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Choosing Wisely CanadaThe Challenge of Low-Value Care

20 February 2015

2015 Quality Forum

Vancouver, BC

Dr. Sam Shortt

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Presentation

Definition

Size & causes of unnecessary care

Choosing Wisely Canada (CWC) origin

& approach

Implementation

Evaluation

Useful resources

Conclusion

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What is Choosing Wisely?

Choosing Wisely is a physician-initiated

campaign to help physicians and patients

engage in informed conversations about

unnecessary tests, treatments and

procedures.

Wise choices will improve the quality of

clinical care and will enhance stewardship of

scarce resources.

# of MDs

100%0%

Frequency of a specific clinical activity

Over Use

What is the Target of Choosing Wisely?

Approximate zone of CPG compliance,

usual practice, available options, etc.

Under Use

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How Big is the Problem?

IOM estimates 30% of care in US is unnecessary

ExamplesService Condition(s) No. of Studies Range of Overuse

Rates, %

(2000–2009)

Coronary angiography MI, CAD 17 8.0 – 21.8

Coronary revascularization CAD 16 1.4 – 14.0

Upper endoscopy Bleeding (upper), PUD 7 19.0 – 23.0

Radiographs in acute

respiratory illnesses

Bronchiolitis, asthma 5 32.0 – 72.0

Colonoscopy Colon CA 4 23.0 – 60.8

Antibiotics URI, acute bronchitis 59 2.0 – 89.0

Bronchodilators Obstructive diseases 6 30.0 – 81.0

Korenstein D, et al. Overuse of health care services in the United States: an understudied

problem. Arch Intern Med. 2012; 172:171-8

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No Comparable Canadian Data

In a Saskatchewan study of pre-school children with respiratory

infections almost half of antibiotic prescriptions were not indicated on

the basis of evidence-based guidelines.

Wang E, et al. Clin Infect Dis. 1999; 29(1):155-60

An Ottawa and Edmonton in-hospital study of lumbar spine MRI - 28.5%

were deemed inappropriate and 27.2% of uncertain value.

Emery et al. Overuse of Magnetic Resonance Imaging JAMA Intern

Med 2013;173(9):823-825.

…As in the US, the 30% figure seems a not unreasonable estimate.

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Multiple Causes of Low-value Care

Physician habit

Patient demand

Physician lack of knowledge

Fear of litigation

Financial incentives

Specialist requirements for referrals

“More or New is Better” fallacy

Time pressures

See: Scott I A, Elshaug AG. Foregoing low-value care: how much evidence

is Needed to change beliefs? Internal Medicine Journal 2013, 43: 107-109.

Asch D et al JAMA 2009;302(12);1277-83

Sirovich B JAMA Intern Med 2014:174(10):1640-48

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Choosing Wisely: Origins and Growth in the USA

2010 Howard Brody challenge in the New England Journal of Medicine

American Board of Internal Medicine Foundation launches 2012

From initial 9 societies to >70 in < 2 years

Partnered with Consumer Reports

Extensive positive media response

Rapid international growth: 1st international meeting June 2014

Early results:

Modeling

Other?

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Choosing Wisely Canada Approach…1

Campaign endorsed by RCPSC, CFPC, all PTMAs, note CMPA

>35 specialty societies participating; 101 list items released to date with

more in development; “Wave III plans.

List creation - must be done in accordance with the following principles:

The development process documented and publicly available

Recommendations within the specialty’s scope of practice

Focus on activities that are (a) frequent, and, (b) may expose patients to harm

Supported by evidence

Messaging: NSS; PTMAs; CMAJ; meetings; accredited online course;

CWC app.

Physicians

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Choosing Wisely Canada

Created early 2014 through an MOU between the Canadian Medical

Association and a team at the University of Toronto lead by Dr. Wendy

Levinson

Funding from Ont. MOH&LTC, CMA., Health Canada

April 2014: 8 lists released; Oct. 2014: another 11 lists released

Over 35 specialties are now engaged with lists in future to be released in

small groups or individually as available over 2015.

Endorsed by all PTMAs, CFPC, RCPSC; principles supported by CMPA

Non-medical partners

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Choosing Wisely Canada Approach…2

Patients

25 patient pamphlets; “Canadianized” from Consumer Reports

Pending initiative with CFPC

Media:

Traditional – 43 million exposed to PSAs during hockey playoffs 2014

Google: 45 day campaign; 9 million viewed ads; 300,000 clicked through

(3.6% vs 0.03% - 0.1%); 200 web visits/day increased to 4000.

Endorsed National Association of Federal Retirees, Patients Canada,

and others

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Choosing Wisely Canada Approach…1

Physicians:

List development: National specialty societies are free to determine the

process for creating their lists, as long as they are done in accordance

with the following principles:

The development process is thoroughly documented and publicly available

Each recommendation is within the specialty’s scope of practice

Tests, treatments or procedures included are those that (a) are frequently

used, and, (b) may expose patients to harm or stress.

Each recommendation is supported by evidence

Messaging

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Implementation

Multi-stakeholder Implementation Committees in Ontario; Alberta; and

conjointly in the 4 Atlantic provinces.

Some common themes

BASIC INTERMEDIATE ADVANCED

o Promote awareness

locally

o Educate physicians √

o Educate patients √

o Make policy changes

o Support QI initiatives

o Measure and evaluate

o EMR/CPOE

integration

o Audit and feedback

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BASIC: Screensaver, North York General

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Available at www.choosingwiselycanada.org

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Basic: the Early Adopters Collaborative

Informally monthly teleconference for sharing tactics and stories

Over 26 regional health authorities and hospitals from coast to coast

participate

Among them:

Fraser Health Authority

Vancouver Coastal Health

Sign up at: www.choosingwiselycanada.org

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Intermediate: Evaluation & Measurement

Two broad themes:

Culture change in medical practice

Positive change in utilization

Culture Change

Baseline surveys off physician attitudes have been done, e.g. CMA e-

panel:

Patients drive inappropriate use of services more often than physicians do.

58% agree or strongly agree

I need more support and/or tools to help me make decisions about which

services are inappropriate for my patients. 69% agree or strongly agree

The primary responsibility for decreasing inappropriate use of services rests

with physicians. 76% agree or strongly agree

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Evaluation…2Utilization: Gathering Baseline Data

1. Don’t repeat dual energy X-ray absorptiometry (DEXA) scans

more often than every 2 years.

2. Don’t screen women with pap smears if under 21 years of age or

over 69 years of age.

< 2 years apart > 2 years apart

Ontario 28% 72%

Alberta 17% 83%

ALBERTA: Cervical Screening Rate 2011-2013

Age 15-20 17.5

Age 70+ 10.3

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Evaluation…3

ONTARIO: Pre-op testing in low risk surgery

Don’t routinely perform preoperative testing (such as chest X-rays,

echocardiograms, or cardiac stress tests) for patients undergoing low-

risk surgeries.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Endoscopy Ophthalmology Other Overall

ECGs

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Intermediate: Support QI Initiatives

QI in the Emergency Department of an Ontario Hospital

Conducted a pre-post CWC implementation comparison for a 10 week

period in 2013 vs. 2014

41% decrease in the number of tests

• 35% fewer patients received any testing in the ED since the

Choosing Wisely intervention

• tests per unique visit reduced from 8.4 tests/per visit to 7.6

tests/per visit –

Total supply savings is estimated as $41,092 for the 10 week period =

~$114K/yr

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Advanced: Cedars-Sinai Blind Spot Monitor-

CW Embedded in CPOE

Cedars Sinai

Think Research (formerly Patient Order Sets)

Impact of Blind Spot Monitor

Prescript ions of Benzodiazepines to Elderly Pat ients

*Comparison periods 7/13/13 to 8/6/13 and 8/7/13 to 8/31/13

Change in number of prescriptions from baseline with active alert*

Age >=65 years Age <65 years

Pilot MD offices -20.9% 3.6%

Control MD offices 10.6% 3.5%

Difference -31.5% +0.01%

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Useful Resources

www.choosingwisely.org

“Confronting Unnecessary Care: Choosing Wisely Canada” at

www.mdcme.ca

Levinson W, Kallewaard M, Bhatia RS, et. al. “Choosing Wisely”: a

growing international campaign. BMJ Quality &Safety 2014;0;1-9.

doi10.1136/bmjqs-2014-003821

Professor James McCormack, UBC, a Choosing Wisely parody of

Pharrell Williams’ hit song ‘Happy’.

https://www.youtube.com/watch?v=FqQ-JuRDkl8&feature=youtu.be

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Helpful Implementation Advice

http://www.wsma.org/doc_library/ForPatients/KnowYourChoices/Choosing

Wisely/WSMA_ActionManual_online_FNL.pdf

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Conclusion

Provision of low-value care is multi-causal, frequent, expensive, and

potentially harmful to patients.

The medical profession, appropriately, has taken ownership of this issue

through the rapidly expanding Choosing Wisely campaign.

This initiative has the potential to improve quality of care and

stewardship of scarce resources.

The challenges are less in list creation than in ensuring uptake in clinical

practice and document the ensuing impact.

A final challenge: the message is about quality, not cost.