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...

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-...

End of Guidelines (Video parody by James McCormack feat. ZDoggMD + friends)

James McCormack (@medmyths, BS Medicine Podcast) does it again!

Clinical Practice Guidelines must change! This is the end of guidelines as we know them.

Yes that is me and Gilbert Welch on the same screen. For realz!

Yes that is me and Gilbert Welch on the same screen. For realz!

We need patient centred care, including discussion of the values of the patient, the harms of intervention, and alternative options. Right now we have a bunch of arbitrary target numbers for treatment that medicalize normal people. These guidelines are mired in conflict of interest as the majority of guideline-authors having egregious conflicts of interest with industry. 

It's time to fix this! I'm honoured to be a part of this effort and call for action. It was awesome fuel for my imposter syndrome being asked to be in one of James' videos alongside some of my 'preventing overdiagnosis' heroes, not to mention ZDoggMD (whose videos I have followed for ages, probably since Hard Doc Life). The video features such like-minded pals including but not limited to: Gilbert Welch, Tim Caulfield, Iona Heath, Victor Montori, Richard Lehman and yep, yours truly - "it's just common sense!"

See for yourself and share widely:

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

A New Kind of Rounds: Type 2 Diabetes in the Elderly CME

Thanks to my local Division of Family Practice and the Practice Support Program (PSP), we were able to put together "A New Kind of Rounds" event all about helping patients find the right amount of medicine. 

Our first event, focussed on Type 2 Diabetes in the Elderly, and specifically the harms of treating this too aggressively. Inspired by the Lown Institute's RightCare Rounds and the DoNoHarm Project, we started with patient cases in which the patient's perspective highlighted the burden of treatment and the potential harms of too much medicine.

After small-group case learning, I presented a didactic session reviewing the unique factors that change our approach to management in the elderly, the best available evidence on diagnosis and treatment targets, the current guidelines, and some resources that clinicians and patients can refer to in order to make shared decisions about the "right amount" of care.

The event was well-attended and it was heartwarming to see the level of engagement on this topic from clinicians in our community; we are reviewing the evaluations to consider some changes to the format. Participants also generated an amazing of possible topics for future events, from hypertension to cancer-screening, and anti-psychotic use in the elderly to the annual physical. 

The slides are available here.

Your feedback is most welcome. You can comment below or e-mail. 

My other lectures can be viewed here.

Source: http://prezi.com/ln78vzbqpu4-/?utm_campaig...

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

Cervical Collars in Trauma? Rethink that!

We take a lot of things for granted.

So much that we do in medicine is "just what we were taught." It is set in stone, it is the way we've always done it because it makes sense and to do otherwise would be wrong, dangerous, or crazy.

There is strong inertia in health care and it can take ages before we question our assumptions; when we do, and we find our assumptions are incorrect, again it takes ages before we accept and employ the updated approach. 

Let me rock your world:

Original graphic by  @skimightythings . This appeared in the Scancrit blog post and I could not help but share it here!

Original graphic by @skimightythings. This appeared in the Scancrit blog post and I could not help but share it here!


The International Liaison Committee on Resuscitation (ILCOR) reviewed this question: "Among adults and children with suspected traumatic cervical spinal injury (P), does spinal motion restriction (I), compared with no spinal motion restriction (C), change neurological injury, complications, overall mortality,  pain, patient comfort, movement of the spine, hospital length of stay (O)?"

The answer? 'No. Not really.' And, there's even a smidgeon of evidence that putting collars on people might harm them.

In line with what is being done in Norway already, this is the conclusion that ILCOR arrived at in in their draft guidelines:

We suggest against spinal motion restriction, defined as the reduction of or limitation of cervical spinal movement, by routine application of a cervical collar or bilateral sandbags (joined with 3-inch-wide cloth tape across the forehead) in comparison to no cervical spine restriction in adults and children with blunt suspected traumatic cervical spinal injury (weak recommendation, very low quality of evidence).
Values and preferences statement: Because of proven adverse effects in studies with injured patients, and evidence concerning a decrease in head movement only comes from studies with cadavers or healthy volunteers, benefits do not outweigh harms, and routine application of cervical collars is not recommended.

Thanks to @smooremd for sending this my way. Learn more in the Scancrit blog post.

Source: http://www.scancrit.com/2015/02/12/cervica...

A summary: How to prevent #overdiagnosis @SwissMedWkly

For anyone who is even remotely interested in the movement to prevent overdiagnosis, I suggest you check out this article, How to Prevent Overdiagnosis, in its entirety.

Dr Arnaud Chiolero et al. have provided a thorough overview of the causes of overdiagnosis, methods to estimate the frequency of overdiagnosis, and interventions to prevent overdiagnosis.

As a teaser, I present to you the summary tables from the article:

We all might argue about the exact contributors to overdiagnosis, but this list (based on a review of the literature) is pretty thorough. Fortunately there is hope to combat the problem, and some specific examples are given:

See the article or follow Dr Chiolero (@swissepi) on Twitter for more.

Source: http://www.smw.ch/content/smw-2015-14060/

Choosing Wisely: Five Things Nurses and Patients Should Question

Nurses are on the frontline of medicine. They know their patients well, support them through every moment of their stay in hospital, and are responsible for a lot of decisions that can help (or harm) patients. 

Since providing high-value and safe care is not just about decisions in the patient-physician encounter, the Choosing Wisely initiative have partnered with The American Academy of Nursing to create a list of 5 things Nurses and Patients should question: 

  1. Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first.
  2. Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
  3. Don’t use physical restraints with an older hospitalized patients
  4. Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it.
  5. Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.

Read in more detail at Choosing Wisely or see the PDF.

The American Academy of Nursing is not the only non-physician group to have their own list; the American Physical Therapy Association (APTA)  also has a list. In addition, there has been broad collaboration with representatives of the other professional roles in the health care team during the development of The Choosing Wisely campaign.

Many of the society lists were created with the involvement of multidisciplinary teams and patient groups, recognizing the fact that it's going to take engagement at all levels to make a meaningful change that is good for patients and good for our healthcare system.

Choosing Wisely Canda: Launch Today!

I can't tell you how excited I am that Choosing Wisely Canada is now live!

Their resources will make discussions between Canadian patients and healthcare providers far more appropriate. The ideas showcased here provide a place for starting a dialogue, inspire patients to ask "why" questions about care, and encourage physicians to think twice about testing and treatment options.

Explore Choosing Wisely Canada.

The first wave includes Top 5 "don't" lists for specialities such as cardiology, family practice, orthopedics, and more. These are evidence-informed guides suggesting avoidance of certain tests and treatments in specific contexts.

The message is not "never" but rather "think twice about," and beware that every test and treatment may bear risks and harms that make it the wrong choice for some patients.

Many of us welcome all the tools we can get for the Shared Decision Making (SDM) approach. This is just Wave 1, and lots more evidence-informed speciality lists will be released soon.

By way of disclosure, I'm a member of the Canadian Medical Association (CMA) and have been involved for just over a year with their work on Health Care Transformation. I was not directly a part of the development of Choosing Wisely. The CMA's role in this timely and important effort is a significant achievement in advocacy and health policy, and I couldn't be prouder to stand with them.