Medications don’t cure everything - with HANDI clinicians can prescribe non-drug options

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Nearly half of the thousands of clinical trials conducted each year are for non-drug treatments. And yet effective non-drug methods are less well-known, less well-promoted, and less well-used than their pharmaceutical cousins. For the past six years the RACGP have been committed to developing an evidence-based handbook for non-drug treatments that mirrors the pharmacopoeias used in daily practice - the Handbook of Non-Drug interventions (HANDI).

CKN spoke with the key driver behind the handbook, Bond University’s Professor Paul Glasziou, and asked him to tell us about how HANDI is filling a gap in patient care and making effective non-drug treatments more visible and easier to use.


Photo courtesy of Bond University

So what is HANDI?

HANDI is an online formulary of non-drug interventions in health care, which have solid evidence of their effectiveness. Non-drug treatments, in the broadest sense, refer to any intervention that would not normally appear in a pharmacopoeia including exercise, physical therapies, diets, supplements and devices.

Advances in non-drug treatments in the past few decades have been substantial and diverse: exercise for heart failure and COPD, ‘mirror’ therapy for poststroke pain, the Epley manoeuvre for benign paroxysmal positional vertigo, knee taping for osteoarthritis, cognitive therapy for depression (and almost everything else!), ‘bibliotherapy’ (specific guided self-help books for some conditions), to name just a few. 

We wrote HANDI to let clinicians offer a greater choice of interventions to a patient, who may want to avoid pharmacotherapy and the risks and lifestyle changes often associated with drug treatment regimes.

It’s based on the idea of modern pharmacopoeias. It’s made up of a number of separate entries; entry one including indications, contraindications and ‘dosing’. The aim is to make ‘prescribing’ a non-drug therapy almost as easy as writing a prescription for a drug.

A focus on evidence-based practice 

The HANDI Project Team includes RACGP project staff and well-known clinical experts from the Australian primary healthcare sector, from General Practice, Physiotherapy, Occupational Therapy, Dietetics, and a physician. The team was selected to have a diversity of disciplines and expertise in evidence-based medicine.

We wanted the HANDI development process to be as robust as possible and our approach is modelled on the Pharmaceutical Benefits Scheme (PBS). The HANDI Project Team chooses candidate treatments and a team member then reads and presents the evidence. The whole team then votes on whether the evidence about benefits and harms is sufficient to warrant an entry. If deemed sufficient, a detailed HANDI entry is then drafted and discussed at a following meeting. More details about our process can be found on the HANDI website.

For inclusion in HANDI interventions must be supported by at least two positive good quality Randomised Controlled Trials (RCTs) with patient-relevant outcomes, or one RCT with strong supportive evidence for the causal connection under investigation. The RAGCP currently use the NHMRC levels of evidence and in the future we will move to a GRADE process. Criteria for inclusion in HANDI are high. Despite looking only at treatments with promising evidence, about half of the proposed interventions based on the criteria above are rejected.

Finding evidence-based non-drug treatments can also be a challenge. The HANDI team collect possible topics from a variety of sources including online evidence summaries (ACCESS and Cochrane databases), and suggestions from the Committee members. If you have any tips or topics for consideration, we would love to hear about them. Please contact the HANDI Project Team at email HANDI@racgp.org.au

How will hospital clinicians benefit from using HANDI?

While HANDI is primarily aimed at general practitioners, the contents are useful to many other groups including emergency medicine, and allied health. HANDI entries are already included in the Mackay HHS clinical Health Pathways website. Many of the entries are relevant to hospital practice. For example, in emergency medicine some relevant entries are:

  • Modified Valsalva manoeuvre for supraventricular tachycardia
  • Manipulation and subluxation of radial head (pulled elbow)
  • Dilute apple juice for rehydrating children
  • The Epley manoeuvre for BPV vertigo
  • The Mother’s kiss technique for nasal foreign bodies
  • Topical heat for bluebottle stings
  • Advice to stay active for people with acute low back pain.

Many hospital clinicians seem to be aware of some of the effective non-drug interventions, but can still lack confidence in whether and how to do it. The entries in HANDI provide the needed details, including a step-by-step illustration, e.g. the Epley manoeuvre entry includes a link to an excellent video that the Cochrane ear, nose and throat group have produced to aid in learning how to perform the procedure.

The entries also aim to give several options that can be used in different settings across urban, rural and remote Australia.

I would like to see HANDI widely used in Australian primary care and for hospital clinicians wherever it is relevant. This would include it being included in teaching trainees and in appropriate clinical pathways.


About Professor Glasziou 

Professor Paul Glasziou is Director of the Faculty of Health Sciences and Medicine at Bond University, where he is also is a Professor of Evidence-Based Medicine, as well as being a part-time General Practitioner. From 2003 to 2010 he was the Director of the Centre for Evidence-Based Medicine in Oxford. Professor Glasziou is well-known for his efforts in improving use of non-drug interventions, and identifying and removing the barriers to using high-quality research in everyday clinical practice. He is the recipient of an NHRMC Australia Fellowship which he commenced at Bond University in July, 2010. He is the Director of a team that is building capacity in health services research and does applied research that can be used to improve the efficiency and organisation of health services. His applied research brings economics to the study of healthcare service models, health-care acquired infection, and screening for chronic and infectious diseases, and interventions that change health related behaviour for chronic conditions.