More isn’t always better: When less is more in medicine

is pervasive in healthcare. Some healthcare providers say they see it every day. For example, with every daily blood draw that is routinely ordered for in-patients that does not offer any clinical value to the patient or change their course of care. Others reflect on that one patient who was harmed, either physically or emotionally, by overuse. Like the patient who underwent a CT scan to rule out a pulmonary embolism, when a blood test would have sufficed. Or the patient who has a routine chest x-ray that finds an incidental small lesion in the lung, leading to a CT scan, then a needle biopsy, then complications of the biopsy, only to discover in the end that the lesion is benign.

Estimates are that up to one third of medical care adds no value to patients. Over testing and treating our patients leads to unnecessary harm and wastes valuable healthcare resources.

Overuse is an epidemic in healthcare. From primary to acute care there are examples of how we order tests and treatments, in spite of strong evidence that they do not help, and may even harm our patients.

Modern medical care is all about making choices. Weighing the potential harms and risks against the potential benefits to our patients and their wellbeing. Doctors do this every day, but generally, we err on the side of doing more, rather than doing less. We are often seeking a quick fix to difficult problems.

For example, for that older patient who is having trouble sleeping, it seems like an easy solution to scribble off a prescription note for sedative medications. But, that small pill comes with big harms and dependency problems. We know that far too many elderly Canadians are taking these drugs. The risks of these drugs include cognitive problems, falls and hospitalizations.

It is estimated that about 80 per cent of healthcare costs can be traced back to a doctor’s decision. However, the problem of overuse doesn’t just have to do with doctors’ choices.

Patients and their family members often request tests or treatments that offer no clinical value. These are generally well-intentioned. Patients are often fearful from hearing stories of healthcare problems of family and friends, or media coverage. They want to be reassured by a healthcare professional that they are well. We live in a society where ‘more is better’ and so we think that more healthcare means better health. Plus, healthcare providers are often under enormous time pressure in the clinic or at the bedside and often order tests or treatments that may not be necessary just to ‘cover all bases’.

The problem of unnecessary use of antibiotics is a symptom of this approach, and overuse is the cause. In Canada, of the over 23 million antibiotic prescriptions each year, about half are inappropriate and unnecessary. Overuse and misuse of antibiotics comes with serious consequences for healthcare. The emergence of antibiotic resistant superbugs and patient complications, like C.diff infections, has been seen with increased frequency in our hospitals.

Turning the tide on the epidemic of overuse requires a conversation from both sides of the exam table or bedside. While clinical practices need to change to stop using treatments or ordering tests that aren’t evidence based, so too do patient and public expectations. There is a need for more public awareness about the potential risks and side effects of over testing, overtreatment and too much .

That is why the Choosing Wisely Canada campaign was launched in April 2014. Modeled after the United States , Choosing Wisely Canada works with Canadian national specialty societies to develop lists of ‘Five Things Clinicians and Patients Should Question.’

These lists identify tests and treatments which are commonly used in each specialty, but are not supported by evidence and may expose patients to harm. To date, more than 175 recommendations have been released by over 30 medical specialty societies, with more to come, including lists created by and for nurses. There is also a list for medical education that was developed by Canadian medical student organizations.

While national specialty society representatives have worked on developing the recommendations, putting them into practice has been led by frontline clinicians and provider organizations from coast to coast. We want to share some examples of how recommendations are improving patient care and sparking innovation at the bedside.

Lose the tube – Sunnybrook Health Sciences in Toronto, Ontario

The Hospital Medicine and Internal Medicine lists both include recommendations related to the inappropriate or unnecessary placement of urinary catheters. Dr. Jerome Leis, an infectious disease specialist, conducted an audit and found that 18 per cent of admitted inpatients on the medicine unit had a urinary catheter even though 69 per cent lacked an evidence-based reason. Leis worked with nurses on the medicine unit to develop a medical directive to standardize removal of catheters when patients were transferred to the medicine ward. The team halved the rate of catheter use on the unit and significantly reduced the rate of urinary tract infections since the medical directive was put in place.

Don’t give two when one will do – Halifax, Nova Scotia

The Transfusion Medicine list includes a recommendation “Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.” In Halifax, a team from Capital Health modified red cell guidelines were developed for elective non-bleeding general hematology and bone marrow transplant patients. This modest initiative had a major impact – it decreased the number of patients transfused by 10 per cent, and was estimated to have saved $1.8 million dollars’ worth of precious blood over two years from 2012-2014.


Drop the pre-op – Manitoba

A number of national specialty societies lists include recommendations against unnecessary pre-operative testing to prior to low risk surgery. These tests, such as chest x-rays or ECGs prior to low risk surgeries like a cataract replacement have been shown to provide no benefit to patients.

Choosing Wisely Manitoba has focused on large-scale projects in the province that can improve patient care and reduce waste.  They zeroed in on pre-operative testing. They set the goal of reducing pre-operative tests by one quarter by working directly with primary care as well as surgical teams to improve information given to patients before surgery. Further, pre-operative order sets and packages shared between physicians have been updated so that it is much more difficult to tick off a box for an unnecessary test. The next steps for this project include updated history physical exam forms from the provincial health authority as well as revised pre-operative guidelines.


Reducing unnecessary urine tests in the emergency department – Alberta Health Services

The Canadian Psychiatry Association list includes a recommendation “Do not routinely order urine drug screen testing on all psychiatric patients presenting to emergency rooms.” This blanket approach to drug testing has not been shown to improve the care of psychiatric patients in emergency departments. In fact, it can cause delays in assessment and management. In Alberta, there is a Strategic Clinical Network dedicated to addiction and mental Health. They chose to tackle stat drug toxicology tests in emergency departments, and did so by providing education to providers and showing data around the pitfalls of stat toxicology tests. The implementation resulted in a 96% per cent decrease in testing over six months.


Less sedatives for your older relatives – McGill University, Montreal, Quebec

A number of medical specialty societies have a recommendation related to inappropriate use of powerful sedative medications, such as benzodiazepines, which are particularly harmful for older adults. These drugs are also very difficult to stop once started. For example, the Canadian Psychiatry Association recommends “Don’t use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia.” In Montreal, a community-based program to educate patients about the harms of sedative hypnotic drugs like benzodiazepines was launched in pharmacies to provide information to elderly patients, and their family members, about how to slowly taper off this drug. The intervention was successful in helping patients talk to their doctors and ask about how to decrease their use of these powerful drugs.


Asking the four questions to reduce overuse

The campaign is also engaging with the public and patients, and has developed patient friendly information to go along with recommendations, including over 30 patient pamphlets.

In addition to that, we wanted to give patients tools to talk to their healthcare providers. Four questions were developed as a way for patients to start the conversation. You may have seen these in your hospital, doctor’s office or community lab. They spread the message that sometimes in medicine, as in life, more is not always better.

  1. Do I really need this test, treatment or procedure?
  2. What are the downsides?
  3. Are there simpler, safer options?
  4. What happens if I do nothing?


What you can do to help

The task of reducing unnecessary care and encouraging appropriateness is up to patients and clinicians. Patients can ask questions, and engage in conversations about unnecessary care. Clinicians can drive improvement using the Choosing Wisely Canada recommendations to inspire innovation and changes to work flows and processes leading to unnecessary tests and treatment.

Local context, practice and cultures vary widely across healthcare settings. We have seen tremendous impact when implementation is focused on local priorities, and there is a growing body of research and data detailing this.

Choosing Wisely Canada encourages and supports local ingenuity in the implementation of recommendations. Our hope is that the stories of individuals and organizationswho are doing so inspire you to look at where you can influence change locally. Reducing unnecessary care is in all of our hands, and together we can work to avoid harm and ensure high quality care for our patients, and our healthcare system.

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