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:

 

COURSE: Practising Wisely - Reducing Unnecessary Testing and Treatment

When I speak to peers and clinicians, one of the most frequent bits of feedback I receive is "Great! I'm on board with delivering more appropriate care, Choosing Wisely, making sure my patients make shared decisions and avoid unnecessary tests and treatments. But... I don't really know how to 'do' it. Where do I start? How to I talk to patients? Where do I go to practice?"

So, it is with extreme pleasure that I announce the expansion of the Practicing Wisely: Reducing Unnecessary Testing and Treatment Course. Originally "Don't just do something, Stand there!," this highly-regarded hands-on learning experience was started by the Ontario College of Family Physicians and is spearheaded by Dr Jennifer Young.

It is now a suite of continuing professional development opportunities for primary care providers, available in a modular format across the country. In the course: 

Participants will identify opportunities to "practise wisely", with a focus on reducing over-prescribing, over-imaging, over-screening and over-monitoring using the latest evidence and tools from diverse sources. This workshop aligns closely with the Choosing Wisely Canada (CWC) campaign to implement good healthcare stewardship and avoid over-medicalization.

The program centres on case studies and incorporates individual reflection and group work. It helps participants to build communication skills to guide their patients through the shift from seeking sickness to enhancing health.


After active engagement in this program, participants will be better able to:

  • Identify opportunities to reduce “too much medicine”
  • Access and assess reliable, renewing online resources
  • Integrate relevant evidence into individual patient care
  • Communicate and build consensus with patients to reduce over-medicalization

    Upcoming Workshops are taking place as follows:

    May 24/17 - Montreal
    May 29/17 - Ottawa
    June 3/17 - Newfoundland
    Nov 22/17 - Toronto

    Find out more about the Practising Wisely program by viewing the main website or reading through this Q&A with Course Director, Dr. Jennifer Young.

    Source: http://ocfp.on.ca/cpd/practising-wisely

    VIDEO: Take Back Health: Join the #RightCare Alliance

    Although the USA is a slightly different animal, with more emphasis on health care as a for-profit industry, many of the same problems exist in Canada and other nations with a primarily single-payer, public system.

    The solution to health care interventions that are unnecessary, unwanted, or even harmful is: a social movement. That's what the Lown Institute thinks, and the Right Care Alliance is gaining momentum.

    Watch this:

    Source: https://www.youtube.com/watch?v=mdeH1bwYYD...

    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.
     

    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/

    Wisdom Teeth: Extracting some meaning

    Ow.

    Wizzie glamour shot! Day 3?

    Wizzie glamour shot! Day 3?

    My chipmunk cheeks are NOT cute.

    I have had the privilege of being a patient on a few occasions, some less serious (Bells Palsy, Pityriasis Rosea) and some more serious (Transverse Myelitis). I'm fortunate to be pretty healthy overall and try to steer clear of trouble.

    I do go to my GP who is an amazing full-scope, old-school, dedicated doc. Even though I think he's amazing, I still say "no" sometimes. Most recently he suggested some screening blood work, and I declined. He gave me the requisition anyway, but needless to say I did not donate any blood to the cause.

    With that said, it will come as no surprise that I never wanted my wisdom teeth out. 

    Healthy Debate has a timely article, Is wisdom teeth removal really warranted?, covering all the evidence and the information one needs to make a decision about whether to get impacted teeth extracted. 

    My wizzies (that's what cool kids call wisdom teeth) were sitting in my mouth, just being teeth, maybe impacted but not really causing any trouble. Until... they started to peek out in my 20s, and now age 30, one of them (right, lower wisdom baddie) created an unreachable space between him and his neighbour molar. Boom! Infection. Periocoronitis. Yuck.

    I did all the conservative stuff and tried to keep baddie's space clean and happy but no matter the fancy syringe or amount of peroxide I blasted in there, the infection continued, slowly smouldering. My dentist suggested I see the oral surgeon.

    He also suggested a bunch of other things, like braces, which I said no to. While I am fortunate enough to have a great dental plan, I did not want the headaches and hassle of that just for cosmetic reasons and the chance that it would slightly improve the way my teeth were wearing. Dr Dentist listened to me and agreed. That was nice! The alternative of leaving my wisdom teeth in would be possible, but the infection would wax and wane and it could do this when I'm out of the country or could require repeated courses of antibiotics, visits to the dentist, etc. So I agreed to go see the oral surgeon (Dr Surgeon) who said all my teeth definitely needed to come out.  Oh, and I'd need a CT scan first to see if the tooth roots were wrapped around the inferior alveolar nerve. 

    Dr Surgeon was awesome at discussing the risks. He also offered an alternate plan if the teeth were intertwined with the nerve. The CT really wasn't optional, as it was needed for planning the technique. I asked if I could just get baddie out, but he suggested it was better to do all of them at once so I wouldn't have to go through the surgery later in life if there were more issues. Getting wisdom teeth out after 25 is not ideal to begin with, and doing it on 4 separate occasions (if needed) would indeed be torture. 

    The reason wisdom teeth are much easier to remove in teenagers is that the teeth don't contain much wisdom at age 18

    Now, my jaw is recovering from having a crowbar go exploring in it. Well, actually I'm sure Dr Surgeon was as gentle as possible but they were stuck in there pretty well. My right side (where the infection had been) healed very well, the left basically did the maximum amount of swelling/trismus possible and I even got a shiner. Round the clock ibuprofen, lots of ice, etc. was somewhat helpful but mostly it just took time to settle.

    Compared to others who've had the same surgery, I got off easy. My inferior alveolar nerves were fine. I didn't get a nasty infection like my brother did when there was a perforation into his sinus(!). I didn't die from complications of the anaesthesia. Phewf!

    Every time I am a patient, I learn things about myself and especially about doctoring.

    If I look at this from a patient-centered experience, I would say there were some good things:
    - able to schedule it at a time that worked for me
    - very clear and upfront about the price, the risks, the recovery process
    - printed instructions were very detailed and included contact info for the surgeons
    - the clinic called to check up on me
    - when a large fleshy lump developed inside my cheek, they were able to fit me in quickly and verify that it wasn't an abscess, reassuring me + my spouse
    - I hardly ever had to wait in the clinic, everything was basically on-time which was incredible!

     

    Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post)  from Sam on Flickr

    Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post) from Sam on Flickr

    On the other hand, there were a few parts that made it hard to navigate:
    - one side of my jaw was not bad and the other with terribly terribly painful, which made me wonder if some complication was happening, it would have been helpful to know that this is "common"
    - I was given a prescription for antibiotics; this was not mentioned in the handout or by the surgeon to my spouse so I was unsure if I should take them or if they were a delayed prescription (eg. take if a complication arises); when the clinic called to check on me the day after surgery I asked the caller whether I should take the antibiotics. She said "yes, of course." And I tried to clarify, "oh, I wasn't sure if everyone takes these or if they were just if some complication developed; I didn't want to take them without being sure because of the risks of antibiotics" and she told me "there aren't any risks."
    [I got a bit upset at that point! Maybe it was the gnawing jaw pain or maybe I was just outraged... I might have mentioned that I was a physician, a card I try not to use because it makes me feel like an entitled a*hole, and that 'yes indeed there are risks...'] 
    Anyway she told me it was routine and I relented. My scan of the evidence didn't confirm that, but because I'd had a chronic infection pre-op I figured Dr Surgeon would probably strongly recommend I take them. I probably could have handled that better by asking about it earlier in the process, but I didn't know there would be antibiotics until I emerged from the post-anasthesia haze at home
    - the handout was great but I wish I would have received a copy before the day of the surgery; one of my values as a patient is "eating popcorn" and I was a bit sad to find out on the operation day that I would not be allowed popcorn for 3 months!!!!!!!!

    What I might apply to my own practice:
    - handouts are useful!
    - people like to know what to expect, so it's good to invest the time explaining some of the possibilities and timelines
    - when doctors or clinics are accessible, it helps! Even if you don't need to call or go there, somehow it feels better knowing that if you need them, it is not impossible to reach them
    - when estimating recovery times, it is probably better to under-promise/over-deliver; I was told to have 3-5 days off work and I wound up needing 7 before I even could see properly out of the eye on the side that was swollen/bruised and open my mouth wide enough to speak clearly
     

    In the end, did I get the right amount of medicine? Maybe. I'm not sure! In hindsight, I would certainly have asked a few more questions (eg. about antibiotics) and I might have opted for removal of just the one baddie wisdom tooth.

    Overall it was very challenging being a patient with a background in health care. When I went numb from the waist down two years ago, I basically dismissed it for three days before my dad (a nurse) insisted I seek attention - and there turned out to be an inflammatory lesion on my spinal cord ('transverse myelitis'). So now, I try really hard to mention things that seem odd or wrong and let other doctors decide if they are important. The consequence of that is that I probably come off as a worrier, but I'm sure I'll find a balance with more adventures as a patient. 

    I just hope this is all the medical adventuring I'll have for a little while, at least.

    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

    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

    Corruption: A devastating factor driving inappropriate health care in India

    The Canberra Times highlights the challenges facing Indian citizens who seek medical attention in "Indian doctors shed light on massive medical procedure scandal."

    Usually when I think about factors that drive inappropriate health care, I imagine it's a case of "good intentions and bad results." When doctors are trying their best for patients, sometime we go too far trying to fix a disease or result and lose sight of the person (the patient). Some negative pressures, like pharmaceutical marketing, fear of lawsuits, fear of being disliked, or a misunderstanding of the latest evidence can drive providers to do thinks that are not the "best care" though these choices may have seemed like good ideas at the time.

    I never thought to put BAD INTENTIONS at the top of the list of things that drive health care providers to provide 'too much medicine' or to choose unwisely. It certainly happens (eg. Mount Sinai catheterization scandal, where people are told to lie in order to get in for unnecessary cardiac catetherizations paid by the public system), but – perhaps just by my wishful thinking – it's not as prevalent as bad acts driven by good intentions.

    In India, maximizing profit appears to be the number one priority of some hospitals. Extra scans, surgeries, and avoidable deaths are all the result of doctors striving to meet "revenue targets" and taking bribes.

    This is a devastating state of affairs.

    One solution comes in the form of  Mission SLIM: the Society for Less Investigative Medicine. Hopefully they find success advocating against unnecessary tests and treatments, though they have their work cut out for them.

    Source: http://www.canberratimes.com.au/world/indi...

    Canadian Association of Pathologists: Why We Support Choosing Wisely Canada

    Dr Christopher Naugler, a pathologist from Alberta (bio), speaks about why the Canadian Association of Pathologists (CAP) support the Choosing Wisely Canada Campaign.

    The "Top 5" list of things physicians and patients should discuss, contributed by the CAP can be viewed here.

    Having never 'screened' someone for Vitamin D deficiency, I didn't realize how over-ordered the test was. It is a test I have ordered in the North in managing cases of rickets (which still occurs in Nunavut) in conjunction with the advice of a pediatrician or pathologist.

    Of course, the Choosing Wisely lists are meant to encourage discussion, and are not blanket statements for all occasions. There are obvious cases where it is wise to order a vitamin D test, and I think the wording of their recommendation captures that :

    #1 : Don’t perform population based screening for 25-OH-Vitamin D deficiency.
    Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections)