Quality Forum: A New Kind of Rounds (Teaching patient-centred care that avoids unnecessary and harmful interventions)

I have followed the Do No Harm project and their articles in JAMA's Teachable Moments section (under the Less is More theme). Then, at the Lown Institute's Road to Right Care conference, I learned more about "Right Care Rounds," and in Nanaimo we developed our own version.

More background information and the talk from our first session, on the subject of treatment of Type 2 Diabetes in the elderly, can be found here.

Following the success of this event, we decided to do more of them. Our next one is tentatively in April and will be on the subject of overtreatment of hypertension. Thinking, "why not spread the message of what we are trying?," we've created a poster that I will present at the BC Quality Forum.

You can view the full poster 'storyboard' by clicking the image below.
 

GUEST POST: The haunting death that fuels my passion: a personal reflection

Dr Amy Tan is Family Physician with a special interest in Home and Hospice Palliative Care in Edmonton, Alberta. With a MSc in Palliative Medicine and Research from the University of Cardiff, she is a vocal advocate for end-of-life planning and the care of patients dying outside of the hospital. She also serves as Director of Undergraduate Education Programs for the University of Alberta's Department of Family Medicine. You can follow her @AmyTanMD on twitter.

This is a re-post of a blog originally posted by Dr Amy Tan on Sept 17 on Medium.


The haunting death that fuels my passion: a personal reflection

Dr Amy Tan

“A young mother of 4 children in her 40's, M*, was diagnosed with terminal breast cancer 4 weeks ago. She was referred, at the time of diagnosis, to a (new to her) family doctor who provides home visits for palliative care patients. At the first home visit, the physician speaks to the patient and her husband about the diagnosis, and how they are coping with this awful news. They have chosen not to tell their children (ranging in age from 8–17) that M’s disease is not curable. M and her husband are able to say aloud that she has a terminal prognosis, yet they are hopeful that she will rally and live much longer than the doctors have told her she would. M is extremely short of breath, requiring oxygen to help with her breathing. She has pain in her chest and ribs from the cancer that has spread into the lymph system in the lungs and bones. In the patient’s culture, talking about death is taboo, fearing that this topic will make death come faster. The doctor tries to sensitively broach this topic in order to prepare the patient and her husband for what is likely to come as death approaches with this disease: the shortness of breath, the pain and accompanying nausea and constipation from the medicines that treat the pain, and the fears about dying and about fighting to breathe, among others. The family doctor offers to talk to the children about what is going on and what to expect. She offers a referral to a social worker to help the patient’s children understand what is happening. These are refused despite the great pain M shows -both physically and emotionally- whenever her children are mentioned.

The doctor’s sixth home visit with M is on a Friday afternoon before a weekend. M is deteriorating quite quickly and again the doctor tries to broach the topic of telling the children what is happening so that they can try to prepare for the awful truth. She again is not successful. The doctor informs the Palliative Home Care service that she is available 24/7 for this patient.

The next night, M wakes up gasping for air and with incredible chest pain . There is fear and panic. 911 is called and M is taken to the Emergency Department of a large hospital by ambulance. A chest x-ray shows M’s lungs are full of cancerous fluid. The patient doesn’t want to be intubated or go to the intensive care unit, and so the Emergency team tries to keep her oxygen levels up with a machine that pushes positive pressure into the lungs. There are no beds available upstairs for her to be transferred to because it was a busy weekend of hospital admissions. M dies 15 minutes later, in a curtained off “bed” in the chaotic Emergency Department, with no privacy, no peace, and struggling to breathe right to the end. M’s husband watches this all and cannot understand nor believe what is happening. He doesn’t get to say goodbye to his wife of 20 years. He is completely shocked that his wife has just died in such a chaotic place. Their four children don’t have any idea that this is happening in the Emergency Department, and worse yet, that their mother has been moving through the terminal, dying phase of her life for at least the last four weeks.

The family doctor finds out the following Monday morning that her patient has passed away. “Why wasn’t she called?” was the first question she asks. Upon reviewing the above events in the Emergency Department report, the doctor cries for M, her family and their agony: the agony of both M and her family not being able to prepare for the end, and the agony of M’s loved ones being traumatized for years afterwards because of this death. This was NOT a good death. She had failed her patient.”

I am M’s doctor, and this happened years ago. Yet, M’s death still haunts me and I often wonder and worry about how her husband and children are doing. How did the children take the news that their mother died? Did the older teenaged children feel betrayed and cheated on the opportunity to say goodbye and prepare for their mother’s death?

I know the husband struggled because he dropped off a letter to my receptionist, asking me to fill out life insurance forms. In the letter, he described that his last memories of M were of her struggling to breathe, and asked to discuss all of this with me when he was ready. I left a message that of course he could discuss anything with me, when he felt that he was ready.

I never saw or talked to him again. The family had moved out of the province a few months later to be closer to family.

I wonder about M and her family every time I hear that a patient (who is expected to die from a terminal illness) has been rushed during a crisis into the acute care system and undergoes life-preserving or death-avoiding management at a critical time in the patient’s life — their death. These stories happen too often (still happening today!) and I wonder if there could be a better way.

I choose to believe that there has to be. But how do we get there?

In the years since M’s death, there has been great work done in many countries to help the public understand that Palliative Care focuses on relieving patients’ symptoms and stress of at any stage (including curative) of a life-limiting illness to improve the quality of life for both patients and their families (1). Palliative Care is not restricted to the end of life (2). Great progress has also been made with Advance Care Planning, which involves discussing and documenting patients’ health-care and end-of-life wishes (3,4).

However, there are still many issues that need to be addressed in the health care system to prevent more “bad” deaths like this. Why is the Emergency Room the only option for patients like M in the middle of the night? Well, it actually isn’t, but it appears to be the most common knee-jerk reaction to go to the Emergency Room when patients don’t know what else to do. This occurs even when there is Palliative Home Care in place for a patient, and a 24-hour phone number is given to the patients to ask questions or express a concern. In an ideal world, this phone call would lead to either reassurance over the phone, or a fairly immediate visit by the Palliative Care Nurse to help address the problem in person. The Palliative Care nurses that I work with are all wonderful, but there are usually only a handful of nurses available for an ENTIRE urban Canadian city, and its outlying areas, at any given time. The system is simply not able to have enough home care nurses available to go to every home to assess every call that is received at all hours of the day and night. In times of great stress and panic, however, many patients and their families need to be helped in person, not over the phone. In an ideal world, each of these patients at home with a terminal illness would have a Palliative Home Care nurse and a family physician who knowsthe patient and family, and are available 24/7 to be called upon, given that most Palliative Care is delivered by family medicine in Canada (5). But, this too is an unrealistic and unsustainable expectation.

An ideal world is not possible. But a better world and system could be made possible.

Society expects that babies will be born at all hours of the night. Kitchen table conversations around the world talk about birth stories and often start with “in the middle of the night….”. People everywhere read and discuss some variation of a “prepare for your baby’s birth” book out there and those who have not have been regaled with numerous stories and tips about what to expect and what to do, often unsolicited by friends, family and strangers alike. When a woman has a pregnancy-related concern in the middle of the night, she knows who to call, and where to go for care. In most larger communities, this place is the local Labour and Delivery ward, where healthcare teams are available in hospital overnight to help achieve the universal end goal of a healthy delivery for both baby and mom. My point is that most do plan extensively and prearrange for someone to be available to help them deliver his/her baby according to his/her wishes, otherwise known as “The Birth Plan”.

We as a society put so much discussion, planning and arranging into a person’s entrance into this world. Why does society not do the same for a person’s exit from this world? Both are guaranteed. We as a society so willingly share and hear from the experiences of others regarding birth, but not death. Why not?

Death is absolutely a scary thing to think and talk about. However, I’ve seen too many times that NOT talking about or planning for death can be even worseWe need doctors and healthcare teams to be better trained to talk about this in a culturally-sensitive and appropriate manner with patients (5), and we need society to be more open to discussing this as a way to make more deaths, however inevitable or unavoidable, better for the patient and loved ones.

Even with increased discussions and planning beforehand, there also needs to be more in place to support dying patients away from the hospital. Perhaps if the healthcare system was able to better support after-hours Palliative Care and End-of-Life care for a large capacity of patients outside of the Emergency Rooms, intensive care units and/or acute care hospitals, the public wouldn’t feel as though assisted dying is the only option when faced with a terminal diagnosis. My clinical experience has shown that most patients with a limited prognosis want to live longer, rather than die sooner, but would like to be as comfortable as possible in as home-like a place as possible, be it home, hospice or a long-term care facility. Supporting end-of-life care more effectively will even save health care dollars by keeping patients out of the acute care hospital beds, which would be an added benefit, rather than the primary intended goal.

Why isn’t there a designated urgent access facility for patients who are known to be dying to directly go to, if they are too overwhelmed at home when the time comes? The closest to this that I have seen has been in small rural hospitals where dying patients are moved out of the Emergency Department quickly to one of the few designated rooms in the small hospital reserved for dying patients. Why don’t we have, in larger hospitals, a parallel ward to the Labour and Delivery ward that would have the capacity to assess Palliative Care patients for a sudden unmanageable increase in their pain, or a sudden onset of confusion, nausea or shortness of breath if they can’t manage at home? They could be treated by a team focused on appropriate goal-oriented comfort care, including social workers, pastoral care, nurses, nurse practitioners, doctors, respiratory therapists, and be managed along with the regular family physician’s on-call team in accordance to the patient’s overall wishes. Patients and their families could be stabilized (medically and/or emotionally) over a few hours and return back home after collaborating with their family physician, or if more care is required, then a transfer to hospice or another more suitable in-patient ward could be made. These decisions would all be made with the ultimate goal to provide as peaceful an “expected” death as can be made possible for the patient, and for his/her loved ones.

To be clear: this is not assisted dying, this is effective Palliative Care providing comfort and ease of suffering at the natural end-of-life of a terminal patient.

In Canada, we are more than halfway into the longest federal election campaign ever, and only in the last couple of days, has health care even been mentioned (6). Palliative and End-of-life Care needs to be a priority, not just for politicians, but for all Canadians. As Canada’s population ages, and is expected to have more than 25% of the population aged 65 years and older by 2036 (7), the system will only be increasingly stressed with more patients facing prolonged chronic diseases (8,9), and/or the terminal phase of their lives and illness. There is also the unfortunate reality that terminal illness does not only occur in the elderly population, and support for all patients facing a life-limiting illnesses needs to be maximized, including that of younger adults and children. While I am in full support for a cohesive national senior’s health plan as advocated by the Canadian Medical Association and supported by the Canadian public (10,11), I believe that there also needs to be a related, but different discussion on a national Palliative Care and End-of-Life delivery plan that better serves the needs of not only the dying patients, but of the patient’s loved ones who are left picking up the pieces after the death of the patient. Their health and well-being after death is directly affected by their loved ones’ death and could have even longer term consequences on society and our health-care system with post-traumatic stress, or prolonged grief, depression or anxiety (12,13,14).

I do not have all the answers for all these questions that I ask, but I think we need to be asking more of these questions and trying to find some answers, in order to find a better way. I just hope that others will also ask themselves these questions, and want to help create a better way that will allow for more good deaths. This way, hopefully patient’s death stories like that of M’s above are more the rare exception rather than the all too common occurrence that is unfortunately currently happening.

*Details of the patient, M, (including name, demographics and disease state) were deliberately changed to protect patient anonymity and confidentiality.


References:

1. Center to Advance Palliative Care. What is Palliative Care. New York, NY Centre to Advance Palliative Care, 2012. Available from:https://getpalliativecare.org/whatis/ Accessed 2015 Sept 15

2. Canadian Hospice Palliative Care Association. FAQS: Definition of Palliative Care? Ottawa ON. Canadian Hospice Palliative Care Association, 2015. Available from [http://www.chpca.net/family-caregivers/faqs.aspx] Accessed 2015 Sept 15

3. Alberta Health Services. Advance Care Planning: Conversations Matter. Edmonton AB Alberta Health Services, 2015. Available from: [Conversationsmatter.ca] Accessed 2015 Sept 15

4. Canadian Hospice Palliative Care Association. Speak Up- Advance Care Planning in Canada. Ottawa, ON Canadian Hospice Palliative Care Association, 2015. Available from [www.advancecareplanning.ca] Accessed 2015 Sept 15

5. Shadd JD, Burge F, Stajduhar KI, Cohen SR, Kelley ML, Pesut B. Defining and measuring a palliative approach in primary care. Can Fam Physician2013;59:1149–50. (Eng), 1156–7 (Fr).

6. Bailey I. Mulcair continues health-care push. The Globe and Mail. (2015, September 14). Available from: [http://www.theglobeandmail.com/news/politics/mulcair-promises-500-million-for-clinics-health-workers/article26356275/] Accessed 2015 Sept 15

7. Canadian Hospice Palliative Care Association. Fact sheet: hospice palliative care in Canada. Ottawa, ON: Canadian Hospice Palliative Care Association; 2014. Available from:www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. Accessed 2015 Sept 15.

8. Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa ON Canadian Hospice Palliative Care Association, 2014. Available from [http://publications.gc.ca/collections/collection_2014/statcan/82-624-x/82-624-x2014001-2-eng.pdf] Accessed 2015 Sept 15.

9. Public Health Agency of Canada. Health-Adjusted Life Expectancy in Canada: 2012. Ottawa ON. Her Majesty the Queen in Right of Canada, 2012. Available from: [http://publications.gc.ca/collections/collection_2012/aspc-phac/HP35-32-2012-eng.pdf] Accessed 2015 Sept 15.

10. Picard A. Canadian Medical Association urges health-care strategy for seniors. The Globe and Mail. (2015, August 24). Available from:[http://www.theglobeandmail.com/news/national/canadian-medical-association-urges-health-care-strategy-for-seniors/article26087150/] Accessed 2015 Sept 15

11. Canadian Medical Association. CMA National Report Card 2015. Ottawa ON. Canadian Medical Association. Available from: [https://www.cma.ca/En/Lists/Medias/cma-national-report-card-2015.pdf?hootPostID=73c32759e704b8d68de4624a9491eafa] Accessed 2015 Sept 15.

12. Kirchhoff KT, et al: The vortex: families’ experiences with death in the intensive care unit. Am J Crit Care 2002, 11(3):200–209.

13. Carr D: A “good death” for whom? Quality of spouse’s death and psychological distress among older widowed persons. J Health Soc Behav2003, 44(2):215–232.

14. Wright AA, et al: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008, 300(14):1665–1673.

​Choosing diagnostic tests wisely: Doing the little things well

* RESEARCH FIRST LOOK *

There was such a wonderful response to the Choosing Surgery Wisely paper from Dr Roland Grad and medical students Nicholas Meti and Mathieu Rousseau, that they have submitted another!

 Dr Grad's poster at PODC2015

Dr Grad's poster at PODC2015

You may remember Dr Grad, a family physician and researcher at McGill University, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign, which he also presented at the Preventing Overdiagnosis conference this year (PODC2015). [click to view the more recent poster in PDF format]

Again, Rousseau and Meti worked with Dr Grad to extend this work and look at InfoPOEMs that dealt with three topics in diagnostic testing: stable TSH measurements, screening mammography, and mid-stream urine collection. Guided by clinical questions pertaining to these topics and the best available evidence, they make a clear case that we need to choose very wisely when considering 'routine' testing. There are some apt qualitative insights provided by physicians reflecting on the practice-changing POEMs (Patient-Oriented Evidence that Matters) included in this research, which will undoubtedly help it to resonate with readers.

Please feel free to leave questions or comments below or contact the authors directly. If you would like to submit a guest-post for consideration, email lessismoremedicine@gmail.com.


Choosing diagnostic tests wisely: Doing the little things well

Rousseau, M., Meti, N., Grad, R. Faculty of Medicine, McGill University, Montreal, Canada.
 

Introduction
 

As clinicians, do we challenge the appropriateness of our diagnostic test ordering? To achieve shared decision-making in health care, it is up to clinicians to communicate both the harms (as well as the benefits) of diagnostic testing. Within the concept of shared-decision making, there are three core practices: 1) Identifying that a decision must be made; 2) Communicating the potential benefits and harms of options to patients; and 3) Incorporating what is important to patients within the decision. The latter may require us to consider other questions: What would be the impact of this test on the patient’s quality of life? What about the interval between follow-up tests? What is the impact on the economy when diagnostic tests and follow-ups are considered at scale? When clinicians think about ordering a test (or not), we suspect their decision is based on “routines” and “experience”. The point of this post is not to argue against the “art of medicine”, but to raise awareness of new research that can inform decisions about diagnostic testing.

In this post, we highlight the findings of three recent diagnostic test studies. Study findings were disseminated to Canadian physicians as ‘POEMs’. For those unfamiliar with this acronym, POEMs are tailored synopses of primary research or systematic reviews, selected in a process that involves searching over 100 journals. [1] Since 2005, the Canadian Medical Association (CMA) delivers one POEM to their members by email on weekdays. As described in a prior guest post (Choosing Surgery Wisely), we identified the following POEMs by analyzing the ratings of all daily POEMs (n=255) collected from physician members of the CMA in 2014.
 

CLINICAL QUESTION: “How much do seemingly stable thyroid tests vary over time? / POEM Title: Stable TSH can be rechecked in 2 years”

In a cohort study, the authors asked how frequently do patients with treated hypothyroidism need to have their TSH measured. [2] From a sample size of over 700 persons treated with levothyroxine, they were able to identify a subgroup that would benefit from less frequent TSH monitoring based on their dose of levothyroxine. They report that patients receiving less than 125 micrograms per day could have their TSH rechecked in two years instead of annually. Importantly, this study highlights that once TSH has normalized, the frequency of subsequent monitoring can be stratified based on dosing.

Monitoring frequency is a relevant issue in the clinic setting. In the absence of evidence, many clinicians assume default rates for all manner of diagnostic test and treatment plans. We read the free-text comments submitted by CMA physicians about this POEM. Some of these physicians expressed surprise at the association between dose and frequency of monitoring. Others reported the following: had they known about this approach, they would have spread out the visits for their healthier patients. This would save time and provide costs savings for the healthcare system. Although not addressed by this study, one physician even raised the question of whether we need to be checking TSH levels at all in an asymptomatic patient.

 

CLINICAL QUESTION: “What are the trade-offs of benefits and harms for women considering a mammogram to screen for breast cancer? / POEM Title: Numbers to help women understand the benefits/ harms of screening mammography”

Welch et al. believe primary care physicians should have more balanced discussions with their patients about the benefits and harms of screening mammography. [3] Their premise is that the majority of discussions focus on the possibility of avoiding death from breast cancer, and do not include a discussion of false alarms nor overdiagnosis. The authors used currently available data from trials of screening mammography to give a range of estimates for harms and benefits with the hope that this information would help decisions about screening. Their results are summarized in this table. Note that the numbers are per-one-thousand women, screened yearly for 10 years:

Figure 1: Estimates of harms and benefits of screening mammography

We received mixed feedback from physicians who read this POEM. Some physicians were grateful to have empiric data to help them in their discussions with patients. One wrote it is “helpful to have the actual numbers presented in such a way that I can share info with the patient when discussing mammograms and screening - always easier when there are numbers that we can look at”, and these numbers “make discussion around breast cancer more objective”. However, others wrote that even though “it is much easier to communicate this information to a patient by simply selecting the age group she falls into, and presenting the numbers for that group [...], I have not yet had a patient who didn't just simply choose the mammogram”. It seems that numbers do not tell the entire story… “because this is an emotional issue, most women we counsel opt for the regular screening”.

The importance of this topic to primary care is high, because as one CMA member wrote “the harms of false positives are seen first-hand in primary care”.
 

CLINICAL QUESTION: “How accurately does a midstream urine culture predict the results of a catheterized urine culture? POEM Title: Interpretation of midstream urine cultures in healthy young women with suspected UTI”

What about the practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture? In a diagnostic test evaluation study, midstream urine cultures with any evidence of E. coli or K. pneumoniae strongly suggested a true infection, while the presence of enterococci or group B streptococci had little predictive value. [4]

Feedback from physicians who read this POEM showed appreciation for the findings and included comments such as this one: “As a walk-in clinic doctor, urinary symptoms are a very common reason for visits. I routinely treat women on spec for these UTI's and don't send their urine for culture unless it is a complicated UTI, the patient has significant comorbidities, or the patient has recently been on antibiotics.”

The practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture was recommended in a recent review by Grigoryan et al. [5] Her group reviewed the optimal approach for treating acute cystitis in young healthy women and analyzed studies totalling 259 397 patients. This showed that “immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone”.

This choosing-wisely-approach to a common infection was perfectly summarized in this comment submitted by another physician: “great info [in this POEM]. Sometimes we just do too much testing”.
 

Conclusion
 

As we reflect on all this, we see that even if one test “can’t hurt”, at scale the impact can be large for publicly funded health care systems. This point has been made by others. For example, Kale et al showed how “routine” diagnostics tests cost large sums of money. [6] Primary health care faces a big challenge in reconsidering how diagnostic testing is used, to ensure better value for all.
 

References
 

1. Grad RM, Pluye P, Tang DL, Shulha M, Slawson DC, Shaughnessy AF. 'POEMs’ suggest potential clinical topics for the Choosing Wisely Campaign. Journal of the American Board of Family Medicine 2015;28:184-189. http://www.jabfm.org/content/28/2/184

2. Pecina J, Garrison GM, Bernard ME. Levothyroxine dosage is associated with stability of thyroid-stimulating hormone values. Am J Med 2014;127(3):240-245 http://www.amjmed.com/article/S0002-9343(13)01021-8/abstract

3. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014; Dec 30 http://archinte.jamanetwork.com/article.aspx?articleid=1792915

4. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013;369(20):1883-1891 http://www.nejm.org/doi/full/10.1056/NEJMoa1302186

5. Grigoryan L, Trautner BW, Gupta K. Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting. JAMA. 2014;312(16):1677-1684. http://jama.jamanetwork.com/article.aspx?articleid=1917443

6. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med 2011;171(20):1856-1858

Choosing surgery wisely: the importance of evidence-based practice

* RESEARCH FIRST LOOK *

Very little research has been done so far in the area of appropriateness in health care, so it is is always a delight to see what is being worked on.

You may remember Roland Grad, a family physician and research at the University of McGill, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign.

Two ambitious McGill medical students, Nicholas Meti and Mathieu Rousseau, worked with Dr Grad to extend that work and look at InfoPOEMs that dealt specifically with surgical interventions which are considered unnecessary or harmful to patients.

Many agree that there's room for the Choosing Wisely campaign to improve; this research presents a potentially fruitful way to do so, particularly for the orthopaedics recommendations which have been heavily criticized to date.


Choosing surgery wisely: the importance of evidence-based practice

Meti, N., Rousseau, M., Grad, R. Medicine, McGill University, Montreal, Canada.

An emerging trend among physician organizations is to attempt to control or reduce the rate of unnecessary medical tests and treatments. Until recently, the principle manner to release updated recommendations for practice was through meetings where experts discussed which tests or treatments needed to be questioned.  

We developed a novel means of analyzing nascent research articles for their applicability towards improving the “Choosing Wisely” topic selection process [1]. This method is based on analyzing the ratings of daily POEMs, collected from physician members of the CMA. POEMs are tailored synopses of primary research or systematic reviews, selected by searching over 100 journals. POEMs are delivered to over 20,000 members of the Canadian Medical Association (CMA) by email on weekdays.

At the 2015 ‘Preventing Overdiagnosis’ conference, one of us (RG) will report on the top POEMs of 2014, as rated by CMA members with respect to their potential to help them to ‘avoid an unnecessary diagnostic test or treatment’ [1]. Of the topics addressed by these top 20 POEMs of 2014, only 2 were discussed in the Choosing Wisely master list of recommendations. Of the remaining 18 topics, three were related to surgical interventions; we highlight their important findings.

In a study published in The Bone and Joint Journal, Kukkonen et al. used the Constant Shoulder Score to show that among patients with symptomatic non-traumatic supraspinatus tears, physiotherapy alone is as effective as physiotherapy combined with acromioplasty after 1-year follow up [2].

In a study published in the New England Journal of Medicine, Sihvoven et al. investigated whether arthroscopic surgery would improve outcomes for select patients with a degenerative tear of the medial meniscus. The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial involving patients without knee osteoarthritis, but with symptoms of a degenerative medial meniscus tear. Surgery was found to be ineffective for non-traumatic partial medial meniscus tears [3].

A study published in JAMA by Primrose et al. [4] questioned the routine practice of intensive follow-up after surgery for colorectal cancer, as there existed no evidence to support this common practice. In a randomized controlled trial, 1,202 participants were assigned to 4 groups: CEA only, CT only, CEA+CT, or minimum follow-up. Their results demonstrated that among patients who had undergone curative surgery for primary colorectal cancer: 1) intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent, compared with minimal follow-up; 2) there was no advantage in combining CEA and CT; and 3) there was no statistically significant survival advantage to any strategy.

One concern about the development of top five lists in Choosing Wisely is the potential for individual specialties to choose the low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included no major surgical procedures in their top 5 list, despite evidence of wide variation in elective knee replacement and arthroscopy rates [5]. This observation is not meant to be a criticism of orthopedic surgeons per se, as many surgeons are strong advocates for their patients (see http://www.thepatientfirst.org). [Less is More readers will remember one of the founders, Dr James Rickert, from What Can Patients Do in the Face of Physician Conflict of Interest]

Our point is to drive home the underlying philosophy of the “Choosing Wisely” campaign: ‘routine’ testing or treatment without evidence-based support can be found insidiously entrenched in all disciplines.


References

1. Grad RM, Pluye P, Shulha M, Tang DL. POEMs Reveal Candidate Clinical Topics for the Choosing Wisely Campaign. Preventing Overdiagnosis Conference, Bethesda, MD, September 2015.

2. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014; 96(1):75-81.  
http://www.ncbi.nlm.nih.gov/pubmed/24395315

3. Sihvonen R, Paavola M, Malmivaara A, et al., for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26):2515-2524.    http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

4. Primrose JN, Perera R, Gray A, et al., for the FACS Trial Investigators. Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer. The FACS randomized clinical trial. JAMA 2014; 311(3): 263-270. 
http://www.ncbi.nlm.nih.gov/pubmed/24430319

5. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value service. N Engl J Med 2014; 370:589-92. 
http://www.nejm.org/doi/full/10.1056/NEJMp1314965