Austin Health was funded under the 2016-17 Better Care Victoria Innovation Fund to enable them to become a Choosing Wisely champion hospital. The Choosing Wisely project at Austin Health took a whole of hospital approach and as a result, impacted care delivery by clinicians and care received by patients across the health service. The project demonstrated statistically significant reductions in the volumes of unnecessary coagulation studies and urine cultures being ordered. Auditing of test indications supported this finding and highlighted that clinicians are ordering in line with clinical recommendations. 

The Choosing Wisely initiative is currently being prepared for scaling across Victoria, in partnership with Austin Health and NPS MedicineWise. The aim is to increase the number of Choosing Wisely champions hospitals across Victoria that supports health professionals in delivering safe, effective and efficient care for patients. 

Professor Harriet Hiscock - Chair, Choosing Wisely Scaling Project Steering Committee
Choosing Wisely addresses the tests and procedures that we do that may offer no value to the patient and in fact may cause harm. Typically these tests lead to further unnecessary investigations which not only increase the cost financially to the health care system but may lead to emotional stress in the patient as well. Unnecessary procedures are actually often a diversion away from effective care and may lead to prolonged length of stay in hospital, additional costs both to the patient and to the health care system.

Dr Simon Judkins - Clinical Director, Emergency Department - Austin Health
Well it was notable at Austin Health that we had an issue with, I suppose, over ordering of many investigations both pathology and radiology as not only in the emergency department, but as patients transitioned into the in-patient teams, so it was something that we really wanted to address. What we wanted to do is address some of the cognitive biases that doctors have around test ordering. So for example junior medical staff having this expectations that their senior clinicians would want a barrage of tests done. We looked at things like patient expectation around tests and then adding over valuing an investigation or test that really doesn't add to their care. But really addressing from a sort of a grass roots level to ensure that we have sustainability and that culture change.

Asmara Jammali-Blasi - Choosing Wisely Statewide Project Lead
So we've done multi-disciplinary behaviour change strategies to target our problem areas and these were education audit and feedback, guideline development and changes to the way that electronic tests are ordered and used together we have seen a significant decrease in inappropriate tests ordered.

Dr Belinda Yeo - Medical Oncologist, Oliva Newton-John Cancer Research Institute - Austin Health
So as a Medical Oncologist we're very familiar with how easy it is to order pathology tests and as a Choosing Wisely clinical lead it's been important for me to see the impact of being able to change our electronic ordering of pathology. We chose to select coagulation studies which is actually four tests that we use and in our Choosing Wisely project for this we did two things, we took away coagulations studies as the group of tests from our common ordering on our electronic ordering system and we also asked clinicians, so educated clinicians to order in fact the individual test that they required rather than ordering all four tests. So we've actually seen significant outcomes, there's actually been 40% reduction in the ordering of coagulation studies so the volume of coagulation studies is significantly reduced. And we've estimated that in the emergency department alone this has saved pathology testing costs per patient by about $75 per visit so a significant change. We've also been able to appreciate that clinicians are ordering these tests with the appropriate clinical indications so there are less tests being ordered without any clinical indication, or inappropriate clinical indications.

Dr Chris Leung - Medical Lead, Clinical Education Unit, Gastroenterologist, General Physician - Austin Health
I think what has really made this project work is that it is a project that's run by clinicians for clinicians. And trying to translate evidence, which normally can take up to 17 years to translate into clinical practice, into best patient care. And develops this culture of always questioning 'do we really need this test?', 'is this test or treatment the right test or treatment for this patient?'. Education of junior medical stuff has been a corner stone of the Choosing Wisely project and that's important because they are the ones that are prescribing the tests and initiate the management algorithms for our patients. In fact, there's a lanyard that we give to them at orientation so that we can certainly remind them on a daily basis that the culture of Choosing Wisely is to always question, always think, always use evidence base for your patients, so they can receive the very best in patient care.

Professor Harriet Hiscock - Chair, Choosing Wisely Scaling Project Steering Committee
We want more health care systems across Victoria to become Choosing Wisely champion sites. So following the success of this project, Better Care Victoria in partnership with NPS Medicine Wise and with Austin Health, choosing to scale up this initiative to up to 10 sites across Victoria. Where we hope we can reduce low value care and improve outcomes for both the health care system and our patients and our clinicians.