e1.choosing wisely: the challenge of low-value care. sam shortt
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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<C, 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.
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