Dr. Wendy Levinson Chair, Choosing Wisely Canada University of Toronto @ChooseWiselyCA

Dr. Sam Shortt Vice-Chair, Choosing Wisely Canada Canadian Medical Association

Objectives

1. To demonstrate why and how physicians should lead the management of finite resources

2. To discuss the origin and evolution of Choosing Wisely® in the U.S. and Canada

Berwick D. JAMA. 2012.

Canadian Examples No overview studies; fragmentary evidence, often drug focused:

Ontario study: patients <16 yrs: 76% of sore throats cases (>80% viral) were treated with antibiotics without a throat culture. [Pennie RA. Can Fam Physician. 1998; 44:1850-6] Saskatchewan study: in pre-school children with respiratory infections almost half of prescriptions were not indicated on the basis of evidence-based guidelines and 49% of the cost of all prescriptions was unnecessary.[Wang E, et al. Clin Infect Dis. 1999; 29(1):155-60]

How to Fix: An Attractive Solution for Governments

“ The most efficient way to eliminate inappropriate care would be to stop paying for it.” Lucian Leape, MD Harvard School of Public Health Quality Review Bulletin 1990, p.45

Getting Started On Not Paying: An Australian Example

A multiplatform approach to identifying services listed on the Australian Medicare Benefits Schedule that have questionable benefit Of almost 6000 items on the Benefits Schedule 156 (3%) were identified as potentially ineffective and/or unsafe services Adam G, Amber M Watt, Linda Mundy and Cameron D Willis Over 150 potentially low-value health care practices: an Australian study Med J Aust 2012; 197 (10): 556-560.

A Canadian Example

“Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely…”

Boutis K, et al. CMAJ October 15, 2013 vol. 185 (no.15) : E731-38.

BUT: ministries of health have only the diagnosis from physician billing data and the ordering physician’s billing number from the ankle x-ray requisition – there is NO clinical data by which to connect them.

Lessons

Bob Evans: “For every complex problem there is a simple solution ….and it’s almost invariably wrong.”

2. There is Another Way

1. Delisting Will Not Work

Changing medical practice: Choosing Wisely Canada

Physicians determine care

1. Which patients are seen and how frequently

2. Which patients are hospitalized

3. Which tests, procedures and surgical operations are administered

4. Which technologies are used

5. Which medications are prescribed

Emanuel EJ. JAMA. 2013.

$$

Fear of litigation

Referring doctor

wants it

Better to get a test than

“do nothing”

I’ve always done this

Patients want it

New tests are

good

“We – physicians – are the only people that can get health care costs under control”. - Zeke Emanuel

“Somebody has to do something, and it's just incredibly pathetic that it has to be us”. - Jerry Garcia

A campaign to help physicians and

patients engage in conversations

about the overuse of tests and

procedures and support physician

efforts to help patients make smart

and effective care choices.

First 9 – now over 60 societies

A campaign to help physicians and patients

engage in conversations about unnecessary

tests, treatments and procedures, and to help

physicians and patients make smart and

effective choices to ensure high-quality care.

How the lists were created

• Societies free to determine the process

• Test or procedure within specialty’s

purview

• Procedures frequent

• Evidence to support

• Process publicly available

15

16

17

April 2, 2014 Launch

• Press conference held in Ottawa

• 9 participating societies included: – Canadian Cardiovascular Society

– Canadian Association of Radiologists

– CMA Forum on General and Family Practice Issues

and The College of Family Physicians of Canada

– Canadian Orthopaedics Association

– Canadian Society for Internal Medicine

– Canadian Rheumatology Association

– Canadian Geriatrics Society

– Canadian Association of General Surgeons

• 22 additional societies to launch at later date 18

Media coverage

Processes

• Societies develop lists

• Disseminate to physician leaders Physicians

• “Canadianize” patient materials with help of societies

• Disseminate broadly Patients

• Coordinated release of lists Media

• Curriculum development (undergrad, postgrad, faculty) Medical Schools

Conclusions

• Choosing Wisely® is primarily about enhanced physician-patient communication

• Informed communication may reduce unnecessary care

• Eliminating marginal care enhances the quality of care

• It also preserves scarce resources

(website) www.choosingwiselycanada.org (Twitter) https://twitter.com/ChooseWiselyCA @ChooseWiselyCA