Choosing Wisely Canada

Spring 2018

In 2017 the Canadian Institute for Health Information (CIHI) reported that up to 30 per cent of tests, treatments, and procedures in Canada are potentially unnecessary and hold no value in medical care. They do not improve the outcome for patients and furthermore could expose patients to harm, adding stress for patients and their families, and consuming precious time and resources in our health-care system.

Choosing Wisely Canada is a national campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make evidence-based and effective care choices.

By working with experts from different clinical specialties - such as cardiology, family medicine, and critical care - Choosing Wisely Canada has developed five recommendations for ‘Do Not Perform’ common tests and treatments in each specialty. These are tests and treatment not supported by the latest medical evidence, exposing patients to unnecessary treatment and potential harm.

The Choosing Wisely Canada campaign was launched in 2014. A multi-professional campaign that includes physicians, nurses, pharmacists and other health care professionals, it is part of a global movement that spans 20 countries across five continents.

London Health Sciences Centre (LHSC) is implementing the Choosing Wisely Canada recommendations for over 15 clinical specialties - reviewing each guideline and how, or if, it fits within the practice here.

Ultimately, Choosing Wisely at LHSC is about clinicians engaging patients and families in dialogue regarding their treatment choices.

Inside LHSC interviewed three physician leaders about Choosing Wisely at LHSC.

Dr. Davy Cheng, LHSC Anesthesiologist and Research Chair of EPICOR, Evidence-Based Perioperative Clinical Outcomes Research; Dr. Andrea Lum, LHSC Radiologist and Chair of the Medical Advisory Committee; and Dr. Robin Walker, Integrated Vice President of Medical Affairs and Medical Education.

At LHSC Choosing Wisely is about customizing care to the patient and ensuring there is communication with the patient. That is how Dr. Andrea Lum, LHSC Radiologist and Chair of the Medical Advisory Committee, explains it.

“We want you, the patient, to be engaged with your health-care provider and to advocate for your health. It is a patient-physician partnership,” she says. “Choosing Wisely informs the dialogue with patients in terms of the tests, drugs and therapies that are right for each patient. It is personalized.”

In radiology, for example, one recommendation is not to use computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered an option.

The rationale? Although CT is accurate in the evaluation of suspected appendicitis, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, it is the preferred initial imaging examination in children. If the results of the ultrasound are unclear, it may be followed by CT. This approach reduces potential radiation risks, is cost-effective and has excellent accuracy.

“The campaign is really a public and physician education campaign to provide medical knowledge to enable a fulsome patient care experience,” says Dr. Lum.

With over 15 medical specialties, and therefore potentially 75 recommendations to be considered, each professional specialty generated its recommendations and applies those with best available evidence and the biggest value impact, says Dr. Davy Cheng, LHSC Anesthesiologist and Research Chair of EPICOR, Evidence-Based Perioperative Clinical Outcomes Research.

To come up with the “Do Not Perform” recommendations, Choosing Wisely Canada brought together professional societies and experts in the field including Dr. Cheng, other physicians and surgeons from LHSC and across the country.

The Canadian Critical Care Society (CCCS) facilitated a panel in which LHSC participated.

“The panel generated over 38 potential recommendations and further assessed and ranked them using evidence, prevalence and relevance, ease of use, prevention of harm, innovation and cost,” says Dr. Cheng. “Ultimately the CCCS defined its five Choosing Wisely Canada recommendations, and two of the five derived from the assessment and proposal from the LHSC team.”

In a large teaching hospital such as LHSC about two-thirds of the care orders are placed by medical residents and, when you are learning, there is a natural tendency to cover all the bases so you don’t miss anything, says Dr. Robin Walker, Integrated Vice President of Medical Affairs and Medical Education.

The recommendations are therefore helpful in a teaching environment.

It is also important to focus on involving patients in their health care.

“In the hospital setting most patients want to have greater participation in their care. Physicians need to proactively encourage patients and families to ask questions. It can be as simple as asking, ‘What are your questions?’ Many times patients and families need the opening to ask their questions, further their understanding and voice their concerns if they have any,” says Dr. Walker.

Broadly implementing a program such as Choosing Wisely Canada is complicated in a multi-specialty hospital such as LHSC, and some areas are further ahead in their adaptation than others.

“Choosing Wisely requires a culture shift. It is about engaging physicians and engaging patients and families,” says Dr. Cheng. “It is also about teaching the young generation of physicians value-based and science-based care. Without this our health-care system is not sustainable.”

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