practice partner
Dr. Donna
McRitchie
In a presentation that generated
buzz, North York General Hospital
(NYGH) in Toronto discussed “rethinking more is better”. Clinical chiefs
reviewed CWC recommendations, suggested additions and circulated them to all
specialty and sub-specialty areas. NYGH engaged
patients throughout design and implementation, and
validated/incorporated insights from stakeholders
into NYGH order sets and medical directives.
Here are just some outcomes. Lab tests ordered
fell by 31% for ER patients (since September 2014)
and 38% in the pre-operative clinic (since February
2015). And mobile chest X-rays in the ICU dropped
12% since January 2015.
Health columnist André Picard of the Globe &
Mail (a keynote speaker at the CWC meeting) wrote
that NYGH has become a poster child for CWC
with these and other results. He quoted Dr. Donna
McRitchie, VP, Medical and Academic Affairs at
NYGH, who said: “A lot of tests are done by routine,
not because they’re helpful.”
Every little change added up. In the ER, for example, 42% of patients were getting one or more
tests, and that fell to 31%. Besides seeing substantial
financial benefits, and sparing patients unnecessary
tests, NYGH reduced ER wait times.
An Alberta initiative – which involved the provincial medical association, both medical schools,
Alberta Health and Alberta Health Services and the
provincial chapter of the College of Family Physicians – also generated much interest at the meeting.
Using a patient pamphlet, physician communication and a media release, the message was sent that
while most Albertans can benefit from vitamin
D supplements, they don’t need regular tests to
do so safely. As of April 2015, vitamin D testing
was eliminated for screening healthy patients. It’s
provided only if other clinical indicators/conditions
are present, e.g., osteoporosis, chronic renal or liver
disease, etc. The result? Vitamin D test ordering in
Alberta fell 93%.
Another CWC session reviewed how the College
of Family Physicians of Canada (CFPC) launched
36
a “Do More Screening Tests Lead
to Better Health?” video that was
targeted at patients. The video focuses
on common and often overused tests
like mammography, thyroid testing, chest
X-ray and ECG, and Pap smears. A short
version will be available for broadcast in doctors’
offices (sound-free format). Three infographics will
support doctor-patient talks.
Dr. Janice Harvey, Physician Advisor, CFPC, says
the material can help prepare patients for a productive conversation with their doctors about truly
necessary screening.
“When we open a dialogue we can improve the
health literacy of our patients, and understand their
agenda and fears. We can shift from blind testing to
focus on prevention,” says Dr. Harvey.
Four questions for discussion
In having those conversations, Dr. Quinn uses this
analogy. Imagine a medication that has serious side
effects, and on balance is worse than the condition.
In this case, the tests, treatments and procedures are
the ineffective and perhaps detrimental medication.
At the CWC meeting, he was part of a panel on how
to have discussions about overuse. As CWC notes,
70% of medical diagnoses can be determined by patient history alone, without any tests. CWC suggests
four questions that trigger productive discussions:
1 Is this test, treatment or procedure really
needed?
2 What are the downsides?
3 Are there simpler, safer options?
4 What happens if you do nothing?
Dr. Quinn says he feels far more gratified when
he takes the time to run through the evidence (or
lack of evidence) for a test, and address the patient’s
concerns. Sometimes, watchful waiting can be the
best strategy.
It doesn’t always happen. He describes a patient who
did come in with abdominal pain. After examining her,
Dr. Quinn felt it was nothing. The patient returned
Dialogue Issue 2, 2016
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2016-06-16 12:27 PM