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...

Quality Forum: A New Kind of Rounds (Teaching patient-centred care that avoids unnecessary and harmful interventions)

I have followed the Do No Harm project and their articles in JAMA's Teachable Moments section (under the Less is More theme). Then, at the Lown Institute's Road to Right Care conference, I learned more about "Right Care Rounds," and in Nanaimo we developed our own version.

More background information and the talk from our first session, on the subject of treatment of Type 2 Diabetes in the elderly, can be found here.

Following the success of this event, we decided to do more of them. Our next one is tentatively in April and will be on the subject of overtreatment of hypertension. Thinking, "why not spread the message of what we are trying?," we've created a poster that I will present at the BC Quality Forum.

You can view the full poster 'storyboard' by clicking the image below.
 

The Most Important #ChoosingWisely List: Med Students & Trainees

Please join me in enthusiastically applying the latest Choosing Wisely Canada recommendations, as developed by the Canadian Federation of Medical Students (CFMS) and the Fédération médicale étudiante du Québec (FMEQ).

This amazing list of 6 items for Medical Students and Trainees to question is extremely important. It does a few things above and beyond what the other Choosing Wisely Canada lists could. Namely, the list:

  • Creates and promotes a culture of appropriateness in care early on in the careers of physicians, ensuring this way of thinking is embedded in their style of practice
  • Recognizes the professionalism, critical-thinking ability, and ethical intelligence of young clinicians
  • Engages medical educators and recognizes the mutual influence that learners and instructors can have on each other's practice
  • Is directed squarely at providers; while discussion between patient and provider may seem notably absent, each of the items is patient centred at a high-level; the list ensures that the goals of the patient – not the learner – are paramount, and that the learner will advocate in this regard

Hopefully the Students and Trainees Advocating for Resource Stewardship (STARS), students selected to champion the Choosing Wisely campaign, will be able to integrate these Top 6 into their medical schools' curricula.

Congratulations to the members of CFMS, FMEQ, and STARS on this fantastic work.

Review the 'Six Things Medical Students and Trainees Should Question' list.

Source: http://www.choosingwiselycanada.org/recomm...

Choosing surgery wisely: the importance of evidence-based practice

* RESEARCH FIRST LOOK *

Very little research has been done so far in the area of appropriateness in health care, so it is is always a delight to see what is being worked on.

You may remember Roland Grad, a family physician and research at the University of McGill, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign.

Two ambitious McGill medical students, Nicholas Meti and Mathieu Rousseau, worked with Dr Grad to extend that work and look at InfoPOEMs that dealt specifically with surgical interventions which are considered unnecessary or harmful to patients.

Many agree that there's room for the Choosing Wisely campaign to improve; this research presents a potentially fruitful way to do so, particularly for the orthopaedics recommendations which have been heavily criticized to date.


Choosing surgery wisely: the importance of evidence-based practice

Meti, N., Rousseau, M., Grad, R. Medicine, McGill University, Montreal, Canada.

An emerging trend among physician organizations is to attempt to control or reduce the rate of unnecessary medical tests and treatments. Until recently, the principle manner to release updated recommendations for practice was through meetings where experts discussed which tests or treatments needed to be questioned.  

We developed a novel means of analyzing nascent research articles for their applicability towards improving the “Choosing Wisely” topic selection process [1]. This method is based on analyzing the ratings of daily POEMs, collected from physician members of the CMA. POEMs are tailored synopses of primary research or systematic reviews, selected by searching over 100 journals. POEMs are delivered to over 20,000 members of the Canadian Medical Association (CMA) by email on weekdays.

At the 2015 ‘Preventing Overdiagnosis’ conference, one of us (RG) will report on the top POEMs of 2014, as rated by CMA members with respect to their potential to help them to ‘avoid an unnecessary diagnostic test or treatment’ [1]. Of the topics addressed by these top 20 POEMs of 2014, only 2 were discussed in the Choosing Wisely master list of recommendations. Of the remaining 18 topics, three were related to surgical interventions; we highlight their important findings.

In a study published in The Bone and Joint Journal, Kukkonen et al. used the Constant Shoulder Score to show that among patients with symptomatic non-traumatic supraspinatus tears, physiotherapy alone is as effective as physiotherapy combined with acromioplasty after 1-year follow up [2].

In a study published in the New England Journal of Medicine, Sihvoven et al. investigated whether arthroscopic surgery would improve outcomes for select patients with a degenerative tear of the medial meniscus. The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial involving patients without knee osteoarthritis, but with symptoms of a degenerative medial meniscus tear. Surgery was found to be ineffective for non-traumatic partial medial meniscus tears [3].

A study published in JAMA by Primrose et al. [4] questioned the routine practice of intensive follow-up after surgery for colorectal cancer, as there existed no evidence to support this common practice. In a randomized controlled trial, 1,202 participants were assigned to 4 groups: CEA only, CT only, CEA+CT, or minimum follow-up. Their results demonstrated that among patients who had undergone curative surgery for primary colorectal cancer: 1) intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent, compared with minimal follow-up; 2) there was no advantage in combining CEA and CT; and 3) there was no statistically significant survival advantage to any strategy.

One concern about the development of top five lists in Choosing Wisely is the potential for individual specialties to choose the low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included no major surgical procedures in their top 5 list, despite evidence of wide variation in elective knee replacement and arthroscopy rates [5]. This observation is not meant to be a criticism of orthopedic surgeons per se, as many surgeons are strong advocates for their patients (see http://www.thepatientfirst.org). [Less is More readers will remember one of the founders, Dr James Rickert, from What Can Patients Do in the Face of Physician Conflict of Interest]

Our point is to drive home the underlying philosophy of the “Choosing Wisely” campaign: ‘routine’ testing or treatment without evidence-based support can be found insidiously entrenched in all disciplines.


References

1. Grad RM, Pluye P, Shulha M, Tang DL. POEMs Reveal Candidate Clinical Topics for the Choosing Wisely Campaign. Preventing Overdiagnosis Conference, Bethesda, MD, September 2015.

2. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014; 96(1):75-81.  
http://www.ncbi.nlm.nih.gov/pubmed/24395315

3. Sihvonen R, Paavola M, Malmivaara A, et al., for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26):2515-2524.    http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

4. Primrose JN, Perera R, Gray A, et al., for the FACS Trial Investigators. Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer. The FACS randomized clinical trial. JAMA 2014; 311(3): 263-270. 
http://www.ncbi.nlm.nih.gov/pubmed/24430319

5. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value service. N Engl J Med 2014; 370:589-92. 
http://www.nejm.org/doi/full/10.1056/NEJMp1314965

Plans for Less is More

After the Preventing Overdiagnosis Conference, I took almost a month off, which we spent tootling around Iceland in a LandRover and enjoying the food and culture of Brussels, Brugge, and Paris.

Back home now, I am also back into the swing of things. It is full speed ahead! In brief:

  • Today, Dr James McCormack (@medmyths) and I will be presenting to the UBC Medicine students in their Doctor, Patient, and Society (DPAS) 420 class on Less is More in Medicine
     
  • I'll be doing various talks on this subject for the Family Medicine Forum (Nov 15, Quebec), Vancouver General Hospital Family Practice Rounds (Dec 9, Vancouver), the UBC CPD Post Graduate Review in Family Medicine (Feb 25, Vancouver), and the Rural and Remote Medicine conference (Apr 10, Montreal)
     
  • To the website, I've added a Media section, which will list any news articles or talks related to the site, and a Declaration section, detailing no conflicts of interest. Many other updates are needed!
     
  • I have tones of notes from the Preventing Overdiagnosis Conference and will try to summarize some of the themes in a following blog post, and update portions of the website accordingly (like the People section - lots of great names to add)

There's so much being written on this subject right now, it is hard to keep up. As busy as it makes me, it is a good problem to have.

 

Teaching Costs of Care: Opening Pandora’s Box

Educating medical students and residents about the costs of care seems to be an important part of equipping them to deliver 'the right amount' of care. However, there is lots of hesitation; this article highlights 5 barriers to avoiding overtesting: fear of malpractice, patient demands, pressure from attending physicians, questions about whose money is being saved, and whether education will make a difference.

Dr. Arora reaches a poignant conclusion, which happens to be consistent with the goals of THIS (Less is More Medicine) website:

And in the words of notable educational psychologist Robert Gagne, the first step in creating a learning moment is getting attention. And, by that measure, this exercise was successful – it certainly did get attention. Yet, it also did something else…it created the tension for change, a necessary prerequisite for improvement. It certainly cultivated a desire to learn more about how to achieve this change

Read more at Costs of Care.

Source: http://www.costsofcare.org/teaching-costs-...