“Common sense is not so common.” ~ Voltaire
On April 6th, 2017, just this week, a joint report titled Unnecessary Care in Canada was released by the Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) that created a bit of a stir in healthcare. The report focused on 8 CWC recommendations about certain tests and procedures. The shocking (or not so shocking) conclusion was “that up to 30% of them are potentially unnecessary. Unnecessary tests and treatments waste health system resources, increase wait times for patients in need and can lead to patient harm.” According to the CIHI, this translates into a whopping more than one million potentially unnecessary tests and treatments each year.
The 8 recommendations sourced from the CIHI and CWC are as follows:
- Don’t do imaging for minor head trauma unless red flags are present
- Don’t routinely do screening mammography for average-risk women age 40 to 49
- Don’t do imaging for lower-back pain unless red flags are present
- Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds
- Don’t perform preoperative testing before low-risk surgeries
- Don’t routinely obtain head CT scans in hospitalized patients with delirium in the absence of risk factors
- Don’t use benzodiazepines and/or other sedative-hypnotics in older adults as a first choice for insomnia, agitation or delirium
- Don’t use atypical antipsychotics as a first-line intervention for insomnia in children and youth
The results of what is actually happening in infographic forms are as follows:
How can unnecessary tests and investigations be avoided?
At first glance, when you read such statistics and digest the amount of money, time and risk involved in so many unnecessary tests and procedures, you can’t help but wonder how this is possible? I think the CWC chair Dr. Wendy Levinson addresses this bang on in a CMAJ News release on April 6th, 2017 – “The notion that more is better is ‘deeply embedded in our culture’, she said, but it shouldn’t apply to medicine.”
Having worked in front line medicine for many years, I can tell you it is very tricky to start pointing fingers in any one direction on this issue. For instance, here is a example scenario. A patient, Jim, presents to his family physician with chronic low back pain and has tried conservative management such as physio, exercise and anti-inflammatories. He does not have any red flags such as cancer, unexplained weight loss, prolonged use of oral steroids, fever, bowel or bladder incontinence, however, it is impacting his activities of daily living and work. Jim is now insisting on a referral to a specialist. Jim has read everything that he can online about back pain and does not want injections, but rather wants to see an orthopaedic surgeon. The orthopaedic surgeon wants an x-ray of Jim’s back prior to even seeing him – so this is done. Not surprisingly, the x-ray revealed degenerative changes – so really no further ahead. In this scenario, the patient, family physician, orthopedic surgeon and radiologist reading the x-ray are all reasonable in their approach, however, the x-ray that was performed was deemed unnecessary.
I consider myself quite conservative when it comes to any clinical medicine – both in how I practice and what I pursue for me and my family. Despite this, I can say of the 8 recommendations, I have been on one side or the other of a couple of them. Having said this, I completely agree with all of the recommendations, except perhaps screening mammography in the 40-49 age group – but I will leave that for now.
Healthcare expenditure is an ongoing concern and rightfully so as it is not sustainable as it stands right now. With the population living longer, the issue will only get worse. The only way it can change is if everyone does their part and remains accountable. One way to do this is to remember – Just because we can, doesn’t mean we should.
Medical advancements will only continue and physicians will have even more options for patient care. These 8 recommendations are only the tip of the iceberg of the more than 225 recommendations of commonly used tests and procedures that are not supported by evidence.
Evidenced-based medicine is what we all strive for in our healthcare system so we should view an initiative such as this from the CWC as an opportunity to become more educated and proactive as healthcare users, and more confident and supported as healthcare providers.