New recommendations aim to guide doctors and patients about testing, treatment options

Mar 22 2017

SURGERIES FOR THE OBESE AND ELDERLY, ANTIBIOTICS AND SCANS FOR ENT CONDITIONS

Surgical options for people with medical conditions including obesity, and the risks of operating on the elderly, feature among 10 new recommendations released today under the Choosing Wisely Australia initiative.

In addition, the number of antibiotics being prescribed and scans ordered for a range of common ear, nose and throat conditions are being questioned to address unnecessary tests, treatments and procedures.

Choosing Wisely Australia, facilitated by NPS MedicineWise, is part of a global social movement aimed at improving the safety and quality of healthcare for patients by eliminating healthcare practices that are not evidence-based and potentially could cause them harm.

Five new recommendations each from the Australian and New Zealand College of Anaesthetists (ANZCA) and The Australian Society of Otolaryngology Head & Neck Surgery (ASOHNS) and Royal Australasian College of Surgeons (RACS) aim to guide discussions between doctors and patients about testing and treatment options.

Obese and elderly should quiz doctors about surgery: Anaesthetists

ANZCA recommends that patients with “significant co-morbidities” should have their surgeries in hospitals that are staffed and equipped for high-risk patients.

ANZCA President David A. Scott said:

Patients with obstructive sleep apnoea and obese patients are at high risk, particularly when their pain management includes opioid analgesics. This is because their breathing can be suppressed by the opioids and they must be monitored carefully by skilled staff.

The hospital must have appropriate staff and resources for the particular patient and their proposed surgery: “Patients and doctors must consider staffing ratios and skill sets required for monitoring, medical support and high dependency unit care, as well as optimal pain management,” Professor Scott said.

ANZCA also recommends doctors weigh the benefits of giving anaesthesia to patients with limited life expectancy, or patients at high risk of death or severely impaired recovery, and first discuss these risks with the patient concerned.

The college warns that many patients aged over 70 are at high risk for problems after surgery, with 20 per cent experiencing complications within five days, 10 per cent needing to be admitted to critical care and five per cent dying within 30 days.

“Discussion with the patient and family about the risks and benefits of hospitalisation and surgery in this context are important,” Professor Scott said. “Quality of life is an important part of this discussion.”

Other recommendations include:

• Pre-surgery tests including blood investigation and chest X-rays should not be routine but be ordered only when the patient’s condition requires it.
• Cardiac stress-testing should not be routinely required for patients with no symptoms who are having low or intermediate risk cardiac surgery.
• Blood transfusions should not be given to otherwise healthy young patients with a haemoglobin count of above 70 grams per litre who do not have ongoing blood loss.

Professor Scott said:

Our recommendation is to avoid blood transfusions in patients with haemoglobin of 70 or more g/L, as there is no evidence of benefit and there are risks in administering a blood transfusion to young healthy patients with stable blood flow.

New advice on antibiotics and imaging for ENT conditions: Surgeons

ASOHNS recommends reducing the instances in which antibiotics are prescribed and computed tomography (CT) and Magnetic Resonance Imaging (MRI) are ordered for certain common conditions.

RACS’ Sustainability in Healthcare Committee Chair, Dr Lawrence Malisano, said:

The new guidelines had been designed to encourage dialogue between clinicians and consumers, to ensure optimal patient safety and the sustainability of the healthcare system in the long term.

“Three out of our five recommendations advise against patients undergoing CT and MRI of the head/brain for three commonly presented conditions – hearing loss, acute rhinosinusitis and hoarseness,” he said.

“CT and MRI scanning is expensive, exposes the patient to radiation and offers no useful information to assist with the initial management of sudden hearing loss.”

In addition to reducing requests for medical imaging, doctors are advised to reconsider prescribing antibiotics for uncomplicated acute outer ear infections and discharge from grommets without other symptoms.

“With these conditions, oral antibiotics can cause significant adverse effects and do not provide adequate coverage of the bacteria that cause most episodes”, Dr Malisano said. “Avoidance of unnecessary oral antibiotics can reduce the spread of antibiotic resistance and the risk of opportunistic infections.

“Patients should be informed of the latest evidence-based advice relating to their specific health condition and are encouraged to discuss all of their options with their doctors and specialists.”

There have been 133 recommendations released through Choosing Wisely Australia by 28 colleges, societies and associations since the initiative launched in April 2015.