1 Choosing Wisely Canada The Challenge of Low-Value Care 20 February Quality Forum Vancouver, BC Dr. Sam Shortt

2 Presentation  Definition  Size & causes of unnecessary care  Choosing Wisely Canada (CWC) origin & approach  Implementation  Evaluation  Useful resources  Conclusion

3 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

5 How Big is the Problem?  IOM estimates 30% of care in US is unnecessary  Examples ServiceCondition(s)No. of Studies Range of Overuse Rates, % (2000–2009) Coronary angiographyMI, CAD178.0 – 21.8 Coronary revascularizationCAD161.4 – 14.0 Upper endoscopyBleeding (upper), PUD719.0 – 23.0 Radiographs in acute respiratory illnesses Bronchiolitis, asthma532.0 – 72.0 ColonoscopyColon CA423.0 – 60.8 AntibioticsURI, acute bronchitis592.0 – 89.0 BronchodilatorsObstructive diseases630.0 – 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

6 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):  An Ottawa and Edmonton in-hospital study of lumbar spine MRI % were deemed inappropriate and 27.2% of uncertain value. Emery et al. Overuse of Magnetic Resonance Imaging JAMA Intern Med 2013;173(9): …As in the US, the 30% figure seems a not unreasonable estimate.

7 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: Asch D et al JAMA 2009;302(12); Sirovich B JAMA Intern Med 2014:174(10):

8 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: 1 st international meeting June 2014  Early results:  Modeling  Other?

9 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

10 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  Endorsed by all PTMAs, CFPC, RCPSC; principles supported by CMPA  Non-medical partners

11 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  Endorsed National Association of Federal Retirees, Patients Canada, and others

12 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

13 Implementation  Multi-stakeholder Implementation Committees in Ontario; Alberta; and conjointly in the 4 Atlantic provinces.  Some common themes BASICINTERMEDIATEADVANCED 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

14 BASIC: Screensaver, North York General

15 Available at

16 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:

17 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

18 Evaluation…2 Utilization: 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 Ontario28%72% Alberta17%83% ALBERTA: Cervical Screening Rate Age Age

19 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.

20 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  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

21 Advanced: Cedars-Sinai Blind Spot Monitor- CW Embedded in CPOE  Cedars Sinai  Think Research (formerly Patient Order Sets)

22 Useful Resources   “Confronting Unnecessary Care: Choosing Wisely Canada” at  Levinson W, Kallewaard M, Bhatia RS, et. al. “Choosing Wisely”: a growing international campaign. BMJ Quality &Safety 2014;0;1-9. doi /bmjqs  Professor James McCormack, UBC, a Choosing Wisely parody of Pharrell Williams’ hit song ‘Happy’.

23 Helpful Implementation Advice Wisely/WSMA_ActionManual_online_FNL.pdf

24 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.