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

Shrinking demand for blood products behind closure of blood donor clinics

Too much blood.

Remembering last year's crisis  – a severe shortage of blood products in Canada – it was surprising to read that Canadian Blood Services will be shutting down four permanent and 16 mobile clinics.

I am a blood donor.* It is with delight that I learn we have too much blood.

Experts cite five main reasons for this surplus:

  1. Minimally-invasive/robotic surgery reduces the amount of blood needed for each patient
  2. Doctors are transfusing when patients have symptoms, not for an arbitrary hemoglobin number (thanks to recommendations that have been made more popular thanks to initiatives like Choosing Wisely, eg item 5 on this list)
  3. Pre-surgery management can help increase patient's blood counts
  4. Better drugs during surgery prevent blood loss
  5. Blood supply is better managed by sharing blood products through hospital networks

It would be interesting to know which of these is has been the most effective at reducing the amount of blood required, but it sounds like most of these are in the best interests of patients and it results in a savings of $2.9 Million annually. However it happened, this is a big win for Canadians.

 

Well, I have donated blood, but every time I travel overseas (often to areas where malaria is present) it seems to prohibit me from donating for a year, and then I got my weird medical condition, so it has been about 3 years since I last donated.

Source: http://www.thewesternstar.com/News/Local/2...

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...

VIDEO: What causes antibiotic resistance? Kevin Wu | TED-Ed

It is goofy (there are butt-faces, silly monsters, Salmonella shooting lasers, and even a fart scene at 2:22) and informative. It is bound to be a classic!!!

Watch this fun video explaining What Causes Antibiotic Resistance thanks the Kevin Wu and Ted Ed.

View full lesson: http://ed.ted.com/lessons/how-antibiotics-become-resistant-over-time-kevin-wu Right now, you are inhabited by trillions of microorganisms. Many of these bacteria are harmless (or even helpful!), but there are a few strains of 'super bacteria' that are pretty nasty -- and they're growing resistant to our antibiotics. Why is this happening?

Source: http://ed.ted.com/lessons/how-antibiotics-...

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...

Demanding Patients? Not so in Oncology

Surveyed physicians tend to place responsibility for high medical costs more on “demanding patients” than themselves. However, there are few data about the frequency of demanding patients, clinical appropriateness of their demands, and clinicians’ compliance with them.

Exactly. This JAMA Oncology paper looked at 5050 patient-provider encounters in the oncology context and found that patients requested things in 8.7% of the encounters, and these demands were only considered inappropriate in 1% of encounters.

Number and Types of Patient Requests or Demands (JAMA Onc)

Number and Types of Patient Requests or Demands (JAMA Onc)

I think we need to be very careful about blaming patients. I do it... but I'm getting better at seeing the bigger picture. Yes, sometimes they are in the stage of denial and struggling to cope with their diagnosis. They may ask for completely inappropriate tests or treatments. Sometimes their expectations are absolutely ridiculous but most of the time this is not the case. The patient is not crazy or 'demanding.' A lot of the time it is we clinicians who put some of the more unrealistic expectations on people's radar.

Educating patients wouldn't change this, except if we can encourage them à la Choosing Wisely to initiate discussions with their physicians about unnecessary tests and treatments.  Educating the clinician, particularly encouraging transparency and openness in communication is really important. However, the biggest thing we can do is to change the overall culture of the health 'system' and our society to make it "okay" to talk about these issues frankly.

I work quite frequently with oncology patients, often in a supportive or palliative role. I find it shocking that many of them have never discussed dying, have not made advanced care plans, and do not understand the goals of their treatment. Often a patient is receiving palliative therapy and yet they believe it is a curative therapy. They may demand aggressive medical treatment, not realizing that they are very close to dying.

Sometimes, when I liaise with the oncologist, he or she explains that they had frank discussions about these things, and I can see it in the notes. It's just been hard to accept and people don't really hear what has been said. Other times, "it just never came up." I find that that hard to believe. It should come up. Shouldn't it?

Not talking about the end of life is doing a patient a disserviceHow can they make decisions about their care without knowing what is going on? It also suggests - as made clear by this study -  that inappropriate interventions might be coming from the clinician, not necessarily initiated at the behest of the patient.

What do you think?

Source: http://oncology.jamanetwork.com/article.as...

Minimally Disruptive Medicine: Thinking differently about nonadherence

In a follow up to Disutility: Finding the balance between benefit and hassle, I present this video from the North American Primary Care Research Group  (NAPCRG) Annual Meeting.

The answer to healthcare is education. Nevermind the other aspects of their life, nevermind that they have multiple diseases, side effects of medications, and not enough time in the day to do all the health 'work' that we give them . Teach patients, yell at patients, scare them into doing what you (the doctor) says. And if they don't take responsibility and do it, then... fire them as your patient!

Or not.

Dr Victor Montori, champion of Minimally Disruptive Medicine, explains a radical new way to think about "nonadherence" and the work that we give our patients to do.

NAPCRG Plenary I: Minimally Disruptive Medicine; Victor Montori, MD


Source: https://www.youtube.com/watch?v=cHSWDMH2rf...

Choosing Wisely Canada: There's an App for that!

It's true! Choosing Wisely Canada now has mobile apps:

They are free and bilingual (French and English) and you'll find them for Google (in the Play store) and for iOS devices (in the Apple store).

The apps are searchable, listing all the recommendations by speciality. There are also links to promotional videos and a library full of PDFs of physician and patient resources.

I have AirPrint enabled on my iPhone and printer, so I could just pull up a handout from the Choosing Wisely App and print it out  - if I don't want to email it - directly for my patients! 

Now there's an example of seamless technology that actually works to help doctors and patients, and will be a part of creating a smooth-operating, high-value health care system.

Source: http://www.choosingwiselycanada.org/news/2...

Physicians are also squeamish about Advance Care Planning discussions!

The Vancouver Sun featured an article, "Refusal to face reality of death leads to increased use of aggressive, futile health-care efforts: Doctor calls on Canadians to 'normalize conversations' about end-of-life care"

It's great to see this kind of story popping up across the news. The more we talk about it, the less scary it is to discuss; the end result is that we'll provide less futile care and offer better palliation, sooner, meaning that patients can have the best possible quality of life until the end.

The title of the video basically says it all; cardiologist Dr Heather Ross talks about the challenges that physicians face when they need to talk with patients about end of life care. It's interesting that she should remark on her discomfort with these kinds of discussions, as that was not something that came up in the study that prompted this Sun feature. 

The study in JAMA Internal Medicine is Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians. You at al. surveyed 1256 Canadian health care providers to identify some of the major challenges with discussing end of life situations and they identified the following:

  • family members' or patients' difficulty accepting a poor prognosis

  • family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments

  • disagreement among family members about goals of care

  • patients' incapacity to make goals of care decisions

Clinicians did not view system factors as significant barriers to these discussions, which I find surprising since we usually talk about underfunding, overcrowding, paperwork, communication errors, and bureaucracy whenever we have a tough problem to solve.

Interestingly, health care providers did not feel that their own skills presented major barriers to having care planning discussions. Well! I find that hard to believe. Clinician factors probably contribute greatly and we seem to have a blind spot for our own weaknesses!  

Fortunately Dr You acknowledges this:

“Overall, the sense from the clinicians is that patients and families tend to get in the way” of making concrete decisions about a patient’s care plans, You said. “This is what they perceive,” You said. 
“But I think it reflects that if patients and families are having a difficult time, then one of the solutions clearly has to be that physicians need to be skilled communicators — they need to know how to navigate these sometimes emotional or difficult discussions and be sensitive,” he said

A clinician's personal discomfort, uncertainty about prognosis, fear of not being liked, and other individual factors are definitely contributors to the difficulty of talking about dying with patients. A lot of the things that make it hard for doctors and nurses to talk with patients about planning for death and dying also contribute to the more general problem of inappropriateness in health care. 

So what can we do? Start here: It's Time to Talk: Advance Care Planning in BC. 

I'm proud to be a part of the Doctors of BC Council for Health Economics and Policy (CHEP), which is where Dr. David Attwell  spearheaded the creation of this policy paper.

Take a look. It's never too late to start talking about it!