Taking Action on Overuse: A Framework for Change (for Health Orgs & Institutes)

It has been a while since I discovered any new organizations doing work on the topic of overdiagnosis and the related issues of overtesting and overtreating. Many different projects and initiatives explore the subject; some, like Choosing Wisely, make lists of 'do not do' recommendations. Others, like Minimally Disruptive Medicine provide thoughtful reflection and model practices to show us how to burden our patients less and engage them more. The Lown Institute and their Right Care Alliance work at many levels, be it in political advocacy, cultural change, or clinical education. 

The Right Care Alliance is sponsored by the Robert Wood Johnson Foundation, something it has in common with Taking Action on Overuse.  While the former is more directed at patients, clinicians, and policy-makers, Taking Action on Overuse is a group that seems devoted to supporting health organizations and institutions. Organizations interested in creating changes to provide fewer unnecessary or harmful tests, treatments, and procedures, can employ the tools Taking Action has created. 

In their words, "Taking Action on Overuse is an evolving framework for health care organizations to engage their care teams in reducing low-value, unnecessary care and make those efforts last. It identifies evidence-based strategies for obtaining buy-in, motivating behavior changes, and providing the necessary support and infrastructure for health care providers to engage and lead their peers in making the changes that improve the value of health care."

Their Assessment can help you figure out whether your institution is ready with best practices, and gently guide you there. Likewise, their Framework can help you create the right conditions for change in a climate where many still believe "more is always better."

Check out their website here to learn more.

Source: https://takingactiononoveruse.org/

The answer to everything wrong in health care

TOP Alberta has released a beautiful infographic Evidence Summary: The Benefits of Continuity in Primary Care, and the document also serves as an overview of the 112 publications they reviewed.

It speaks for itself. Maybe the title of this post is a bit grandiose, but as a shameful hypocrite [I have very little continuity in my clinical practice, something I'm working to remedy] I cannot underscore how important this idea is.

Every physician, nurse, administrator (yes, you!), health policy person, and their uncle needs to not only know this but act on it. Continuity is what we need.

It's not a fad. It's something that we used to have. And it has slowly been eroded, without too many people noticing, as we kept focussing on the newest technology and the latest pharmaceuticals as if they would solve everything.

In BC, the essential nature of continuity has been recognized particularly with the work of Marcus Hollander and was implemented in the GP for Me/Attachment Initiative. Unfortunately (some might dispute this), changing physician incentives to try to encourage more attachment hasn't made much of a difference for patients. So while we know that we need continuity, we don't know how to 'make' the system or the providers do it.

It's a perfect storm for patients: Can't find a GP, or if you can it's hard to build a relationship with them because they are so busy/unavailable/don't have enough time to spend with you; the GP doesn't know all the details of your care as pharmacists/naturopaths and others expand their scope and don't communicate with the GP; the medical records at the hospital or from the specialist in the other city don't link with those of the GP so no one knows what is going on; when a referral or requisition is sent, there is no confirmation that is was received so it might be that you are just waiting, or it might be that it has been lost and you will never hear back about the appointment; when a home care support worker or nurse comes, it is a different person each day and they don't know you or your needs, and they aren't allowed to do the things you need help with most.

Health care really is about caring for people, and how can we do this when we do not build robust and lasting relationships?

The review did not cover provider satisfaction but personally and in BC studies so far, physician satisfaction is improved by continuity with patients. However, this is not how most young graduates are practicing; Yet another great reason that we need to look more into this.

Is it too good to be true? Before we rush ahead and try to force the "magic pill" of continuity, we need to know more about why it's being eroded, and if we can save it, then how?

 

Source: http://www.topalbertadoctors.org/file/top-...

Is it worth it? The role of Health Technology Assessment (HTA) and using evidence with patients

"These are my people," I thought to myself on the long plane ride West, destined for home to a verdant explosion of nature after three days in snowy Ottawa. Maybe it was the season, but I think it was more the people around me that reignited my enthusiasm for change in health care.

In April, I was invited to Ottawa to be a part of the Canadian Agency for Drugs and Technologies in Health (CADTH) symposium closing plenary on the subject of Health Technology Assessment (HTA), a term that I had (embarrassingly!) not really heard of until receiving that invitation.

Despite feeling woefully out of place as a mere clinician, surrounded by successful policy analysts, clever researchers, health economists, and seasoned advocates, I had an incredible time. As I milled about taking in various presentations and getting my feet wet as part of a panel on Disinvestment, I found myself suddenly realize: everyone around me "gets" it.

What a gift: when you are asked to share your passion, say whatever you want to say, and know that the people listening are listening and nodding "yes" to some of the things that fall out of your mouth?

As I think more and more about how I can have a positive impact on the health and well-being of people, I think about the role of HTA in policy change, and about how evidence belongs to everyone. Being a bit camera-phobic I was reluctant to highlight this 8 minute video, but it was an honour that I do not wish to squander and I hope that some of what I said resonates with you too.

The 2017 CADTH Symposium is Apr 23-25, with the theme "Measuring Value in Theory and the Real World." If you are a student or patient group representative, you may be eligible for a travel scholarship. Check it out!

No benefit to locked mental health wards: 15yr study

A once 'sound' idea is now in question.

A 15-year study has concluded that there is no benefit in locking up many mentally ill patients.

Looking at about 350k cases, the researchers selected 145 738 cases, matched for propensity around suicide attempts. In open units, elopement and suicide attempts were less frequent than in locked units.

An open-door policy could be preferable for those with depression, anxiety or psychosis, as it promoted a better therapeutic atmosphere and more positive health outcomes

Even if this large study is imperfect, it gives us a perfect illustration that what seems sensible or logical does not necessarily result in the expected outcome. Although it makes sense that locking people up should not only help them stay put but also keep them safe,, that seems not to be the case.

Counterintuitive? Yes. But brains and bodies often do not conform to the rules of logic. This is in part due to the fact that we have only a superficial understanding of the complexity of our behaviours and physiology. 

How else are we hurting people when we think we are helping them? 

The full article is in Lancet Psychiatry

Source: http://www.radionz.co.nz/national/programm...

Dangerous Idea: Becoming a Squeaky Clean Doctor

Every year as part of the College of Family Physicians of Canada's Family Medicine Forum (FMF), there is a call for abstracts for the Dangerous Ideas Soapbox.

This is the part of the conference during which physicians can share radical ideas for change in primary care. Four abstracts are chosen and presented. The successful ideas are later published in the Canadian Family Physician; see 2015's Dangerous Ideas.

This year, Alan Cassels and I submitted an idea, suggesting physicians completely divorce from pharmaceutical/device industry influence, particularly in medical education.

The idea was quite a dangerous one, particularly surprisingly because the CFP has come under fire (including from Alan) for their own conflict-of interest as far as taking industry money to fund physician continuing education. See: It's time to examine pharma funding of doctors' education - Healthy Debate, and Drug companies wine and dine family physicians - Toronto Star.

Our submission was not successful in the application for the Dangerous Ideas Soapbox, but we share an expanded version of it here for your consideration. 


Our idea: We propose that general practitioners should swear off attending any lectures, CME events, workshops or conferences which are funded, even partly, by those companies and organizations with ties to pharmaceutical and device manufacturers. Even events where the presenters have at least one tie to a pharmaceutical company within the last five years, or is supported by an association that receives funding by the pharma or device industry (including patient and disease groups), would be avoided.  Clinicians and researchers who are working or consulting for, owning shares or patents in, or carrying out speaking engagements on behalf of industry would not be invited to present content to general practitioners. 

How will this work? Physicians’ colleges, professional associations, and university-based continuing education programs would eliminate their dependency on industry-funded speakers, conferences, dinners, workshops and talks. Over time, physicians’ groups would develop their own conference content, invite only independent speakers, and collaborate with organizations that have the capacity for education, without the industry influences. CME credit would not be provided for events in which industry conflict of interest is present. Physicians will have to seek out independent and ‘clean’ sources of information about new drugs and treatments and will more likely rely on independent reviews produced by groups like the Cochrane Collaboration, La Revue Prescrire, and Up-to-Date which all have strict policies around conflict of interest.

Why does this matter? This would drastically change the landscape of prescribing and lead to better and more appropriate treatment, in the best interests of patients and outside the influence of the pharmaceutical industry. Significant harm has been done to patients because of overzealous marketing, off-label endorsement, and the lobbying “machine” of industry which has developed a condition for every medication. Ultimately, with a divorce from industry-tainted education, physicians will increasingly favour treatments that are well-evidenced and most appropriate for the goals of care of their patients. This is likely to be be less costly for patients and the system, and would place increasing emphasis on non-drug alternatives. Also, the image of physicians as “pushers” or “in the pocket of the drug companies” would be reduced over time, enhancing trust from the public.

Why is this dangerous? Physicians have long been part of a system that has allowed the adverse effects of pharmaceutical and device marketing to influence prescribing and patient care. Physician organizations claim they cannot provide education without funding from industry; industry lobbyists argue that interaction with physicians is the only way patients can discover and reap the benefit of new innovations. Some physicians, naive to evidence to the contrary, believe that they are justified in accepting education, meals, and gifts because they (alone) are somehow immune to industry influence. A divorce from industry is not a popular idea, as evinced by the number of physicians and organizations that still feel it is ethical to incorporate this funding into medical education.

The current system is harming patients, but it can be stopped. Those physicians who are concerned that their patients perceive them to be shaped by drug marketing can become “Squeaky Clean” and wear that badge proudly.  

CMA General Council (#cmagc): A Success for Canadian Health Care

Advocacy and policy making is just one of the levels I am working at in order to improve health care for Canadians. Sometimes there are direct links to a "Less is More" approach. The Canadian Medical Association (CMA) calls this kind of topic "appropriateness." Although the CMA's annual meeting (General Council) this year only had a few ties to this way of thinking, a few readers have asked me about the event as a whole and so I share my reflections here:

It was an incredible General Council (GC) in Halifax, NS this August. I was able to participate as a Delegate for British Columbia and I cannot explain the feeling of immense purpose and privilege involved in voting on the policy and positions of the national organization of physicians; I was elated to be a part of the formation of some incredibly socially progressive resolutions that will have a real and positive impact on the health of Canadians. We resolved to divest our organization of investments in fossil fuels, to support the principal of a universal/national pharmacare program and a basic guaranteed minimum income, to encourage informed discussions around childhood vaccination in all school age children, and to endorse harm reduction strategies like a national guideline for naloxone availability (for opiate overdoses).

There was some outcry, understandably, from those who live in areas of the country whose economies depend almost entirely on the fossil fuel industry. They were out-voted. We cheered when we made the symbolic gesture – it was not a lot of money for our organization to re-invest in other industries. It was just an incredible statement for our organization to show that the health of the planet affects the health of its people, and we are willing to take the longer view.

The general assembly agreed to disagree on the exact details of how a patient would access physician-assisted death; council continued to extend the privilege of speaking to all attendees which allowed many conscientious objectors (observers, not official delegates) to express their concerns about participation in this, now legal, act. We all trusted in the process of consultation involving government, the public, the CMA (through various other channels besides GC), and other interested bodies (regulatory colleges, insurers, etc.) and will wait to see what this more broad process concludes as far as the exact process for physicians and patients.

It was all quite cordial, actually. The conscientious objectors were respectful and registered their concerns clearly. The voice of youth was loud and clear, with many young physicians and medical students participating as non-voting ambassadors, and a few of us resident and early career physicians voting as delegates. Our push for change was LOUD! The momentum built in the room and many of us felt like serious headway was made for our patients.

As ever, we heard: “you young people are what is ruining our society.” In person the meeting was quite pleasant but those physicians following online, especially on twitter, were outraged.

Mainly, it was those who opposed universal healthcare who were ashamed of what the CMA General Council had done. Everyone voting must be “left wing radicals” and “communists.” All the young people “lack the context” to create and endorse the correct resolutions. 

But, we were there, and we did it. Yes, many of the resolutions we made and voted in may never come to fruition this year. We don’t have unlimited time and finances as an organization and to be effective we must focus on a few narrow issues. However, it is still a big win for Canadians to be able to reference this groundbreaking policy. Setting precedent and having a public record of endorsement of an organization as respected as the CMA may be just enough to help grassroots initiatives get the edge they need to grow into persuasive bringers of change.

Thinking specifically about the “less is more” approach to health care, we also passed many resolutions to help strengthen palliative care programs to make them accessible for more people, and called for regulations around genetic testing/precision medicine and telemedicine [I was a Mover]; we warned that Canada cannot blaze forward with these technologies without consideration of the considerable risks they may pose for patients.

We also recommended that our National Senior’s Strategy and the policy paper "A Prescription for Optimal Prescribing" be updated to include a specific section addressing polypharmacy, which passed on the consent agenda [I was a seconder]. See the video of my colleague, Mover Ralph Jones, speaking briefly to this motion after we knew it had passed, with what I suspect is a nod to Johanna Trimble of IsYourMomOnDrugs? 

The CMA's incoming president for 2016-17 (our choice from BC), Dr Granger Avery, and our colleagues Drs Horvat and Routledge spoke to a disallowed motion that called for efficiency in our health care system. See their video here. Perhaps next year we can refine and submit more motions on appropriateness and efficiency? I have a few drafted already!

In a few narrow ways and in the broader sense, GC was a key step forward in advancing efforts for more appropriate health care. With a strong emphasis on addressing the real determinates of health, the solution of de-emphasizing tests and treatments that are harmful or not necessary also gains strength. Slowly, recognition for the importance of health in all policies is emerging. If a person cannot afford food, it doesn’t really matter if their dose of blood pressure medication is optimized. Right?

It feels fantastic to be a vocal part of an organization of 80 000 Canadian physicians that “get it.”

I love Healthcare Triage! VIDEO: Malpractice, Healthcare Costs, and Tort Reform

Dr Aaron Carroll (@aaronecarroll) & Co. are amazing!

Healthcare Triage (@HCTriage) has a YouTube channel that hosts a range of videos, most of which pertain to the "Less is More in Medicine" movement. The Less is More blog has featured their work before, 1) when Healthcare Triage did a video about Choosing Wisely, and 2) when Dr Carroll wrote Why Survival Rate Is Not the Best Way to Judge Cancer Spending for Upshot in the NY Times. In early June, they posted another great video, busting some major medico-legal myths.

One of the main excuses physicians make for ordering too many tests and treatments is that they have to practice defensive medicine. You must 'cover your ass' (CYA) to ensure nothing is missed, lest you face a horrible lawsuit. Physicians pay a ransom to malpractice insurance in order to help protect their reputation (and earnings) should a case come forward.

Many frivolous lawsuits exist and a lot of poor care is not legally pursued. Physicians think that tort reform will solve everything. Not so. Watch the video to learn more:

Source: https://www.youtube.com/watch?v=sK-E_d1MGt...

RightCare Action Week: Get involved (LOWN INSTITUTE)

The Lown Institute is an amazing American organization devoted to transforming health care; particularly, they believe that performing unnecessary medical tests and treatments is unethical and unacceptable, and have undertaken work to empower patients and health care providers to achieve "the right care."

I had the privilege of attending their Road to Right Care conference in March of this year, and I am pleased to be able to promote the following initiative: 

RightCare Action Week

RightCare Action Week is a grassroots initiative for clinicians and others who want to take action that demonstrates how much better our healthcare system can be. 

Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations.

From Oct. 18 to 24, 2015, people like you across the country will take action to show patients that we have not forgotten what good medical care is. Actions can be as simple as taking a deeper social history or doing a house call.

What can you do right now? Sign up for RCAW, vote on actions you’ll support from our growing list of possibilities, or suggest one of your own.

Here are some themes you should consider before suggesting an activity for either a single day of RCAW or the entire week.

Actions that:

·      Highlight the conflict between the healing culture and business culture

·      "Suspend business as usual" 

·      Connect patients to clinicians and clinicians to their colleagues to provide better care

·      Encourage clinicians to take as much time as needed with patients

RightCareActionWeek.org is designed so that anyone can suggest or discuss activities on the forum.

The only way to transform healthcare is if we present what better healthcare looks like. RCAW is our chance to do that. Sign up to join us now.

RCAW is an initiative of the RightCare Alliance. 

 

For more information email us at organize@lowninstitute.org or visit us at www.rightcareactionweek.org

Source: http://rightcareactionweek.org/

Choosing Wisely Canada: 3rd Wave of Reccomendations

Choosing Wisely Canada has released their 3rd wave of recommendations!

Groups like the Canadian Association of Emergency Physicians (CAEP), Canadian Society of Hospital Medicine (CSHM), three psychiatry groups (Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association) and three surgical groups (Canadian Spine Society, Canadian Society for Vascular Surgery) have all developed lists of the top things that patients and doctors should question. The Canadian Society for Transfusion Medicine also added 5 new recommendations. See the new recommendations here.

This round was particularly interesting for me as I got to witness the process of the development of the CSHM list and participate in some stages, though not extensively. It's a tough task, whittling down all the ideas to find well-evidenced items that represent key areas for improvement, and try to avoid duplication of other specialty society recommendations. The group has to consider that many things which are good ideas and really really important to tackle, may not be suitable as the evidence behind them may be vague.

For example, though we all felt that discussing 'goals of care' or advance directives and resuscitation statuses (eg. DNR) with patients is very important, there's little data about why/how/when this should happen and what impact it actually has on patient well-being. Should it be discussed by the hospitalist? The GP? On all admissions? Only when a patient's status changes?

Ultimately it was impossible to make a firm statement that was robustly rooted in evidence, though our 'gut' feeling was strongly that we need to be having these discussions and that patients and doctors both should be starting conversations on the subject.

Choosing Wisely, as ever, forms a great starting place for discussing overuse of harmful and unnecessary tests and treatments. Yes, some of the recommendations are 'low-hanging fruit' but we have to start somewhere, and Choosing Wisely is great at getting us started talking about the facts that "more is not always better" in medicine.

Source: http://www.choosingwisely.ca

Doctors warned not to encourage young women to freeze their eggs

Aging is a normal part of human existence.

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As we age, parts of our body change the way in which they work - or stop functioning all together. For women, natural aging means a slow down and then a stoppage in our ability to be fertile.

With women increasingly devoting the early part of their lives to establishing a career, many are delaying pregnancy. Some are freezing their eggs for later use. Physicians, employers, and society as a whole are starting to encourage this practice.

This is troubling in a few ways. Drs Petropanagos and colleagues write (in the CMAJ) that it raises some significant social implications, reinforcing that "motherhood is a central aspect of womanhood." 

Egg freezing as a way of preserving women’s reproductive options reinforces the social norms and expectations that construe motherhood as a central aspect of womanhood. Women are encouraged to freeze their eggs as a way to “have it all” (that is, to have both a family and a career), implying that for those women who want both these things, egg freezing makes this possible. Although individual women may benefit from egg freezing to satisfy their reproductive desires, physicians should not assume that having a genetically related child is equally important to all women who ask about social egg freezing.

Our bodies do things for a reason. Delaying pregnancy and then using frozen eggs exposes women (and their new children) to greater and greater risks, due to complications of pregnancy and childbirth. 

Fighting the natural changes makes aging a 'medical problem' rather than a part of our existence that we can embrace and accept. I agree with the authors' suggestion that there are better solutions, like funded child-care, that could enable women to really have a choice when it comes to balancing motherhood and a career.

Read the National post article here, or the original CMAJ article here.

Source: http://news.nationalpost.com/health/doctor...