Top POEMs of 2017 Consistent with Principles of the Choosing Wisely Campaign

Dr Roland Grad is back again with another persuasive publication regarding POEMs that align with principles of the Choosing Wisely campaign.

I find that infoPOEMs are a quick way to learn about new developments in practice and many of the topics align well with my interest in avoiding unnecessary and harmful care. Drs Grad and Bell have reviewed last year's POEMs with that lens, and their paper offers a great source of input for Choosing Wisely recommendations, as well as a launching point for changing your own practice.

Dr Grad will be presenting the poster at the Preventing Overdiagnosis 2018 conference in Copenhagen.

A POEM is a synopsis of a research study that reports patient-oriented outcomes, such as improvement in symptoms, quality of life, or mortality; is free of important methodologic bias; and recommends a change in practice for many physicians. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for physician-members of the Canadian Medical Association. . . . The recommendations cover musculoskeletal conditions (e.g., avoid arthroscopy for initial treatment of a meniscal tear), respiratory disease (e.g., avoid screening for lung cancer without informing your patient of the risk of a false-positive test result), infections (e.g., do not routinely add trimethoprim/sulfamethoxazole to cephalexin for nonpurulent uncomplicated cellulitis), and cardiovascular disease (e.g., do not prescribe niacin, alone or in combination with a statin, to prevent cardiovascular disease). These POEMs describe interventions whose benefits are not superior to other options, are sometimes more expensive, or put patients at increased risk of harm. Knowing more about these POEMs and their connection with the Choosing Wisely campaign will help clinicians and their patients engage in conversations that are better informed by high-quality evidence.

You can read the full publication here, in AFP.

Previous contribution from Dr Grad and colleagues to this blog can be found here:

 

VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...

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...

Wake up and smell the #overdiagnosis

Alan Cassels is not a shy kind of guy. He tells it like it is and is not one to stay quiet even if what he says may be unpopular. 

And usually it is pretty unpopular. 

However, it is necessary. From calling out the BC government's inaction on Choosing Wisely to fighting the overmedication of Canadian seniors and digging into the Sex, drugs, and rockin' beat of tramadol and tramacet's marketing machine, he is not afraid to talk about the elephants in the room, when it seems no one else is willing.

 

Cassels is a policy analyst, author, and champion debunker when it comes to pharmaceutical policy and the medicalization of Canadians.

In his most recent article for Focus Magazine, Cassels highlighted the Preventing Overdiagnosis conference, the harms of prostate cancer screening, and my perspective on the issues. 

I've had the chance to work with Cassels on a few small projects but to be called a 'resistor' by him feels like quite a pretty high honour! Check it out in Focus.

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.

New Choosing Wisely toolkit with patient handouts - Family Medicine, CFPC

The College of Family Physicians of Canada (CFPC) and its Patient Education Committee (PEC) are pleased to release a new Choosing Wisely Canada™ (CWC) toolkit. This innovative initiative is aimed at educating the public about anticipated changes in how family physicians approach health care prevention.  

Building on the success of the CWC campaign, the CFPC launched a whiteboard video titled Do More Screening Tests Lead to Better Health? This video was developed by the Dr. Mike Evans Lab group and focuses on a number of common screening tests: vitamin D malabsorption, mammography, thyroid testing, chest X-ray and electrocardiograms, Pap smears, dual-energy X-ray absorptiometry (DEXA), and annual physical exams.

The new CWC toolkit provides the following resources: 

Please see www.cfpc.ca/ChoosingWisely for more information, and if you want to see patient handouts and shared decision-making tools from other sources, check out the Less is More Hands On Tools page.

 

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...