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.

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-...

CONFERENCE: Hellish Decisions in Healthcare Jan 2017

Hellish Decisions in Healthcare is designed as a space for healthcare leaders, professionals and researchers within the international healthcare community to shape healthcare policy and systems to deliver Triple Value.

  • Personalised value, the delivery of services informed by what matters to the individual

  • Technical value, determined by how well resources are used within services for each purpose

  • Allocative value, determined by how the assets are allocated to services for different purposes.

The decisions and strategies needed to deliver Triple Value will not always be immediately apparent and nor will they be easy to make; the Value in Healthcare Forum is a safe place where these strategies can be developed and where strategic discussions can be had with the key thought and implementation leaders in healthcare.

Read more on the website and do Register by Oct 15 for the Early-Bird Discount.  The event will be in Oxford, Jan 12 to 13th, 2017.


For more events related to "Less is More," "Choosing Wisely," "Preventing Overdiagnosis," "Shared Decision-Making," etc, go here.

 

Source: https://www.phc.ox.ac.uk/events/hellish-de...

​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

Quaternary Prevention, P4

We still lack a unifying name, but initiatives like "Right Care," "Choosing Wisely," "Preventing Overdiagnosis," "Prudent Healthcare," and others all seek to describe, categorize, confront, or improve upon the status quo of what's being done: too much medical stuff and too little caring for people.

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    Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

 

Quaternary Prevention

You may have read lately about Quaternary Prevention (Prévention quaternaire) or P4, a major initiative of this movement. This – in the words of Ray Moynihan – "awkwardly titled" idea came originally from Dr Marc Jamoulle (@jamoulle), a Belgian GP, almost 30 years ago.

He coined the term "Quaternary Prevention" to describe 'an action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are ethically acceptable.' Essentially, it is a process that explicitly considers and thus enables avoidance of iatrogenic harm. 

"Quaternary prevention should take precedence over any alternative preventive, diagnostic and therapeutic, as dictated by the principle of primum non nocere." (Wikipedia)

P4

*NB*: Be careful not to confuse Jamoulle's term P4 with the more popular P4; predictive, preventive, personalized, and participatory (P4) medicine, with a focus on detecting and dealing with disease before it even exists, may (arguably) be the antithesis to Quaternary Prevention.

Jamoulle's idea came first, anyway. His original 1986 article Information and computerization in general practice (en français) started the discussion around quaternary prevention, with a particular focus on how information technology can dehumanize healthcare. He has refined the idea, with presentations at WONCA world conferences and many publications (listed here).

View Dr Jamoulle's page on Quaternary Prevention "P4" or read more

Although the cumbersome title will probably dissuade related initiatives from taking the name and falling under the umbrella of 'quaternary prevention,' we are all united in the spirit of our efforts. I remain in awe that Jamoulle and others had the wisdom to begin the discussion of harms of overdiagnosis in a time while mammography was just gaining momentum, ADD was rarely diagnosed and yet to be redefined as ADHD, and I was still in diapers.

Transforming Primary Care: Rx | The Quiet Revolution (DOCUMENTARY)

Thanks to Dr Dave Elpern (Cell2Soul) who shared this video, a 90-min PBS documentary, Rx: The Quiet Revolution.

In this inspiring 90-minute documentary, filmmaker David Grubin – the son of a general practitioner – takes his camera across America to focus on the challenges and triumphs in our country’s health care delivery system. The four segments that comprise Rx: The Quiet Revolution introduce us to a diverse group of doctors, nurses, and health care professionals who are transforming the way we receive our medical care: lowering costs by placing the patient at the center of their practice

Certainly the vignettes of Dr. Loxterkamp remind me of Vancouver's Home ViVE program and the kind of doctoring I aspire to. Likewise, the Nuka approach is something that could work beautifully for Nunavut, if and when the people are ready.

The film highlights four programs that are revolutionizing the way health care is delivered. What they all have in common is a patient-centred approach, remembering that people and relationships are at the heart of health:

 

- On Lok Lifeways Program for All-inclusive Care of the Elderly (PACE) program: "On Lok’s goal is to allow frail and elderly seniors with chronic illnesses or disabilities — who would normally require nursing home care — to live with dignity in their own home"

- The Seaport Community Health Center, where Dr Loxterkamp is re-inventing the patient's medical home: "Some of our patients miss the 'old-fashioned country doctor,' the one they could call whenever they needed to be seen– before the computer, before a team of assistants separated them from their doctor, and when they mattered more than their disease."

- Alaska's Southcentral Foundation which developed the Nuka System of Care: "This is a name given to the whole health care system created, managed, and owned by Alaska Native people to achieve physical, mental, emotional and spiritual wellness. Nuka is an Alaska Native word used for strong, giant structures and living things. The relationship-based Nuka System of Care is comprised of organizational strategies and processes; medical, behavioral, dental and traditional practices; and supporting infrastructure that work together - in relationship - to support wellness."

-  The Center for Telehealth at the University of Mississippi Medical Center: Their Diabetes Telehealth Network aims to "provide people with diabetes more consistent and timely access to clinicians through the use of telehealth technology in their homes"

 

The documentary can be seen online in its entirety here.

Source: http://rxfilm.org/

BCMJ: Measuring and improving quality of care in family practice

With about 400 articles on the subject of "Less is More" overdiagnosis, overtesting, overtreatment, undertreatment, etc. in my Instapaper queue, I figured I should start tackling them again with brief précis or reflective posts so that you can have the benefit of my curating.

I'll probably alternate between older foundational articles and new interesting stuff.

Today: a new article in the British Columbia Medical Journal (BCMJ) by Dr. Martin Dawes, head of Family Practice at UBC, my alma mater.

Quality assurance for family practice should be determined locally and provincially, with a distributed model of quality assurance for the province rather than a centralized model, to increase the likelihood of positive change in response to variations in practice.

Dr Dawes captures it well when he writes of the need for a quality measurement system which takes into account appropriate variations in practice, and that such a system must flex and be  adjusted as we understand more about the meaning of the data we are collecting.

I was glad to see that Dr Dawes, unlike many others, doesn't put all the weight solely on achieving  "targets." It's not that guidelines and clinical measures should be forgotten about, however they are but one part of the larger quality picture and fortunately he spells this out. I worry that governments and health authorities have not yet arrived at this way of thinking.

While I appreciate that things like accessibility are mentioned in the article, I do note the lack of emphasis on (or even mention of) the role of a strong relationship or attachment between doctor and patient in high quality care. Hopefully this is something that decision-makers are well-aware of, and they take it so for granted that they don't explicitly mention it in their articles.  :P

This article is a timely piece as physician organizations, health authorities, and governments in Canada begin the discussion about 'what is good care?', 'how can we measure it?', and 'what can we do to make it better?'

Read more in the BCMJ.

Source: http://bcmj.org/premise/measuring-and-impr...