Evolve Top 5 List Development

All RACP specialties are invited to develop their Top 5 List of low-value practices. The Evolve Top 5 List development process is rigorous and robust. To develop an Evolve Top 5 List, a specialty requires a:

• Lead Fellow: Acting as an Evolve Clinical Champion and the primary point of contact with RACP
• Working Party: Small group of specialty members that drive/manage the evidence review process and Evolve Top 5 List development. The specialty may either establish a new Working Party, or utilise its existing Executive, Policy and Advocacy Committee or other Council as its Working Party. The evidence review process can be undertaken by an RACP Policy and Advocacy Officer. However, the Lead Fellow and Working Party members are responsible for review and sign-off of the final product.
• Membership Body: Provides feedback throughout the Evolve Top 5 List development process and is actively engaged in implementation of the final Evolve Top 5 List.  

 There are three steps involved in developing a specialty's Evolve Top 5 List​: 

• Development of an initial list of low-value practices in your specialty;
• Refinement of the initial list through research and data analysis, and seeking feedback from the specialty's membership; and
• Finalisation of the ​Evolve Top 5 List using pre-determined criteria and membership feedback to identify the final Top 5 low-value practices

Development

During the development stage, the Working Party, Membership Body or other bodies within the specialty (e.g. Special Interest Groups, Clinical Quality Committees, Research Committees) identify as many low-value practices as possible. The specialty may choose which bodies it consults with to obtain the initial candidates for low-value practices.

Involving the wider membership body at this early stage may lead to the identification of a larger list of low-value practices for consideration, including practices that may be overlooked by the Working Party or other smaller decision-making bodies. However, this approach may lead to disengagement with the initiative as the wider membership body will also be expected to vote on the resulting shortlist during the finalisation stage.

As a guide, a minimum of 10 candidates for targeted low-value practices should be identified. However, the more ideas that are suggested, the more likely it is that a specialty will converge on the most appropriate Top 5 items to include in the Evolve Top 5 List.

Refinement

Developing an Evolve Top 5 List requires extensive research into the identified low-value practices. After receiving the initial low-value practices, the practices that are inconsistent with the aim of Evolve and the least difficult to change are removed. The remaining practices require a rigorous evidence review, which is conducted by the RACP Policy & Advocacy Team in consultation with the specialty. The aim of the refinement stage is to provide a shortlist of candidate low-value practices to a manageable number (e.g. 10 or less).

Recommended selection criteria for identifying an appropriate candidate for an Evolve Top 5 List include:

• Is the practice being undertaken by your specialty?
• Is the practice one that is still being undertaken with noticeable frequency within the specialty or healthcare system?
• Is the practice one where there is well established evidence that it is being used inappropriately or is of limited effectiveness (and, in extreme cases, potentially harmful)?
• Can reducing the frequency of the practice or phasing it out altogether make a real difference to the safety and quality of patient care?
• Is progress in reducing the frequency of the targeted practice potentially or actually measurable?

For consideration during the refinement stage:

• Ideally, the low-value practices identified in an Evolve Top 5 List should be those undertaken by the relevant specialty. While it is within the discretion of the specialty to choose which low-value practices it targets, RACP does not recommend targeting low-value practices being undertaken by other specialties or healthcare providers. However, there is room for the occasional exception. For example, where practices associated with other specialties or health providers have a direct impact on the specialty’s own clinical practices such as referral practices or testing already undertaken on, or treatment already administered to, patients before they reach the specialist.
• Evolve aims to target low-value practices that are far from marginal and still ongoing. Reducing the identified low-value practice should improve the safety, quality and efficiency of the healthcare system. The RACP Policy & Advocacy Team will undertake an evidence review to determine the frequency at which an identified low-value practice is occurring. If there is an absence of precise data, then impressionistic views based on a specialists’ professional experience can be considered.
• The RACP Policy & Advocacy Team will support the specialty to determine if there is well-established evidence that identifies the low-value practice as inappropriate, of limited effectiveness or potentially harmful. An initial rapid review of the evidence can be undertaken, which will suggest whether there is enough evidence or if the evidence is in low-quality studies. This will determine if the low-value practice is an appropriate target for an Evolve Top 5 List.
• Following feedback from Choosing Wisely and academic groups, the last two criteria were introduced as an additional guide on how to develop more measurable and actionable recommendations to ensure that the recommendations have an impact on healthcare. Evolve Top 5 Lists that have met these two criteria can be easily translated into Implementation projects. RACP encourages specialties to be specific and follow the suggested criteria when identifying low-value practices.

Finalisation

Following the refinement stage, it is recommended that the specialty:

• Compile the evidence obtained during the refinement stage to formulate specific ‘Do not…’ recommendations. These recommendations should include a brief explanation of why this low-value practice should not be applied. Reasons provided should align with the evidence reviewed and accompanied by relevant citations, ideally of the strongest and most recent evidence.

 During the finalisation stage, it is recommended that the specialty’s membership body is included by:

• Developing an online survey that presents the shortlist of recommendations, the reasons for each recommendation and the citations. The online survey should be designed to ask each participant to assign a score to each recommendation for a range of criteria. Ideally, the criteria used should be similar to the selection criteria used by the Working Party to produce the shortlist (i.e. the five selection criteria suggested for the refinement stage).
• Encouraging each member of the specialty to undertake the survey. The higher the response rate, the more representative the results are of the breadth and depth of experience within the specialty, and the priorities of its membership.

If the specialty develops an online survey, a Top 5 List can be identified by selecting the recommendations on the shortlist with the five highest average scores (averaged across all criteria).

RACP notes the following caveats and further observations:

• It is within the discretion of the specialty whether it chooses to undertake finalisation by distributing an online survey to all members or not. Some specialties may choose not to do this because they do not expect their response rate to be significant or because they are unable to access a full membership contact list.
• If an online survey is adopted, it is within the discretion of the specialty what scoring criteria it chooses to use within the survey and/or how it chooses to weight each criterion.
• It is within the discretion of the Working Party to not fully adopt the results suggested by the scoring outcomes of the online survey. However, the Working Party is required to be transparent in stating the reasons for not doing so. For example, because the Working Party has decided to consolidate some recommendations in the shortlist or because some recent new priorities for reduction in particular low-value practices emerge due to external developments (e.g. MBS reviews).
• While it is not compulsory, if the specialty decides that it may want to publish on its Evolve list development process it may be advisable to initially seek ethics approval for publication of survey results.

In recent years, some additional steps have been added to the Finalisation stage. The additional steps have been designed to integrate Evolve with the Choosing Wisely initiative, and to ensure other specialties and healthcare providers are better informed of the Evolve Top 5 Lists and any repercussions these lists may have on another specialty.

• Where there are Top 5 Lists with implications for other RACP specialties and other providers from outside the College, such as recommendations that relate to imaging or prescribing, RACP routinely distributes the Top 5 Lists to these specialties and provider associations for a consultation period of 4 weeks. These Top 5 Lists are also distributed to NPS Choosing Wisely for a similar consultation period. NPS serves as a convenient intermediary for some of these provider associations.
• It is within the specialty’s discretion whether it chooses to adopt any of the specific feedback obtained from these consultations. As noted, the consultation is undertaken primarily as a means of early dissemination and to integrate our efforts with Choosing Wisely. It also ensures that no crucial evidence or relevant insights are missed when finalising the Top 5 List.The ‘consultation text’ and the final text of the Top 5 List may differ depending on the quality of feedback received. However, the text may not change much. RACP considers the consultation stage as essential to the finalisation stage. When determining the timeframe for the development of an Evolve Top 5 List, consultation with external bodies should be considered.

Following finalisation and approval, arrangements will be made for an Evolve Top 5 List Launch by the RACP Policy & Advocacy Team. The launch may include media, social media, ASM promotion and other advocacy activities approved by the specialty and RACP. Launch activities may also involve Choosing Wisely in Australia and New Zealand.

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