Choosing Wisely Bottom up clinician led effort to identify and reduce low value health care Premised on the balance of benefit versus potential harms May reduce cost but that is not an explicit goal Recent but now international CWC recommends – CWNL implements

Choosing Wisely - Happy Video

Why Are We Involved? NL SUPPORT aims to increase Patient Oriented Research We were doing studies of healthcare utilization in various settings The initial thought was to produce reports and dashboards to inform decision making Then we realized it takes more to induce change

How We Work Identify who to contact based on utilization data Not limited to Family Practice – specialists and hospital practice are also involved Goal is a provincial reach Some interventions need public involvement, others just clinicians Will work with clinicians to facilitate change, non-coercive, personal data remains confidential Interventions are chosen based on the issues

Use of Blood Urea in General Practice 1 July – 31 December 2015

First Campaign Blood urea testing in non-urgent care Limited impact on the system but Allowed us to test how we could reach clinicians with a message Used Eastern health data from last half of 2015 so limited to Eastern Health family doctors Goal was to reduce use of a test which is rarely needed in this setting

Practice Points Blood urea is not necessary to evaluate stable kidney function eGFR should not be used to evaluate acute deterioration in Kidney function In acute deterioration, blood urea may be increased by decrease in blood volume, hypercatabolism, or by bleeding retained in the body.

Tests results separately, 1 July – 31 December 2015 In general practice, blood urea is usually ordered with serum creatinine, and is unnecessary in stable patients.

eGFR vs Urea, 1 July – 31 December 2015: *High blood urea with normal eGFR in stable patients creates unnecessary diagnostic confusion

Blood Urea in Patients with normal eGFR

Top 20 general practitioners who submitted Urea test the most:

Number of Urea Tests submitted by General Practitioners:

First Campaign: Reduce Urea Testing In Family Practice Summary slide an email from NLMA: 300 active doctors Click to obtain personal utilization data: 1/3 Required information by paper 43: 1/8

Use of Antibiotics A bigger target with public involvement – helped develop communications strategy

Second Campaign: Antibiotic use Email and education slides Decision aids by post Peer comparison in 3 months

First Public Campaign: Antibiotic use Press release: TV x 3, Radio x 4 Slides on website Video Twitter and Facebook

Third Campaign Use of carotid imaging We had utilization data from the Vascular lab at SCMH – targets Fam Med and Specialists There is an issue with overuse of US but The bigger issue is likely the underuse in a timely manner for those with TIA or minor stroke Need for a provincial intervention targeting the under use of imaging in this context – US or CT angiography of carotids

The Problem Secondary Stroke rate in NL as % of total Strokes Secondary stroke occurs after a warning event such as TIA or very mild stroke

The Problem Most secondary strokes: Are disabling or fatal Occur within 48 hrs-2 weeks Are PREVENTABLE with rapid management Are often the result of high grade carotid artery disease ;

The Solution Rapid Carotid Endarterectomy (CEA) substantially lowers risk of stroke in symptomatic patients

Carotid Territory TIA is a medical emergency! Rapid onset symptoms include: Unilateral weakness of face/arm/leg Speech disturbance (aphasia and/or dysarthria) Monocular visual loss (Amaurosis Fugax), or loss of one visual field (Homonymous Hemianopia) Immediate work-up required CT head Carotid studies

Current Utilization at St. Clare’s Vascular Lab 2007-15 What’s happening here? Current Utilization at St. Clare’s Vascular Lab 2007-15 Carotid artery studies 17,600 Indicated based on symptoms 40% Not indicated based on symptoms 60% Test result shows high-grade stenosis 33% Most requests arrive too late after symptoms onset Access to urgent testing is diminished by a waitlist for tests that are not indicated

Choosing Wisely Recommendations Don’t order a procedure that will not change the patient’s clinical course Carotid Studies are not indicated for: Syncope Headache Dizziness Tinnitus Carotid bruit Pain Generalized weakness

What you can do! Arrange urgent carotid imaging for patients with rapid onset of carotid territory symptoms When referring, provide type and timing of symptoms, ensure referrals are legible and transmit urgently.

Ranking of Doctors by Total Number of Referrals for Carotid Artery Testing (2007-2015)

Ranking of Doctors by Percentage of Tests Indicated (2007-2015)

Ranking of Referring Physicians by Percentage of Test Results Showing High Grade Stenosis (2007-2015)

Warning signs of stroke

Upcoming Campaigns Peripheral vascular disease testing LDH and Troponin testing in the community Ferritin testing Colonoscopy Antibiotics in Nursing Homes Low back pain imaging Antipsychotics in Nursing Home