choosing wisely
www.choosingwiselycanada.org
indicators of overuse. It’s a great opportunity to
learn from one another,” said Dr. Levinson at
the report launch.
O’Toole pointed out substantial variations
within and between regions around prac-
tices. For example, in one year the rate of
chronic benzodiazepine use by seniors ranged
from 5% in Saskatchewan to 25% in New
Brunswick. Mammogram screening rates for
average-risk women goes from 13% in Que-
bec to almost 39% in Nova
Scotia. In Alberta, just 9%
of endoscopy patients have
four critical
pre-op tests; the number is
17% in Saskatchewan and
questions
20% in Ontario.
1) Is this test, treatment or
In Ontario itself, some
procedure really needed?
disparities between areas
were striking. Consider
2) What are the downsides?
patients aged 18-64 who
3) Are there simpler, safer
visited emergency in
options?
2015-2016 for minor head
4) What happens if you do
trauma (i.e., no red flags).
nothing but watch and wait?
The rate of potentially
unnecessary CT scans was
31% for the province as a
whole, but among the 14 LHINs was any-
where from 13% to 46%.
Looking at Ontarians with uncomplicated
low-back pain, 4.5% had a CT or MRI scan
that wasn’t indicated. The variations between
primary care practices ranged from 0.8%
of patients who had such scans to a high of
33%.
At the April webinar, Dr. Laurent Marcoux,
President-elect of the Canadian Medical As-
sociation, said the culture of medicine is the
biggest target for change. No doctor wants to
harm a patient (or the system), yet that’s what
can happen with over-diagnosis. “We think
that more is better than less,” he stated.
Not always, and that belief is hard to break.
Dr. Levinson said doctors can assume it takes
much longer to discuss the reasons not to
40
Dialogue Issue 2, 2017
have a test or treatment. In fact, she said these
conversations only take a minute on aver-
age, and can prevent return visits and longer
conversations down the road.
Practitioners take action
In April 2014, Sunnybrook Health Sciences
Centre in Toronto found that 69% of their
catheter use lacked an appropriate medical
reason. The team developed an evidence-
based medical directive to empower nurses to
remove urinary catheters if patients met spe-
cific criteria. As a result, urinary catheter days
are down 50% in medical patients, without
any inappropriate catheter removals (based on
random audits). One of the doctors created a
toolkit called “Lose the Tube” to support the
transformation.
The report also highlighted the success of
the North York Family Health Team in scal-
ing back prescriptions of proton pump inhibi-
tors (PPIs). These potent acid blockers may
cause harmful side effects. Studies suggest that
over half of people who take them probably
don’t need them. Antacids or other less pow-
erful drugs can deal with simple heartburn.
The North York team identified 1,600
patients who were taking potentially inap-
propriate PPIs. The group flagged them for
physician consultation – on indications for
use, side effects, risk, other treatment options
– when they came for regular appointments.
Over 18 months, 60% of patients who were
engaged stopped or reduced their PPI use, all
from a simple intervention.
At a system level, the benefits of curbing
unnecessary tests can be huge. It all comes
down to conversations with patients and four
critical questions (see sidebar).
“Research shows that when physicians listen
deeply, understand patient concerns and wor-
ries, and have a discussion about the pros and
cons, patients feel reassured,” says Dr. Levin-
son. “That’s what we’re seeking.”
MD