VIDEO: #ChoosingWisely in Cypress Health Region

Since 2015, The Saskatchewan Health Quality Council has been moving forward the very important agenda of Appropriateness of Care.

 

In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

The Cypress Health Region has demonstrated their commitment to Choose Wisely:

Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

Source: https://www.youtube.com/watch?v=gkqKRYpKbQ...

A national discussion on unnecessary care #ChoosingWisely #Canada

I am sharing this in case it has not made the rounds. The Canadian Institute for Health Information (CIHI)/Choosing Wisely Canada (CWC) report, Unnecessary Care in Canada, should be available in April. In the meantime you can read briefly about CIHI's role with CWChere.

(Original post)


A National Discussion: Unnecessary Care in Canada

The Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) invite you to join us for a discussion on the extent of unnecessary care in Canada.

This webinar will introduce a new CIHI/CWC report, Unnecessary Care in Canada, and facilitate a conversation about the magnitude of and variation in unnecessary care across several areas covered by CWC’s recommendations.

The event will include

  • A moderated panel discussion with:
    • David O’Toole, President and CEO, CIHI;
    • Dr. Wendy Levinson, Chair and Co-Founder, CWC; and
    • Dr. Laurent Marcoux, President-Elect, Canadian Medical Association
  • Speakers from the Canadian Partnership Against Cancer, North York General Hospital and other organizations, who will share their success stories about addressing unnecessary care
  • Q & A session

Date: April 6, 2017
Time: 9 to 10:30 a.m. ET

Please note that this webinar will be conducted in English only and will use Eastern Time. To accommodate multiple time zones, a recorded copy of the webinar will be made available. When you register, please specify if you would like the recorded version.

Registration: To participate, you must have access to the internet, as well as speakers/headphones. The webinar will be accessible on iOS and Android devices (both mobile phones and tablets).

To register for the webinar, please email Alison Clement at aclement@cihi.ca

DON'Ts for Long Term Care Patients: #ChoosingWisely Canada

I have been a serious fan and also a concerned critic of Choosing Wisely Canada (CWC) over the years. Overall the campaign is excellent, encouraging conversations between patients and providers to help prevent harmful and unnecessary tests, treatments, and procedures.

While I love the new emphasis on the high-level message "More is not always better," my feelings have always been lukewarm on the lists of Choosing Wisely Canada (CWC) recommendations, created by (mostly) physician associations not by Choosing Wisely Canada, as they vary in strength, currency, and courage. For example, the CAEP (Emergency physicians) list is quite clear, direct, and practice changing. The Orthopedics list is irrelevant, and not wisely chosen at all, lacking the moral fortitude to tackle common, high-paying procedures that have limited/no evidence to support them.

The most recent lists reinvigorate my interest! It is exciting to see a list from the Canadian Nurses Association (CNA), as nurses have an incredible role in advocating for patients and in helping patients make decisions. Hospital-based nurses usually know their patients well and might even have a better sense of their goals and needs than would a physician; a nurse's advice can easily sway a patient to see "too much" medicine, but it can equally reassure that patient that a test or other intervention may not be right for them.

Image from unknown source on twitter; quote from an interview with the  Centre for Advancing Health

Image from unknown source on twitter; quote from an interview with the Centre for Advancing Health

Because most mornings I work in a program that is designed to help frail elders avoid unnecessary/ unwanted admissions to hospital, the Choosing Wisely list for Long Term Care (LTC) is extremely relevant to my practice. #1 (see below) resonates particularly with me, so I'm glad to see it is the first on the list. I see countless patients who could (and should) be looked after in their full-care facility but unfortunately they have turned up at the hospital. There are a number of reasons this happens, including the inability of the facility to contact the GP or the GP's inability to attend the patient in an urgent fashion, the family's 'insistence' that the patient be "checked out" at the hospital, a lack of clarity on the patient's goals, unclear understanding of the natural history of their disease, insufficient staffing at the care facility, etc. And sometimes these patients really do need to be at the hospital.

We clearly have a lot to learn both in how we communicate and in how we approach care for patients in long term care. This list is a great addition to the tool kit that might help us give LTC patients the right care for them:

  1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

  2. Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia. 

  3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

  4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 

  5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 

  6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
     

See the list here or download the PDF.

Source: http://choosingwiselycanada.org/recommenda...

Choosing Wisely Canada Talks

Earlier this month, I participated in a Choosing Wisely Canada Talks webinar. Drs Kimberly Wintemute and Anthony Train shared insights around a clinician's professional obligations and led a discussion around practical tips for having conversations with patients in these scenarios. You can see their talk and others in the Choosing Wisely Canada Talks series online.

This primary care discussion was incredibly relevant, and we covered a few tough topics including:

  1. A healthy patient requesting non-indicated screening blood work
  2. A patient requesting unnecessary imaging eg. MRI for lower back pain
  3. When a naturopath has told patient to ask MD to order a series of blood work
  4. A patient with a viral infection insisting on antibiotics
  5. Chronic use of sedatives/hypnotics including benzodiazepines in an older patient

It was great to have a mixture of people, including a patient voice, in the webinar. Some of the themes that emerged were around building a trusting relationship, exploring the patient's fears or goals and addressing those, having a discussion about risks vs benefits, using analogies/humour to convey a message, and using physical exam and other techniques to reassure patients.


"Choosing Wisely Talks take place on the 1st Thursday of every month from 12pm-1pm ET. Each workshop is led by an inspiring guest speaker, usually someone who has made significant gains in implementing the Choosing Wisely recommendations. Through a webinar format, participants tune-in to a live presentation by the guest speaker, followed by an interactive Q&A discussion. Participants usually leave each workshop with:

  • A greater appreciation for the impact of overuse
  • Ideas and inspiration for their own Choosing Wisely implementation project
  • A better grasp on potential barriers and opportunities to successful implementation"

 

Go to the website and use the right-hand menu to add these valuable events to your calendar or sign up for the newsletter. The next session is November 3rd from 12-1PM Eastern Time.

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!

Toolkits from Choosing Wisely Canada

At the Choosing Wisely national meeting March 30th, Choosing Wisely Canada (CWC) announced a new direction.

In lieu of the 10 million challenge, they are instead putting significant effort into empowering CWC enthusiasts by way of facilitating "DIY Toolkits."

These tool-kits are PDF documents, starting with a catchy title and cover art (provided by CWC), and filled with user-generated content, meant to enable you to apply some of the Choosing Wisely recommendations to your institution or practice. So far, the topics include reducing unnecessary indwelling (Foley) catheter use, proton-pump inhibitor prescriptions, 2nd units of red blood cell transfusions, pre-operative investigation, and sedative/hypnotic use in the elderly.

Click on the image below to check out the first 5 or go to the page to learn how to submit your own:

Source: http://www.choosingwiselycanada.org/in-act...

Patient-Friendly Portal for Choosing Wisely Canada

Choosing Wisely Canada (CWC) has been on a roll lately with some exciting initiatives, including reaching out and empowering medical students to be leaders for change.

They've also just launched the patient-focussed part of the website, started ramping up the 10 million challenge, and upped the PR push to advocate for culture change with the slogan "More is not always better."

I love that the campaign is growing beyond creating lists about unnecessary and harmful tests and treatments, and blossoming into a strong organization that is beginning to tackle some of the drivers of overtesting and overtreating at the root of the problem.

I always worried that CWC wouldn't do enough "big picture" stuff, but I am so very glad to be proven wrong!

 

Check out the new patient portal or join the 10 million challenge, a Canada-wide collective action initiative to help prevent 10 million unnecessary tests and treatments by the year 2020. And, keep a close eye on Choosing Wisely Canada because I have a feeling there's a lot more to come!

Source: http://choosingwisely.ca/

MedStopper de-prescribing online app now live!

It is with great pleasure that I introduce: 

MedStopper 
 

Polypharmacy, the state of being on multiple (too many) medications, is an increasingly recognized problem. Though variably defined, everyone agrees that polypharmacy leads to dangerous consequences for patients, particularly in the elderly.

It is so much easier to start than to stop a medication. Now, there is help!

An incredible team, mostly from British Columbia, many of whom I'm had the pleasure of working with, have developed this superb resource. MedStopper is an online tool to help stop medications for patients.

Aimed at clinicians, this deprescribing aid allows you to created a medication list, suggests which medications need to be stopped first, and advises the safest way to go about stopping them. 

Screen Shot 2015-09-19 at 12.50.18 PM.png

Smiley/frowny faces show you the extent to which the medicine: may improve symptoms, may reduce risk for future illness, and may cause harm. If the patient is considered frail, the recommendations are adjusted accordingly.

The tool is a synthesis of many things, so you can view the Beers/STOPP criteria, the NNT or a risk/benefit calculator if available, and print out the plan if you desire.

Not sure if you (or your patients) are on too many medications? Use the Rxisk questionnaire.

Try out MedStopper today and be sure to use the feedback section to let the team know if there are any glitches or errors.

Congratulations to the group on creating this hands-on, easy to use, and practice changing tool. 

Source: http://medstopper.com/

Focus on Choosing Wisely Canada from CMAJ

Choosing Wisely Canada and the Canadian Medical Association Journal (CMAJ) have teamed up to create this excellent digital book. It includes background information on the campaign and why it exists, practice cases which highlight unnecessary or harmful tests & treatments, and guidance on five clinical topics. There are also true or false questions that test your knowledge about which medical interventions are warranted.

This digital book is a really cool way to get familiar with the campaign and might be a fantastic manual for teaching. Have a look:

Source: http://viewer.zmags.com/publication/d5b8a5...

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