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Objectives1. To describe the “epidemic of overuse”2. To describe the Choosing Wisely Canada
campaign 3. To share specific strategies to implement
Choosing Wisely in medical education and practice
Issue of medical overuse
Medical overuse facts• IOM - 30% of health care spending wasteful, no added
value to patient care• Saskatchewan study - pre-school children with
respiratory infections 50% of prescriptions inappropriate• 2 teaching hospitals in Alberta and Ontario:
– 28% of lumbar spine MRIs inappropriate (27% uncertain value)
– 9% of head scans for headache inappropriate (+ 8% questionable)
• CWC study - 28% of bone mineral density (DEXA) scans and 37% of pre-operative tests in Ontario inappropriate
Cultural factors
Systems factors
Physician and patient factors
Overuse
Physicians determine care1. Which patients are seen and how frequently2. Which patients are hospitalized3. Which tests, procedures and surgical
operations are administered4. Which technologies are used5. Which medications are prescribed
Emanuel EJ. JAMA. 2013.
I’ve always done this
Better to do something than
nothing
The patient wants it
New tests are good
Referring doctor wants it
I don’t want to get sued
$$
Choosing Wisely campaign
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What is Choosing Wisely Canada?• A national campaign, led by the medical
profession to:
– Help physicians and patients engage in conversations about unnecessary tests, treatments and procedures
– Help physicians and patients make smart and effective choices
– Ensure patients get care they need and avoid tests, treatments and procedures that could cause harm
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Objectives1. To encourage physicians to engage in conversations with patients about the
overuse of tests, treatments and medical procedures.
2. To empower patients to make informed choices, in consultation with their physicians, about getting the right care while limiting exposure to unnecessary tests, treatments and medical procedures.
3. To cultivate a culture of responsible stewardship of health care resources among physicians – from those in medical schools to those in professional practice.
4. To engender public dialogue on the issue “more is not always better”, when it comes to medical tests, treatments and procedures.
5. To engage health system and non-medical stakeholders, at provincial/territorial and national levels, in the implementation of the Choosing Wisely Canada campaign.
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Campaign approach
• Societies develop lists• Disseminate through multiple channelsPhysicians
• Develop patient materials• Disseminate broadly through multiple channelsPatients
• Coordinated approach toward media• Multiple voices, a common messageMedia
• Work through health care stakeholder organizations to implement and support adoptionStakeholders
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Operating principles for Top 5 lists
Process must be publicly available
Must be evidence to support list
items
List items must be frequent
List items must be within
society’s purview
Societies free to determine
process
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Patient education pamphlet
characteristics
Plain language
Easily accessible
Canadian-specificEducational
Evidence-based
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Working with provinces
• PTMAs (Alberta, NS, Quebec)
• Health regions (Vancouver Coastal Health)
• QI organizations (Ontario)
• Measurement organizations (Physicians Learning
Program, Health Quality Saskatchewan)
Search for “Choosing Wisely Canada” on your app store or visit our website for links to download
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Visit our website for direct link or search https://www.mdcme.ca/
Patient engagement
More Is Not Always Better: purpose1. Promote the message that in medicine as it is
in life, “more is not always better”2. Educate patients about when they might
need a particular test or treatment, and when they don’t
3. Encourage patients to talk with their doctor about unnecessary care
Implementation
Early Adopters Collaborative• National learning collaborative of those who
have expressed interest in or are in the process of implementing the CWC recommendations
• Collaborative serves as learning platform where groups could showcase their work and create toolkits for use by future adopters
The Implementation Spectrum
ENGAGEMENT & EDUCATION QUALITY IMPROVEMENT HARD CODING
o Leadership engagement
o Physician education
o Patient education
o QI projects
o Measurement
o Audit and feedback
o Policy changes
o EMR/CPOE integration
o Order set changes
Individuals as the change unit
Engagement-oriented
Lower risk
Soft Hard
Organization as the change unit
Rules-oriented
Higher risk
Cedars-Sinai Blind Spot Monitor:CW Embedded in CPOE
Pre InterventionJan 1 – Sep 9
Post InterventionSep 10 – Nov 25
mean orders mean orders % change p-value
Antipsychotics Patients ≥ 70
203 166 -18.2% <0.001
Benzo-SedativesPatients ≥ 65
133 116 -12.5% <0.001
ButalbitalAdults
4.13 3.58 -13.3% <0.04
Vitamin-D levels322 286 -13.7% <0.001
Impact Analysis
Rates per 10,000 encounters
Analysis compares 10 week period (Sep. 15 – Nov. 21, 2013-2014)
41% decline in number of tests pre- and post- program implementation
Choosing Wisely NYGH Initial Impact Analysis
• Pre-op Clinical Lab Testing: 40%
• Inpatient Lab Testing: 5%
• Impatient CT Exams: 5%
• ICU Chest X-Rays: 20%
larger = more transfusions
darker = more inappropriate
Rajkomar A, Moriates C, Mourad M, Wachter R. Innovations in Data Visualization to Drive Down Unnecessary Transfusions [abstract]. Journal of Hospital Medicine. 2014; 9 (suppl 2). http://www.shmabstracts.com/abstract/innovations-in-data-visualization-to-drive-down-unnecessary-transfusions/. Accessed September 3, 2015.
Diagram stratified by quantity and appropriateness per physician
Rajkomar A, Moriates C, Mourad M, Wachter R. Innovations in Data Visualization to Drive Down Unnecessary Transfusions [abstract]. Journal of Hospital Medicine. 2014; 9 (suppl 2). http://www.shmabstracts.com/abstract/innovations-in-data-visualization-to-drive-down-unnecessary-transfusions/. Accessed September 3, 2015.
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Family MedicineModule
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STARTER KIT IMPLEMENTATION TOOLKITS
Participating in the 10M Challenge: Instructions
CWC Slide Pack
CWC Recommendations Spreadsheet (160+ items)
CWC in Action:Case Examples
General Quality Improvement Module Urinary Catheter Module
Transfusion Module
Benzodiazepines Module
ED Lab Testing Module
Pre-op TestingModule
More to Follow
Evaluation
Multifaceted measurement• Physician attitudes and self-reported
experience (physician survey)
• Patient receptiveness to message
• Physician ordering – this will take time to change
• Implementation in medical education
At least somewhat familiar with CW
Agree/strongly agree that primary responsibility for ordering rests with physicians
Agree/strongly agree patients will benefit from CW recommendations
Agree/strongly agree that patients drive inappropriate use of services
0% 20% 40% 60% 80% 100%
Ontario Family Physicians
Physician attitudes & awareness
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Patient attitudes & awareness
Physician has primary responsibility
Patients need more decision support
Patients drive overuse more than physicians
Believe 1/3 of care is unnecessary
Aware of CWC
0% 20% 40% 60% 80% 100%
Ipsos Reid (2015). Awareness and Attitudes towards Choosing Wisely Campaign.
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Patient attitudes & awareness
24%
76%
Yes No
I asked my doctor why she or he felt the test or treatment was
necessary
I ignored my doctor's advice, but did not discuss it with him or her
I took the test or treatment without discussing it with the
doctor, even though I felt it was unnecessary
44%
31%
25%
Has a doctor ever recommended a test or treatment that you did not feel was necessary for your health?
How did you respond (to what you thought was unnecessary treatment)?
Don’t routinely perform preoperative testing (such as chest X-rays,
echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries)
Preoperative testing
Electrocardiograms Transthoracic Echocardiograms Stress Tests Chest X-rays0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ontario Alberta
Alberta preoperative testing prior to elective surgery in fiscal years 2005/06-2006/07 Thanh et al. (2010)Ontario preoperative testing prior to elective low risk surgical procedures in fiscal years 2008/09-2011/12 Kirkham et al. (2015)
Institution
Prop
ortio
n of
Pro
cedu
res
Medical education
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International
Website for providers
www.ChoosingWiselyCanada.orgwww.ChoisirAvecSoin.org
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Social media
www.twitter.com/ChooseWiselyCAwww.twitter.com/ChoisirAvecSoin
www.facebook.com/ChooseWiselyCanada www.facebook.com/ChoisirAvecSoin
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Important contactsDr. Wendy Levinson, [email protected]
Karen McDonald, Project [email protected]
