Choosing Wisely: The Canadian Society of Nephrology's List of 5 Items Physicians and Patients Should Question

The impact of the Choosing Wisely Canada campaign on the simultaneous use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers: interrupted time-series analysis

BACKGROUND

Choosing Wisely is a high-profile campaign seeking to reduce the use of low-value care. We investigated the impact of a Choosing Wisely Canada recommendation against using a combination of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) for the management of hypertension, heart failure or diabetic nephropathy on population-level use of these medications in British Columbia, Canada.

METHODS

We identified all people (any age) who were continuously registered with BC's Medical Service Plan between 2010 and 2017 with the targeted conditions. Using prescription claims data and an interrupted time-series analysis, we estimated the number of people on combination therapy per month, the proportion of days covered (PDC) by combination therapy per month and proportion of all combination prescriptions started per month in the 2 years before and after the introduction of the recommendation on Oct. 29, 2014.

RESULTS

Of 1 104 593 people (mean age 65 yr, standard deviation 16 yr) in our study cohort, 4.6% were exposed to combination therapy, largely prescribed by family physicians (84%). The number of people on combination therapy and the PDC were declining before the recommendation, but the proportion of combination prescriptions started in the 2 years before the recommendation was increasing. After the recommendation, we observed no statistically significant changes in any outcome. The pre-existing downward trend of the monthly number of people decelerated (16.8, 95% confidence interval [CI] 14.0 to 19.5) and the proportion of prescriptions started increased (0.13%, 95% CI 0.08% to 0.18%).

INTERPRETATION

The Choosing Wisely Canada recommendation against using a combination of ACE inhibitors and ARBs was not associated with reduced combination therapy use in the targeted conditions. The observed pre-existing declines in this practice questions the process of selecting recommendations, and the optimal implementation and value of Choosing Wisely campaigns without other reinforcing interventions.

Analysis of the association between emergency dialysis start in patients with end-stage kidney disease and non-steroidal anti-inflammatory drugs, proton-pump inhibitors, and iodinated contrast agents

BACKGROUND

The association between the use of potentially nephrotoxic drugs [Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Iodinated Contrast Agents, Proton Pump Inhibitors (PPIs)] and emergency start of dialysis in patients with chronic kidney disease has not been well explored, although these compounds are commonly prescribed or available without prescription.

METHODS

In this study, the Renal Epidemiology Information Network (REIN) registry data of all patients ≥ 18 years of age who started dialysis in France in 2015 were matched with those in the French National Health Insurance Database. The association between clinical characteristics, nephrotoxic drug exposure and emergency dialysis start was investigated. Patients were categorized into four classes of NSAID and PPI exposure (new, current, past, no user) on the basis of the pre-dialysis exposure period (1-30, 31-90, and 91-365 days). For iodinated contrast agents, exposure in the 72 h and 7 days before dialysis was analyzed.

RESULTS

Among the 8805 matched patients, 30.2% needed to start dialysis in emergency. After adjustment for socio-demographic and clinical variables, new NSAID users were more likely to experience emergency dialysis start [OR = 1.95; 95% CI (1.1-3.4)]. This association was higher for new than for current users [OR: 1.44; 95% CI (1.08-1.92)]. Emergency dialysis start was also associated with iodinated contrast agent exposure in the previous 7 days [OR: 1.44; 95% CI (1.2-1.7)]. No significant relationship was detected between PPIs and emergency dialysis start.

CONCLUSIONS

Using both clinical and healthcare data, this study shows that emergency dialysis start is independently associated with recent exposure to NSAIDs and iodinated contrast agents. This suggests the need to strengthen the information given to healthcare professionals and patients with regard to nephrotoxic drugs.

The Frequency of Routine Blood Sampling and Patient Outcomes Among Maintenance Hemodialysis Recipients

RATIONALE & OBJECTIVE

Surveillance blood work is routinely performed in maintenance hemodialysis (HD) recipients. Although more frequent blood testing may confer better outcomes, there is little evidence to support any particular monitoring interval.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING & PARTICIPANTS

All prevalent HD recipients in Ontario, Canada, as of April 1, 2011, and a cohort of incident patients commencing maintenance HD in Ontario, Canada, between April 1, 2011, and March 31, 2016.

EXPOSURE

Frequency of surveillance blood work, monthly versus every 6 weeks.

OUTCOMES

The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiovascular events, all-cause hospitalization, and episodes of hyperkalemia.

ANALYTICAL APPROACH

Cox proportional hazards with adjustment for demographic and clinical characteristics was used to evaluate the association between blood testing frequency and all-cause mortality. Secondary outcomes were evaluated using the Andersen-Gill extension of the Cox model to allow for potential recurrent events.

RESULTS

7,454 prevalent patients received care at 17 HD programs with monthly blood sampling protocols (n=5,335 patients) and at 8 programs with blood sampling every 6 weeks (n=2,119 patients). More frequent monitoring was not associated with a lower risk for all-cause mortality compared to blood sampling every 6 weeks (adjusted HR, 1.16; 95% CI, 0.99-1.38). Monthly monitoring was not associated with a lower risk for any of the secondary outcomes. Results were consistent among incident HD recipients.

LIMITATIONS

Unmeasured confounding; limited data for center practices unrelated to blood sampling frequency; no information on frequency of unscheduled blood work performed outside the prescribed sampling interval.

CONCLUSIONS

Monthly routine blood testing in HD recipients was not associated with a lower risk for death, cardiovascular events, or hospitalizations as compared with testing every 6 weeks. Given the health resource implications, the frequency of routine blood sampling in HD recipients deserves careful reassessment.

Engaging residents to choose wisely: Resident Doctors of Canada resource stewardship recommendations

BACKGROUND

Resident doctors are integral to healthcare delivery in Canada. Engaging residents in resource stewardship is important for professional development, but also as they are drivers of healthcare resource use. To date, no national resident-specific resource stewardship guideline has been developed. Resident Doctors of Canada (RDoC) in collaboration with Choosing Wisely Canada (CWC) sought to develop an evidence-informed, consensus-based list of five recommendations to promote resource stewardship.

METHODS

RDoC convened a taskforce with diverse geographic and specialty representation to develop candidate recommendations targeting resident resource stewardship behaviours using a consensus-based process, supported by a literature review. Residents across the country provided feedback on the candidate recommendations via an online questionnaire. The taskforce used this feedback to finalize the list.

RESULTS

The taskforce prepared 28 candidate recommendations for consideration. A detailed literature review and consensus process narrowed this list to 12 candidate recommendations for consultation. A total of 754 residents (754/10,068 residents = 7.5%) representing all provinces and levels of residency training reviewed and ranked the candidate recommendations. The highest-ranked recommendations comprised the final list.

CONCLUSION

Resident doctors are willing and able to demonstrate leadership in advancing resource stewardship by the development of a national resident-specific list of Choosing Wisely Canada recommendations.