1. Purpose and scope

This document is a policy of the Australasian College for Emergency Medicine (ACEM). It aims to encourage leadership in the area of responsible stewardship of healthcare resources as it relates to the delivery of emergency medicine.

This policy applies to all Australian and Aotearoa New Zealand emergency departments.

2. Introduction

Resource stewardship in healthcare encompasses a number of activities at various levels (from government to patient) aimed at providing efficient, effective and evidence-based health interventions. Local Australian studies have identified large numbers of ‘low value’ healthcare practices that continue to be supported and publicly funded. Examples include the indiscriminate use of radiological imaging for lower back pain and testing for C-reactive protein.¹

ACEM and other medical colleges are actively involved in resource stewardship activities through their publication of guidelines and policies. ACEM provides guidelines regarding diagnostic imaging and pathology testing for physicians and other clinicians, as well as policies relating to appropriate processes and procedures of patient care. ^2,3

The American College of Emergency Physicians (ACEP) and the Medical Schools Council in the United Kingdom also have policies in place that set standards for physicians and other clinicians in their day-to-day practice. The ACEP Policy Statement on Emergency Physician Stewardship of Finite Resources encourages the appropriate use of medical resources and outlines the dual responsibility of physicians and other clinicians toward society as well as their patients.4 In the Consensus Statement on the Role of the Doctor, the Medical Schools Council outlines the duty of doctors to utilise resources wisely and effectively and to engage in debate about this use. ⁵

Similarly, the Australian Medical Association has a Code of Ethics (2016) which promotes ethical principles that doctors can put into practice in their interactions with patients, as well as with their colleagues and other members of society.6 Section 4.4 of the Code of Ethics makes it incumbent upon doctors to utilise their knowledge and experience in order to ensure that resources are not wasted.

Guidelines, codes, policies and statements align with the obligation of medical colleges, institutions and practitioners to facilitate resource stewardship.

3. Policy

ACEM believes that emergency medicine has important and unique roles and responsibilities in the ACEM supports initiatives and actions that maintain or improve patient outcomes and facilitate resource stewardship through the promotion of sustainable resource allocation and disinvestment from ineffective interventions or practices.

ACEM also supports initiatives that enable decreased variation in clinical practice and clinical policies.

In order to be effective, resource stewardship initiatives in healthcare must have the authority to disinvest in some areas and invest in others on the basis of evidence rather than custom or other motivations. A resource stewardship framework must include collaboration between medical specialties, clinicians, healthcare funders and consumers. Policy, procedures and actions must also be taken into consideration in such a framework.

A resource stewardship framework encompasses funder (federal or state government), provider (health authority, hospital, department, or individual physician/clinician) and consumer (consumer advocacy groups or individual patients) responsibilities.

4. Responsibilities

4.1 Funder level

In order to encourage responsible resource stewardship at the state or federal level, ACEM supports strategies relating to public funding and public health policy development that are founded on evidence-based and ‘comparative effectiveness’ research.7 Comparative effectiveness research can aid in guiding decisions on treatment options through the provision of evidence on the effectiveness, benefits and harms of treatments. ⁸

4.2 Provider Level

At a national level medical colleges and associations can facilitate resource stewardship by setting standards and participating in campaigns which encourage the responsible use of resources on the behalf of physicians and other clinicians as well as healthcare services in general.

ACEM has shown leadership in resource stewardship activities through participating in the NPS Medicine Wise ‘Choosing Wisely’ campaign. The Choosing Wisely campaign was formally launched in the United States in 2012 and was launched in Australia in April of 2015. This campaign allows for medical colleges, physicians and other clinicians to collaboratively identify and develop lists of treatments, tests and procedures that are commonly used but confer little to no clinical utility or patient benefit.9 From these lists guidelines that limit ineffective actions can be developed.

There are also many national bodies in both Australia and New Zealand that are responsible for setting standards of care which impact upon resource stewardship. These include:

• Medical Services Advisory Committee
• Australian Commission on Safety and Quality in Healthcare
• National Health and Medical Research Council
• Independent Hospital Pricing Authority
• Consumer Health Forum of Australia
• National Health Committee
• Health, Quality and Safety Commission of New Zealand
• Centre for Public Health Research

In order to set standards and promote activities that improve and foster resource stewardship, it would therefore prove useful if such bodies were provided with the capacity to report to a single coordinating institution.

At a local provider level, assessment of the evidence base and collaborative development of policy to limit ineffective procedures and to decrease task duplication, are proven resource stewardship mechanisms.

ACEM encourages its Fellows and trainees to incorporate advocacy and teaching into their individual day-to- day practice and to be mentors and role models in avoiding use of ineffective testing, procedures, interventions or other care options. Fellows and trainees are expected to show leadership in their ED and hospital through the provision of evidence-based care following the ACEM Quality Framework and Quality Standards. ^10,11