2. Objectives 1.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 2

3. Issue of medical overuse

4. 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

5. Cultural factors Systems factors Physician and patient factors Overuse

6. 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.

7. 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 $$

8. Choosing Wisely campaign

9. 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 9

10. Objectives 1.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. 10

11. Campaign approach Societies develop lists Disseminate through multiple channels Physicians Develop patient materials Disseminate broadly through multiple channels Patients Coordinated approach toward media Multiple voices, a common message Media Work through health care stakeholder organizations to implement and support adoption Stakeholders 11

12. 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 12

13. 13

14. Patient education pamphlet characteristics Plain language Easily accessible Canadian- specific Educational Evidence- based 14

15. 15

17. Working with provinces PTMAs (Alberta, NS, Quebec) Health regions (Vancouver Coastal Health) QI organizations (Ontario) Measurement organizations (Physicians Learning Program, Health Quality Saskatchewan) 17

18. Search for “Choosing Wisely Canada” on your app store or visit our website for links to download

19. 19 Visit our website for direct link or search https://www.mdcme.ca/https://www.mdcme.ca/

20. Patient engagement

21. More Is Not Always Better: purpose 1.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

24. Implementation

25. 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

26. The Implementation Spectrum ENGAGEMENT & EDUCATIONQUALITY IMPROVEMENTHARD 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

27. Cedars-Sinai Blind Spot Monitor: CW Embedded in CPOE

28. Pre Intervention Jan 1 – Sep 9 Post Intervention Sep 10 – Nov 25 mean orders % changep-value Antipsychotics Patients ≥ 70 203166-18.2%<0.001 Benzo-Sedatives Patients ≥ 65 133116-12.5%<0.001 Butalbital Adults 4.133.58-13.3%<0.04 Vitamin-D levels 322286-13.7%<0.001 Impact Analysis Rates per 10,000 encounters

30. Analysis compares 10 week period (Sep. 15 – Nov. 21, 2013-2014) 41% decline in number of tests pre- and post- program implementation

31. 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%

32. 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.http://www.shmabstracts.com/abstract/innovations-in-data-visualization-to-drive-down-unnecessary-transfusions/

33. 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.http://www.shmabstracts.com/abstract/innovations-in-data-visualization-to-drive-down-unnecessary-transfusions/

34. 34

35. Family Medicine Module 35 STARTER KITIMPLEMENTATION 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 Testing Module More to Follow

38. Evaluation

39. 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

40. Physician attitudes & awareness

41. Patient attitudes & awareness 41 Ipsos Reid (2015). Awareness and Attitudes towards Choosing Wisely Campaign.

42. Patient attitudes & awareness 42 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)?

43. Don’t routinely perform preoperative testing (such as chest X-rays, echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries)

44. Preoperative testing 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)

45. Institution Proportion of Procedures

46. Medical education

47. 47

49. International

51. Website for providers www.ChoosingWiselyCanada.org www.ChoisirAvecSoin.org

52. Website for patients www.ChoosingWisely.ca

53. Social media 53 www.twitter.com/ChooseWiselyCA www.twitter.com/ChoisirAvecSoin www.facebook.com/ChooseWiselyCanada www.facebook.com/ChoisirAvecSoin

54. 54

55. Important contacts Dr. Wendy Levinson, Chair wendy@choosingwiselycanada.org Karen McDonald, Project Manager karen@choosingwiselycanada.org 55