Dialogue Volume 13 Issue 2 2017 - Page 40

choosing wisely www.choosingwiselycanada.org indicators of overuse. It’s a great opportunity to learn from one another,” said Dr. Levinson at the report launch. O’Toole pointed out substantial variations within and between regions around prac- tices. For example, in one year the rate of chronic benzodiazepine use by seniors ranged from 5% in Saskatchewan to 25% in New Brunswick. Mammogram screening rates for average-risk women goes from 13% in Que- bec to almost 39% in Nova Scotia. In Alberta, just 9% of endoscopy patients have four critical pre-op tests; the number is 17% in Saskatchewan and questions 20% in Ontario. 1) Is this test, treatment or In Ontario itself, some procedure really needed? disparities between areas were striking. Consider 2) What are the downsides? patients aged 18-64 who 3) Are there simpler, safer visited emergency in options? 2015-2016 for minor head 4) What happens if you do trauma (i.e., no red flags). nothing but watch and wait? The rate of potentially unnecessary CT scans was 31% for the province as a whole, but among the 14 LHINs was any- where from 13% to 46%. Looking at Ontarians with uncomplicated low-back pain, 4.5% had a CT or MRI scan that wasn’t indicated. The variations between primary care practices ranged from 0.8% of patients who had such scans to a high of 33%. At the April webinar, Dr. Laurent Marcoux, President-elect of the Canadian Medical As- sociation, said the culture of medicine is the biggest target for change. No doctor wants to harm a patient (or the system), yet that’s what can happen with over-diagnosis. “We think that more is better than less,” he stated. Not always, and that belief is hard to break. Dr. Levinson said doctors can assume it takes much longer to discuss the reasons not to 40 Dialogue Issue 2, 2017 have a test or treatment. In fact, she said these conversations only take a minute on aver- age, and can prevent return visits and longer conversations down the road. Practitioners take action In April 2014, Sunnybrook Health Sciences Centre in Toronto found that 69% of their catheter use lacked an appropriate medical reason. The team developed an evidence- based medical directive to empower nurses to remove urinary catheters if patients met spe- cific criteria. As a result, urinary catheter days are down 50% in medical patients, without any inappropriate catheter removals (based on random audits). One of the doctors created a toolkit called “Lose the Tube” to support the transformation. The report also highlighted the success of the North York Family Health Team in scal- ing back prescriptions of proton pump inhibi- tors (PPIs). These potent acid blockers may cause harmful side effects. Studies suggest that over half of people who take them probably don’t need them. Antacids or other less pow- erful drugs can deal with simple heartburn. The North York team identified 1,600 patients who were taking potentially inap- propriate PPIs. The group flagged them for physician consultation – on indications for use, side effects, risk, other treatment options – when they came for regular appointments. Over 18 months, 60% of patients who were engaged stopped or reduced their PPI use, all from a simple intervention. At a system level, the benefits of curbing unnecessary tests can be huge. It all comes down to conversations with patients and four critical questions (see sidebar). “Research shows that when physicians listen deeply, understand patient concerns and wor- ries, and have a discussion about the pros and cons, patients feel reassured,” says Dr. Levin- son. “That’s what we’re seeking.” MD