating a fever reduce the risk of seizures?

Sometimes, children with fever may have a fit or seizure because of the fever. This is called a “febrile convulsion”. Medicine to bring down a fever, such as paracetamol and ibuprofen, does not help to reduce the chance of your child having this type of complication.

When should I take my child to the doctor?

Babies under 3 months of age with a temperature above 38ºC need to be checked by a doctor.
Older children with a temperature above 40ºC should also be seen by a doctor.
If your child has a fever and any of these warning signs, see your doctor urgently:
- Rash, unusual sleepiness or floppiness, pain, irritability or persistent crying, inability to swallow, breathing difficulty, vomiting or loss of appetite.
If you are worried about your child, whether or not they have a fever, you should take them to a doctor.

Check with your doctor or phone Healthline on 0800 611 116 if you are worried.

For more information about fever in children, visit: https://www.healthnavigator.org.nz/health-a-z/f/fever-children/ or https://www.kidshealth.org.nz/fever

Why was this resource developed?

Supporting evidence for the issues discussed in this resource

For a list of supporting evidence for the issues discussed in this resource, please see:

https://hqsc.govt.nz/choosing-wisely/recommendations-and-resources/for-clinicians/paediatrics-and-child-health/

http://www.choosingwisely.org.au/recommendations/acn

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Last updated 20 January 2019

Medicines

Reviewing medicines

A medicines review can help improve your treatment and prevent medicine problems. Ask your doctor or pharmacist to organise a review of all your medicines regularly — especially if you or someone you care for is an older person and take several different medicines.

Why should I have my medicines reviewed?

Medicine problems like side effects are more common when you get older — and can often occur when your medicines, health, or health care services change.

If you are an older person it is important that your medicines, current health problems and treatment goals are reviewed regularly. This helps to make sure you receive the best treatment.

When your doctor or pharmacist reviews your medicines they will check:

what medicines you are taking and why
how many different medicines you take
the dose of each medicine you take
how you are taking these medicines
how well your medicines are working
side effects or other problems you may have with your medicines.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2013), What is a medicines review? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Safe use of non-steroidal anti-inflammatory drugs (NSAIDS)

Do you take medicines called ACE inhibitors or angiotensin receptor blockers, as well as medicines called diuretics? It is usually safe to take medicines these together. However, if you also take a pain relieving medicine called a non-steroidal anti-inflammatory drug (NSAID) you could harm your kidneys. NSAIDs are used to treat pain and swelling. You can buy them from the supermarket, service station or pharmacy.

Stopping a medicine

Stopping a medicine can seem daunting, especially if you’ve been taking the medicine for a long time. But for many older people, stopping a particular medicine may actually benefit their health. Medicine problems such as side effects and interactions are common when you are an older person. The more medicines you take, the more likely you are to experience these problems. Many older people successfully stop medicines without feeling worse. In fact, you may feel better and improve your quality of life — especially if your symptoms were being caused by your medicines.

A health professional may recommend you stop taking a medicine because:

the medicine is causing, or may cause, harmful side effects and medicine interactions
the medicine isn’t working or won’t help you achieve your treatment goals
the medicine is no longer needed for your current medical conditions
you are having difficulty taking the medicine
other treatment options are more suitable for you.

When should I stop taking a medicine?

Your doctor or another health professional will recommend the best way to stop your medicines when this is necessary. Their advice is very important, as your medicines may need to be stopped carefully.

You may be able to stop a medicine immediately — and this is usually recommended for any medicine that is causing you harm.

But some medicines need to be stopped gradually. This is because they can cause serious symptoms or other problems if you suddenly stop taking them. Medicines that may do this include:

some antidepressants
anxiety medicines
corticosteroid medicines
some medicines for the heart, blood, and blood vessels
levodopa (used for Parkinson’s disease)
pain relief medicines that contain opioids
sedatives and medicines for sleep problems.

Stopping medicines like those listed above usually involves slowly reducing your dose over time, or slowly reducing how often you take the medicine. Exactly how you do this can depend on:

the medicine you need to stop
the dose you are taking
how long you were taking the medicine for
your current health
previous experiences with stopping the medicine.

What you are most comfortable with is also important, so let your health professional know if you have any preferences so you can agree on a plan.

Stop one medicine at a time

You may need to stop taking several of your medicines. This doesn’t mean they will all need to be stopped at the same time.

A health professional may advise you to stop one or two medicines at a time so it is more manageable and safer for you. Which medicine to stop first will depend on which medicine is clearly not benefiting you, is causing side effects, or is most likely to cause you harm.

Reviewing your progress

When you are stopping a medicine let your health professional know if you are experiencing any new symptoms or changes in how you feel.

A medicine may need to be restarted if you realise you were feeling better while taking it, or because you’d like to try stopping it another time.

Symptoms you develop when stopping a medicine or reducing the dose may also mean you will need to reduce the medicine more slowly. Sometimes these symptoms get better over time, without you having to restart the medicine or previous dose.

What else can I do?

Talk to your health professional about what you want to achieve with your health and wellbeing.
Discuss any problems or concerns you have about your medicines with a health professional.
Ask if any new symptoms you are experiencing could be due to any medicines you are taking.
Ask your doctor or pharmacist about having your medicines reviewed.
Use a medicines list to help keep track of your medicines: record any changes that are made to your medicines, and show the list to all the people involved in your health care.
Find out what other services and resources can help you manage your health and medicines.

You may find it helpful to have a carer or family/whānau member with you when talking to anyone involved in your health care — especially if English is not your first language.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource (redo link)

Adapted from NPS MedicineWise (2013), When and how to stop taking a medicine. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

When can medicine problems occur?

While problems with medicines can happen at any time, there are some situations when they are more likely to happen. Medicine mistakes are particularly common if you are going into or leaving hospital. Around half of medication errors in hospitals occur when you are admitted or discharged home. Changes in your health and your medicines can also result in more side effects, interactions and medicine mistakes. Lack of communication with — and between — the people involved in your health care often contributes to medicine problems happening. You may find it helpful to have a carer or family/whānau member with you when talking to anyone involved in your health care.

When your medicines change

Let your doctor, pharmacist and other health professionals know about:

any problems you experience or concerns that you have after starting a new medicine
any changes that are made during your treatment (e.g. changes in the dose you take).

All medicines — prescription and non-prescription — can cause side effects, interactions and other medicine problems. Non-prescription medicines include over-the-counter medicines from a pharmacy or supermarket, and complementary medicines such as herbal remedies, vitamins and minerals.

Starting a new medicine

Side effects and medicine interactions are often more likely — and can be more severe — when you first take a new medicine. This can be because your body isn’t yet used to the effects of the medicine.

Side effects that can be more problematic when you start taking a medicine include:

dizziness or light-headedness
drowsiness or reduced alertness
feeling agitated or restless
nausea or vomiting

Starting another medicine may also mean that you begin to have trouble managing all of your medicines, especially if you are already taking several different medicines.

Changes in the dose of your medicines

Side effects and medicine interactions may depend on the dose of the medicines you are taking. Generally, the more of a medicine you take, the more likely you are to experience these problems.

You may begin to experience side effects and interactions when your medicine dose increases. With some medicines, decreasing the dose could also affect another medicine you take.

Dose adjustments can mean changes to when and how much of your medicines you take, which may make it harder for you to manage your medicines, or easier to confuse and mix them up.

Having to take a medicine for a long time can cause problems too. For example, dependence on sleeping pills such as temazepam is more likely when you take them for longer than 2 weeks.

When your health changes

If you develop a new medical condition or a new symptom, you may be prescribed another medicine. This can increase your chance of side effects and medicine interactions.

Medicines you currently take for one medical condition may affect a newly diagnosed condition. For example, heart failure can be worsened by a non-steroidal anti-inflammatory medicine taken to relieve pain or inflammation.

Problems can also arise if you take a medicine left over from a previous illness or a medicine that is not prescribed or recommended for you. What’s right for another person or medical condition may not be right for you. Do not share medicines with other people, even if they have the same health problem.

Some medical conditions or symptoms can also interfere with how well you manage your medicines. Common causes of medicine problems include:

confusion or memory loss
poor eyesight or hearing
difficulty swallowing
reduced physical ability due to muscle or joint problems.

When your health care services change

Multiple health problems when you are older can mean that you will need to see more than one doctor or other health professional, and sometimes you may need to be cared for in hospital.

Going into and leaving hospital

New medicines are often started in hospital, and medicines you have been taking for a long time may be changed or stopped. This can increase your chance of medicine problems for various reasons. For example, you may:

end up taking more medicines after you leave hospital
be prescribed medicines that can cause serious problems
have to take your usual medicines differently, or in a more complicated way
be given a different brand of medicine from the one you usually take.

Lack of communication and medicine mistakes in hospital:

Hospital staff may not have correct or complete information about all the medicines you are currently taking.
You and your usual doctor may not be fully informed about changes to your medicines after you leave hospital, including new and stopped medicines.
Your doctor may not immediately receive the information they need about your hospital treatment.

Keeping an up-to-date medicines list is a good way to keep track of all the medicines you are taking.

Seeing many health professionals

It is important that you tell all the people involved in your health care about all the medicines you are taking. This will help to make sure that they have all the information they need when prescribing or recommending medicines for you.

For example, your GP needs to know about medicines prescribed by your specialist before they prescribe another medicine for you. This is important to help you avoid medicine problems such as side effects and interactions.

What else can I do?

Use a medicines list to help keep track of your medicines: record any changes that are made to your medicines, and show the list to all the people involved in your health care.
Talk to your health professional about your health, your wellbeing, and your medicines. Ask if any new symptoms you are experiencing could be due to any medicines you are taking.
Ask your doctor or pharmacist about having your medicines reviewed if you have recently spent time in hospital.
Find out about other ways that you and your carers can help to prevent medicine problems.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2013), When can medicine problems occur? 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on of any information in this resource.

Working out your treatment goals

Different factors are important to different people when it comes to taking medicines. Different medicines can have different effects too.

What is a treatment goal?

Whether you start, stop or continue taking a medicine when you are an older person will depend on what you want to achieve with your health and wellbeing.

These treatment goals may be to:

relieve or prevent symptoms
avoid disease or its complications
treat an illness or stop it getting worse
maintain your physical and mental wellbeing
improve your quality of life
extend your life

How do I determine my treatment goals?

Your health, wellbeing, and ability to cope with illness or disease can be different from other people — and can change for you at any time. This can influence your treatment goals and the medicines you take.

Talk to your health professional about what you want to gain from treatment, or what it is about your current health that troubles you most. That way you and your health professional can find out if a medicine or another treatment can help.

One size does not fit all

As an older person you may be very fit and healthy, or you may have a medical condition that you are able to manage yourself. You may have disease symptoms that tire or slow you up, or that reduce your ability to carry out daily activities on your own. Or perhaps you or someone in your care is very frail, completely dependent, or near the end of life.

These differences can mean that what you want from treatment as a fit and healthy older person will be different from your needs if you are very frail or sick. Preventing disease and staying active may be most important when you are fit and healthy — while improving symptoms, mobility and quality of life may be the goal if you are frail or dependent on care.

Treatment goals can change over time

Also keep in mind that your treatment goals can change. For example, if the symptoms of your medical condition worsen, or your values, experiences or concerns about your medicines change.

What can I do?

Ask your health professional to review your medicines regularly to check they are still needed and are achieving your treatment goals. Discuss any problems with, or concerns you have, about your medicines with your doctor or other health professional at any time.

Find out about other ways that you and your carers can help to prevent medicine problems.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Adapted from NPS MedicineWise (2013), Working out your treatment goals. 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. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Making decisions

Discuss your treatment options with a health professional

To determine whether a medicine or other treatment is right for you when you are older, talk to your doctor, pharmacist or other health professional.

Your doctor, pharmacist or other health professional will need to know about:

your current health problems
what you want to achieve with your health and wellbeing (your treatment goals)
any side effects and other medicine problems you may experience

What can I do?

You can work with your health professionals to make the best decisions about your medicines by:

Preparing a list of questions to ask about your health and medicines.
Asking for the consumer medicine information (CMI) for your prescription and pharmacist-only medicines.
Checking whether any non-prescription and complementary medicines can interact with your current medicines before you take them.
Talking about any changes in how you feel, especially when taking new medicines or doses.
Asking about a medicines review and any other services or resources that can help you.

Download this resource

Adapted from NPS MedicineWise (2013), Discuss your treatment options with a health professional. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Making decisions for older people

Making decisions about medicines when you are older is not always straightforward — for you, your doctor, or anyone else involved in your care. At times there will be a clear need for you to take a particular medicine, and the benefits for your health condition will likely outweigh the risk of side effects or other medicine problems. But often the decision is not so clear cut, and the balance of benefits and risks will depend on what is most important to you — including what you want to achieve with your health and wellbeing.

What do I want to achieve with my medicines?

Medicines can have different beneficial effects — from relieving your symptoms to extending your life.

What you need to gain from medical treatment should always be considered when you are deciding about medicines. This is always important even when a doctor, carer, or family/whānau member is deciding for you.

Whether you start, stop or continue taking a medicine, or make other changes (e.g. to your dose) will also depend on the risks and benefits of treatment for you.

Your doctor can work with you to help you decide:

how you want to improve your health and wellbeing
what benefits or risks there are with your treatment options
which medicines are likely to benefit or cause you harm.

Find out about other ways that you and your carers can help to prevent medicine problems.

Making a decision to take a medicine

‘Will it work?’ is often one of the main concerns for people who are deciding to take a medicine.

Your decision can also be shaped by your experience of health problems, your personal life, what you want to get from your treatment, and your priorities and values.

Staying active and maintaining quality of life are important considerations too. Worsening health, side effects, and the cost of your medicines may all be factors you will also need to consider.

Download this resource

NPS MedicineWise (2013), Making decisions about medicines for older people. 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. NPS MedicineWise and Choosing Wisely New Zealand does not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Surgery

Pre-surgery tests: when you need them and when you don't

If you’re going to have surgery, you may have some tests first. These might include blood tests, a chest x-ray, lung test (spirometry) and a heart stress test.

These tests may be helpful if you have certain health conditions or diseases, to make sure it is safe to go ahead with the surgery. For example, if you have a blood-clotting problem, a test can show if you’re at risk of too much bleeding during surgery.

But most healthy people don’t need the tests, especially before low-risk surgery. Most of the time, a careful medical history and physical exam are all you need.

These tests are not needed on everyone before surgery:

Blood tests

Pre-op blood tests are not helpful in planning low-risk surgery. Even when minor abnormalities are found in these blood tests, this doesn’t usually change the plans for surgery.

Chest X-rays

Many people are given a chest X-ray to “clear” them before surgery. Some hospitals require a chest X-ray for almost every patient. But unless you have symptoms of lung problems, chest X-rays are not helpful before most surgery. Chest X-rays are not good at picking up who may have complications from anesthesia. Pre-op chest X-rays may make good sense if you are about to have heart or chest surgery.

Spirometry

Spirometry is a way to test how well your lungs work. This test might be useful if you are about to have surgery on your lungs, or you have problems with your breathing. But this test should not be done routinely before all surgery.

Cardiac stress testing

This test puts your heart under stress (either by you exercising, or by injecting a chemical into your blood) to see if it is working normally. This test is not needed routinely before surgery, unless you have symptoms of heart disease or are at very high risk of a heart attack.

The tests usually aren't helpful for low-risk surgery

Results of these routine tests rarely change their surgeon’s decision to operate, or make surgery safer.

The tests are especially unnecessary before low-risk surgery—such as eye, hernia, or skin surgery, or a breast biopsy. In these and many other surgeries, the risk of complications is very low.

In fact, even major surgery is safe for most healthy people who feel well and are moderately active without symptoms. All they usually need is a medical history and physical exam.

Tests can lead to more tests

Medical tests can sometimes lead to false alarms (“false positive” results). This is even more likely if you do not have any symptoms, such as in a routine pre-op test. False alarms can cause a lot of stress for you and your whānau, and cause you to have even more tests to find out if there really is a problem. For example, a blood test may be followed up with a repeat test, an ultrasound, a biopsy, or a test that exposes you to radiation, such as an X-ray or CT scan.

These tests may have risks. And it can needlessly delay your surgery.

Some test can have risks

A chest X-ray uses radiation. Risks from radiation exposure may add up, so it is best to avoid it when you can.

While most tests are very safe, false alarms may lead to more risky tests that involve risks like bleeding, allergic reactions or radiation.

For instance, an abnormal heart stress test might need to be followed up with coronary angiography (cardiac catheterization), a test that uses dye and X-rays to look at your heart vessels.

When are tests before surgery a good idea?

Blood tests

If you have certain health conditions or diseases, or your medical history shows the need, blood tests may give your doctor helpful information. For example:

If you bruise easily, use a blood-thinning medicine, had bleeding problems in an earlier surgery or dental procedure, or have a family history of bleeding problems, you may need a blood test to find out if your blood clots normally.
If you have a disease such as diabetes, you will probably need to have a test to make sure it is under control.
Women of childbearing age may need a pregnancy test.
You may also need the tests before a major operation such as heart, lung, or brain surgery.

Chest X-rays

It may be a good idea to have a chest X-ray before you have surgery if:

You have signs or symptoms of a heart or lung condition. These include chest pain, coughing, shortness of breath, swelling in the ankles, fever, a recent heart attack, or a cold or other lung infection that does not go away.
You have a heart or lung disease, whether or not you have symptoms, and you have not had a chest X-ray within the last six months.
You are older than 70 and you have not had a chest X-ray within the last six months.
You are having surgery on the heart, lungs, or any other part of the chest, and you have not had a chest X-ray within the last six months.

Heart stress test

It may be a good idea to have a heart stress test before you have surgery if:

You have a severe heart condition or you’re experiencing symptoms that could be heart-related, such as chest pain, breathing difficulty, or a loss of stamina.
You are about to have intermediate-risk surgery (such as knee or hip replacement) or high-risk surgery (such as a bypass operation) and you have risk factors (including diabetes, kidney disease, or a history of heart disease or stroke) and poor exercise tolerance making it hard to assess heart-related symptoms.

The decision to have any tests before surgery should be based on your individual situation. Talk to your doctor about what may be right for you.

What will the test results mean for my surgery?

Based on the test results, your doctor may watch your condition more closely during or after your surgery. You may need to delay the surgery until a problem is under control. Or your doctor may change the procedures and anesthesia.

Why was this resource developed?

Supporting evidence for the issues discussed in this resource

For a list of supporting evidence for the issues discussed in this resource, please see: https://hqsc.govt.nz/resource-library/choosing-wisely/recommendations-and-resources/for-clinicians/australian-and-new-zealand-college-of-anaesthetists/

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada (2014), “Lab tests before surgery: when you need them—and when you don’t”, Choosing Wisely Canada (2012), “Heart tests before surgery: when you need them—and when you don’t”, and Choosing Wisely Canada (2015), “Chest X-rays before surgery: when you need them—and when you don’t”. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Cancer

Prostate cancer

If you are diagnosed with low-risk prostate cancer, you have a number of treatment options, including doing nothing. You may be anxious to start treatment as soon as possible, but it’s important that you take the time to fully understand all the options, benefits, and risks.

Prostate cancer management options you may wish to discuss:

Active surveillance

This aims to monitor your prostate cancer for changes that may require further treatment. It is suitable for earlier cancers and involves regular tests. Some of the tests you may have include a prostate specific antigen (PSA) blood test, digital rectal examination (DRE), biopsy or imaging scans.

Radiation therapy

This treatment destroys cancer cells inside and around the prostate, using radiation. It can be given as ‘definitive’ treatment instead of surgery, and it can also be used if the cancer comes back after surgery. It can either be External Beam Radiation Therapy which treats the prostate with high energy X-rays, or brachytherapy which involves implanting radioactive ‘seeds’ into the prostate to kill cancer cells.

Surgery

This aims to remove the entire prostate and some of the surrounding tissues. It could be done a number of ways, including keyhole surgery.

Hormones therapy

This treatment temporarily stops your body from making testosterone and aims to reduce the tumour size or slow down the tumour growth. It may be given short-term in conjunction with radiation therapy. Not everyone will receive hormone therapy.

Treatment isn't always needed

Many men with low-risk prostate cancer are treated immediately, with surgery or radiation. However for many men with low-risk prostate cancer, treatment is not necessary and it can cause sexual, urinary, and bowel problems.

Often, prostate cancer is low-risk

Many prostate cancers are found with a prostate-specific antigen (PSA) blood test. Often these cancers are low-risk. This means:

the tumour is small
it is contained within the prostate
the PSA blood test is not very high (less than 10 µg/L).

For most men with low-risk prostate cancer, the tumour is probably growing so slowly that it will not become life-threatening. Usually a man with low-risk prostate cancer passes away from something else, even if he doesn’t get treatment for prostate cancer.

Active surveillance may help your quality of life

With active surveillance, you have regular checkups, including a PSA test and rectal exam. You’ll get a prostate biopsy if needed. You can start treatment at any time if the cancer starts to grow.

Active surveillance is a good choice for many men with low-risk prostate cancer, because they can avoid the side effects of treatment. This is an especially important choice if you are older or in poor health.

Treatment can have side effects

Side effects from surgery or radiation may include:

impotence—not getting erections that are firm enough to have sex
leaking urine. There may be complete loss of bladder control, but this is less common
frequent, urgent, bloody, or painful bowel movements.

When should you get immediate treatment for prostate cancer?

If your cancer is advanced or higher-risk, you will probably need treatment right away. Signs of higher-risk cancer include:

PSA value that is quite high (more than 10 µg/L) or rapidly rising
test results show that the tumour is outside the prostate gland. Or that the tumour is growing rapidly and is likely to spread outside the gland.

Ask your team if your cancer shows any of these signs. If so, active surveillance may not be a good choice.

Choosing a treatment for prostate cancer:

Most men with low-risk prostate cancer have time to think about their choices. These tips may help you reach a decision.

Review your health history

Give your cancer care team your full personal and family medical histories. Ask how your age and general health could affect treatment. Ask if you have any condition that might increase the risks of treatment, for example, conditions such as diabetes, heart problems, or bowel disease might increase your risk of sexual, urinary, or bowel problems.

Think about your values

Discuss these questions with your spouse or partner:

Do I want to get rid of my cancer, even if I might have sexual or urinary problems?
Which side effects would upset me most?
Would I be okay with active surveillance, even if I am worried and have to see the doctor more often?

Find out all of your treatment options

There are two specialists you should talk to – a radiation oncologist and a urologist. Your GP can give you referrals to both of these and help you make a decision that is right for you. Often this comes down to personal preference once you have all the information. Typically:

A radiation oncologist can discuss active surveillance and radiation treatment.
A urologist can discuss active surveillance and surgery.

For more information about prostate cancer visit: https://www.targetingcancer.com.au/treatment-by-cancer-type/prostate-cancer/

Why was this resource developed?

This Choosing Wisely resource is based on the top five clinical practices which patients and health professionals should question, according to the Royal Australian and New Zealand College of Radiologists – Faculty of Radiation Oncology[1] in October 2016.

Supporting evidence for the issues discussed in this resource

For a list of supporting evidence for the issues discussed in this resource, please see:

[1] https://hqsc.govt.nz/resources/choosing-wisely/recommendations-and-resources/for-clinicians/the-royal-australian-and-new-zealand-college-of-radiologists-faculty-of-radiation-oncology/

[2] Prostate Cancer Working Group and Ministry of Health. 2015. Guidance on Using Active Surveillance to Manage Men with Low-risk Prostate Cancer. Wellington: Ministry of Health.

It's OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada (2014), “Low-risk prostate cancer: don’t rush to get treatment” and the Cancer Institute New South Wales, Australia (2016) “Prostate cancer management options”. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Ovarian cancer screening

Ovarian cancer is a malignant tumour in one or both ovaries. It usually occurs in women over the age of 50 who have gone through the menopause, but can also occur in younger women.

If a woman has symptoms that might be ovarian cancer, doctors will often order a blood test (“CA-125”) and a pelvic ultrasound.

But for women who don’t have symptoms, these tests are not helpful in looking for ovarian cancer. Here’s why:

The test results are not always accurate

Women with a high CA-125 level don’t always have ovarian cancer. Instead, they may have another cancer or a different condition such as cirrhosis, pelvic inflammatory disease, fibroids, or endometriosis.

And half of women with early cancer have a normal CA-125 level.

Also, ultrasounds are not good at finding early ovarian cancer. They often show cysts that are benign (not cancer). This can lead to unnecessary surgery.

Studies using CA-125 and ultrasound testing to screen women for ovarian cancer, have found these tests do not help prevent deaths from ovarian cancer.

The tests can lead to risky procedures

If a CA-125 test or ultrasound shows something that isn’t normal, doctors will often do surgery to check the ovary for cancer. The ovary is usually removed. One major study showed that 15 women out of 100 had complications from surgery.

Even with a laparoscopy or “keyhole” surgery, there’s a risk of injury. The surgery is done through a tiny cut with very small tools.

Some women choose to have both ovaries removed during the procedure. This can cause early menopause, which can increase the risk of hip fractures, heart attacks, and possibly dementia.

When are the tests worth the risks?

The CA-125 test and an ultrasound may be helpful if you have symptoms of ovarian cancer (see overleaf).

Also, if your doctor feels something abnormal on a physical exam, these tests may help diagnose the problem.

You should talk to your doctor about being tested if you have a high risk of ovarian cancer, including:

A family history of ovarian, breast, uterine, or colon cancer.
Or, inherited risks, such as the BRCA1 or BRCA2 gene mutation or Lynch syndrome. These are major risks of ovarian cancer.

If you have ovarian cancer, the CA-125 test can be helpful. Your doctor can use the test to check if treatment is helping, or if the cancer has come back.

What are the symptoms of ovarian cancer?

Most women have very few symptoms but you may experience one or more of the following:

lower abdominal pain or pelvic pain
pain during sex
pain related to your bowels
a feeling that you want to pass urine urgently and more frequently
a change in appetite or feeling full quickly
a distended (swollen) abdomen.

Why was this resource developed?

Download this resource

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely USA/Consumer Reports (2014) “Screening tests for ovarian cancer – when you need them and when you don’t”. and the Royal College of Obstetricians and Gynaecologists (2016) “Information for you – Ovarian Cancer”. 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 does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Published: 8 Dec 2021 Modified: 28 Jan 2022

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1. Do I really need this test or procedure?

2. What are the risks?

3. Are there simpler, safer options?

4. What happens if I don't do anything?

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Blood tests

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Extra Units of blood are not helpful

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Supporting evidence for the issues discussed in this resource

Having them every day may not be necessary

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Anaemia in hospital – blood transfusions

What is a blood transfusion?

Where does blood come from?

How much blood do you need?

What is anaemia?

Extra Units of blood are not helpful

Using more blood units may increase risks

The supply of blood relies on donations

Do patients ever need more than one unit of blood?

Why was this resource developed?

Supporting evidence for the issues discussed in this resource

Having them every day may not be necessary

Having them every day may not be necessary

Common blood tests

Getting too many blood tests has risks

You may need a blood test every day if:

Other tests you may need

Imaging and diagnostics

Most men and women under age 65 probably don’t need the test because:

Who should get a bone-density scan?

You may need a follow-up bone-density test after several years

How can you keep your bones strong?

Why was this resource developed?

Supporting evidence for the issues discussed in this resource

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The problem

The risks

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