objectives 1.to describe the “epidemic of overuse” 2.to describe the choosing wisely canada...

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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

Website for patients

www.ChoosingWisely.ca

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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, Chairwendy@choosingwiselycanada.org

Karen McDonald, Project Managerkaren@choosingwiselycanada.org