Integrating Choosing Wisely, Value-Based Care Principles, Into Undergraduate Medical Education: A Pilot Study

BACKGROUND

Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign.

METHODS

Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles.

RESULTS

A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18).

CONCLUSION

Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students' knowledge of these principles during medical school.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study

BACKGROUND

Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities.

METHODS

Female patients age ≥70 years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed.

RESULTS

Of the 31 756 patients meeting omission criteria, 25 771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes.

DISCUSSION

Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Reducing 25-Hydroxyvitamin D Testing in a Large, Urban Safety Net System

BACKGROUND

25-Hydroxyvitamin D testing is increasing despite national guidelines and Choosing Wisely recommendations against routine screening. Overuse can lead to misdiagnosis and unnecessary downstream testing and treatment. Repeat testing within 3 months is a unique area of overuse.

OBJECTIVE

To reduce 25-hydroxyvitamin D testing in a large safety net system comprising 11 hospitals and 70 ambulatory centers.

DESIGN

This was a quality improvement initiative with a quasi-experimental interrupted time series design with segmented regression.

PARTICIPANTS

All patients in the inpatient and outpatient settings with at least one order for 25-hydroxyvitamin D were included in the analysis.

INTERVENTIONS

An electronic health record clinical decision support tool was designed for inpatient and outpatient orders and involved two components: a mandatory prompt requiring appropriate indications and a best practice advisory (BPA) focused on repeat testing within 3 months.

MAIN MEASURES

The pre-intervention period (6/17/2020-6/13/2021) was compared to the post-intervention period (6/14/2021-8/28/2022) for total 25-hydroxyvitamin D testing, as well as 3-month repeat testing. Hospital and clinic variation in testing was assessed. Additionally, best practice advisory action rates were analyzed, separated by clinician type and specialty.

KEY RESULTS

There were 44% and 46% reductions in inpatient and outpatient orders, respectively (p < 0.001). Inpatient and outpatient 3-month repeat testing decreased by 61% and 48%, respectively (p < 0.001). The best practice advisory true accept rate was 13%.

CONCLUSION

This initiative successfully reduced 25-hydroxyvitamin D testing through the use of mandatory appropriate indications and a best practice advisory focusing on a unique area of overuse: the repeat testing within a 3-month interval. There was wide variation among hospitals and clinics and variation among clinician types and specialties regarding actions to the best practice advisory.

Highlights from the Second Choosing Wisely Africa conference: a roadmap to value-based cancer care in East Africa (9-10 February 2023, Dar es Salaam, Tanzania)

The ecancer Choosing Wisely conference was held for the second time in Africa in Dar es Salaam, Tanzania, from the 9th to 10th of February 2023. ecancer in collaboration with the Tanzania Oncology Society organised this conference which was attended by more than 150 local and international delegates. During the 2 days of the conference, more than ten speakers from different specialties in the field of oncology gave insights into Choosing Wisely in oncology. Topics from all fields linked to cancer care such as radiation oncology, medical oncology, prevention, oncological surgery, palliative care, patient advocacy, pathology, radiology, clinical trials, research and training were presented to share and bring awareness to professionals in oncology, on how to choose wisely in their approach to their daily practice, based on the available resources, while trying to offer the maximum benefit to the patient. This report, therefore, shares the highlights of this conference.

Adherence to the Canadian CT Head Rule in a Nova Scotian Emergency and Trauma Center

Background and aims Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada (CWC), aims to address unnecessary care and tests through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five tests, procedures, and treatments to question within the emergency department setting. The Canadian CT-scan Head Rule (CCHR) has been found to be the most effective clinical decision rule in adults with minor head injuries. This study aimed to better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center in Halifax, Nova Scotia. Materials and methods Our mixed methods design included a narrative literature review, a retrospective chart audit, and a qualitative audit-feedback component with physicians who work in the emergency department (ED). The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Results Analysis of qualitative data is included here, in parallel with in-depth analysis to contextualize findings from the chart audit. A total of 302 charts of patients presenting to the surveyed site were retrospectively reviewed for this study. Of the 37 cases where the CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated as per the CCHR, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusions Our review revealed that the CCHR was adhered in 87.8% of cases at the surveyed ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical to achieving the goal of reducing unnecessary CTs. This work will be presented to the physician group to engage and understand factors that are enablers in the process of ED minor head injury care.

Patterns of diabetes testing for older adults without diabetes in Ontario's nursing homes: A population-based study

BACKGROUND

Asymptomatic diabetes testing may be of limited value for older nursing home residents, but most diabetes guidelines lack upper-age cutoffs for screening cessation. We evaluated patterns of glycated hemoglobin (HbA1c) and serum blood glucose (SBG) testing among older residents without diabetes in Ontario, Canada.

METHODS

This population-based retrospective cohort study used provincial health administrative data from ICES to identify older nursing home residents in Ontario without diabetes between January 1, 2015 and December 31, 2018. We examined HbA1c and glucose testing rates overall, by age, sex, and near end-of-life. The number of tests needed to identify one case of diabetes (using HbA1c thresholds of 6.5% and 8.0%) were also calculated.

RESULTS

Among 102,923 older nursing home residents (70.3% women; average age 85.6 ± SD 7.7 years), 46.1% of residents received ≥1 HbA1c test over an average follow-up period of 2.15 (± SD 1.49) years, and 18.2% of these tested residents received ≥4 HbA1c tests. The crude HbA1c testing rate was 52.6 tests/100 person-years (95% CI 52.3-52.9). Testing rates among residents aged ≥80 years was 50.7 HbA1c tests/100 person-years (95% CI 50.4-51.0), and 47.8 tests/100 person-years (95% CI 46.5-49.0) among residents near end-of-life. The number of tests to identify a case of diabetes (HbA1c ≥ 6.5%) was 44, while the number of tests to identify a case of actionable diabetes (HbA1c ≥ 8%) was 310. Less than 1% of residents with an HbA1c test met criteria for actionable diabetes.

CONCLUSIONS

Nursing home residents without diabetes receive frequent diabetes testing, with high testing rates even in residents over 80 years old and residents near end-of-life. The high number of tests needed to identify a case of actionable diabetes highlights the urgent need to re-evaluate diabetes testing practices in nursing homes.

Choosing Wisely in pediatric healthcare: A narrative review

Background

It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment.

Methods

In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare.

Results

To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe.

Discussion

We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.

A retrospective two-center cohort study on the use of routine chest X-ray after peripherally inserted central catheter placement under ultrasound and intracavitary electrocardiography guidance

Background

The placement of peripherally inserted central venous catheters (PICCs) has traditionally relied on measurements and anatomical landmarks. It involves post-placement chest X-rays (CXRs) and occasional repositioning, which incur additional direct and indirect costs, such as delays in care and staff time. The aim of this study was to assess the cost-effectiveness of a routine post-procedural CXR in the era of ultrasound and intracavitary electrocardiography (IC-ECG)-guided PICC insertion.

Methods

A retrospective two-center study was conducted to review the clinical records of all patients who had PICCs in the Venous Access Center of Peking University Cancer Hospital & Institute and The Affiliated Qingdao Central Hospital of Qingdao University between 1 January 2019 and 30 June 2020. PICC placement was only available to patients who were 18 years or older, had in-sinus rhythm. The incidence of catheter misplacement after insertion was measured. Cavoatrial junction or the lower third of the superior vena cava (SVC) were defined as ideal catheter tip locations. A logistic regression analysis was performed to examine potential risk factors associated with PICC-related complications and a cost analysis was conducted to assess the economic impact of the use of CXR.

Results

There were 2,863 samples from 2,653 patients included. The overall incidence of intraprocedural and primary catheter misplacement was 7.3% (n=210) and 0.70% (n=20), respectively. There was a high risk of primary catheter misplacement when the left-arm was chosen for placement [odds ratio (OR): 11.163; 95% confidence interval (CI): 3.720-33.495; P<0.001]. The overall cost of performing CXR for screening of PICC-related complications was $23,858 per year, and that of using CXR to diagnose 1 case of catheter misplacement was $1,789.

Conclusions

This study confirms that misplacement of PICCs guided by ultrasound and IC-ECG is rare and that postprocedural CXR is very costly. In our setting, routine postprocedural CXR is unnecessary especially when the PICC is catheterized in the right arm, and is not a wise option.

Highlights from Choosing Wisely 2022 for Resource Limited Settings: Reducing Low Value Cancer Care for Sustainability conference, 17th-18th September, Mumbai, India

The 'Choosing Wisely 2022' conference, organised by the ecancer foundation, was held at the Tata Memorial Hospital, Mumbai, India, on 17 and 18 September. It was a successful event with 159 delegates attending it in person and around 328 delegates attending online. Thirty oncology experts from across the world shared their thoughts during this meeting. The theme of the conference was to focus on cancer care, in low- and middle-income countries (LMICs). The emphasis of discussion was on ways to select more cost-effective and high value treatments and interventions and minimise financial toxicity. In addition, cancer research from LMICs needs to be improved substantially. Collaboration and networking amongst cancer institutions in LMICs is essential.

Choosing Wisely in clinical practice: Embracing critical thinking, striving for safer care

In recent years, the Choosing Wisely and Less is More campaigns have gained growing attention in the medical scientific community. Several projects have been launched to facilitate confrontation among patients and physicians, to achieve better and harmless patient-centered care. Such initiatives have paved the way to a new "way of thinking." Embracing such a philosophy goes through a cognitive process that takes into account several issues. Medicine is a highly inaccurate science and physicians should deal with uncertainty. Evidence from the literature should not be accepted as it is but rather be translated into practice by medical practitioners who select treatment options for specific cases based on the best research, patient preferences, and individual patient characteristics. A wise choice requires active effort into minimizing the chance that potential biases may affect our clinical decisions. Potential harms and all consequences (both direct and indirect) of prescribing tests, procedures, or medications should be carefully evaluated, as well as patients' needs and preferences. Through such a cognitive process, a patient management shift is needed, moving from being centered on establishing a diagnosis towards finding the best management strategy for the right patient at the right time. Finally, while "thinking wisely," physicians should also "act wisely," being among the leading actors in facing upcoming healthcare challenges related to environmental issues and social discrepancies.

Overuse of medical care in paediatrics: A survey from five countries in the European Academy of Pediatrics

Studies and initiatives such as the "Choosing wisely" (CW) campaign emphasise evidence-based investigations and treatment to avoid overdiagnosis and overtreatment. The perception of the extent of medical overactivity among professionals and drivers behind are not well studied in the paediatric field.

AIM

We aimed to investigate the physicians' opinion and clarify the main drivers regarding medical overactivity in member countries of the European Academy of Paediatrics (EAP).

METHODS

In this study, paediatricians, paediatric residents, primary care paediatricians, and family doctors treating children were surveyed in Norway, Lithuania, Ukraine, Italy, and Switzerland. Over-investigation was defined as "diagnostic work-up or referral that is unlikely to provide information which is relevant for a patient" and overtreatment was defined as "treatment that does not benefit or can harm more than benefit the patient." The original questionnaire was developed in 2018 by a working group from the Norwegian Paediatric Association.

RESULTS

Overall, 1,416 medical doctors participated in the survey, ranging from 144 in Lithuania to 337 in Switzerland. 83% stated that they experienced over-investigation/overtreatment, and 81% perceived this as a problem. The majority (83%) perceived expectations from family and patients as the most important driver for overtreatment in their country. Other drivers for overuse were use of national guidelines/recommendations, worry for reactions, and reduction of uncertainty.

CONCLUSION

This is the first study investigating knowledge and attitude toward medical overactivity in European countries. Despite different cultural and economic environments, the patterns and drivers of increased investigations and medicalisation are similar.

Less Is More? The Association between Survival and Follow-Up Protocol after Treatment in Oral Cavity Cancer Patients from a Betel Quid-Prevalent Region

The optimal follow-up protocol after treatment of oral cavity cancer patients is still debatable. We aimed to investigate the impact of frequency of different imaging studies and follow-up visits on the survival of oral cavity cancer patients. The current study retrospectively reviewed oral cavity cancer patients who underwent surgical intervention in our hospital. Basic demographic data, tumor-related features, treatment modalities, imaging studies, and clinic visits were recorded. Cox proportional hazard model was used to examine the influence of variables on the survival of oral cavity cancer patients. In total, 741 patients with newly diagnosed oral cavity cancer were included in the final analysis. Overall, the frequency of imaging studies was not associated with survival in the multivariate analysis, except PET scan (hazard ratio [HR]: 5.30, 95% confidence interval [CI]: 3.57–7.86). However, in late-stage and elder patients, frequent head and neck CT/MRI scan was associated with a better prognosis (HR: 0.55, 95% CI: 0.36–0.84; HR: 0.52, 95% CI: 0.30–0.91, respectively). In conclusion, precision medicine is a global trend nowadays. Different subgroups may need different follow-up protocols. Further prospective study is warranted to clarify the relationship between frequency of image studies and survival of oral cavity cancer patients.

Reducing cytogenetic testing in the era of next generation sequencing: Are we choosing wisely?

INTRODUCTION

In most laboratories, next generation sequencing (NGS) has been added without consideration for redundancy compared to conventional cytogenetics (CG). We tested a streamlined approach to genomic testing in patients with suspected myeloid and plasma cell neoplasms using next generation sequencing ("NGS first") as the primary testing modality and limiting cytogenetics (CG) to samples with morphologic abnormalities in the marrow aspirate.

METHODS

Based on morphologic interpretation of bone marrow aspirate and flow cytometry, samples were triaged into four groups: (a) Samples with dysplasia or excess blasts had both NGS and karyotyping; (b) Samples without excess blasts or dysplasia had NGS only; (c) Repeat samples with previous NGS and/or CG studies were not retested; (d) Samples for suspected myeloma with less than 5% plasma cell had CG testing cancelled.

RESULTS

Seven hundred eleven adult bone marrow (BM) samples met the study criteria. The NGS first algorithm eliminated CG testing in 229/303 (75.6%) of patients, primarily by reducing repeat testing. Potential cost avoided was approximately $124 000 per annum. Hematologists overruled the triage comment in only 11/303 (3.6%) cases requesting CG testing for a specific indication.

CONCLUSIONS

Utilizing NGS as the primary genomic testing modality NGS was feasible and well accepted, reducing over three quarters of all CG requests and improving the financial case for adoption of NGS. Key factors for the success of this study were collaboration of clinical and genomic diagnostic teams in developing the algorithm, rapid turnaround time for BM interpretation for triage, and communication between laboratories.

Appropriate use criteria for ancillary diagnostic testing in dermatopathology: New recommendations for 11 tests and 220 clinical scenarios from the American Society of Dermatopathology Appropriate Use Criteria Committee

BACKGROUND

Appropriate use criteria (AUC) provide patient-centered physician guidance in test selection. An initial set of AUC was reported by the American Society of Dermatopathology (ASDP) in 2018. AUC reflect evidence collected at single timepoints and may be affected by evolving evidence and experience. The objective of this study was to update and expand AUC for selected tests.

METHODS

RAND/UCLA (RAND Corporation [Santa Monica, CA]/University of California Los Angeles) methodology used includes the following: (a) literature review; (b) review of previously rated tests and previously employed clinical scenarios; (c) selection of previously rated tests for new ratings; (d) development of new clinical scenarios; (e) selection of additional tests; (f) three rating rounds with feedback and group discussion after rounds 1 and 2.

RESULTS

For 220 clinical scenarios comprising lymphoproliferative (light chain clonality), melanocytic (comparative genomic hybridization, fluorescence in situ hybridization, reverse transcription polymerase chain reaction, telomerase reverse transcriptase promoter), vascular disorders (MYC), and inflammatory dermatoses (periodic acid-Schiff, Gömöri methenamine silver), consensus by panel raters was reached in 172 of 220 (78%) scenarios, with 103 of 148 (70%) rated "usually appropriate" or "rarely appropriate" and 45 of 148 (30%), "appropriateness uncertain."

LIMITATIONS

The study design only measures appropriateness. Cost, availability, test comparison, and additional clinical considerations are not measured. The possibility that the findings of this study may be influenced by the inherent biases of the dermatopathologists involved in the study cannot be excluded.

CONCLUSIONS

AUC are reported for selected diagnostic tests in clinical scenarios that occur in dermatopathology practice. Adhering to AUC may reduce inappropriate test utilization and improve healthcare delivery.

Utility of CD4 Cell Count and Viral Load Assay in Hospitalized Patients with Known HIV Infection: High Value Care Exercise

PURPOSE

Healthcare spending as a percentage of Gross domestic product (GDP) is at all-time high and continues to rise in the United States. The Centers for Medicare and Medicaid Services estimate that 33% of resources spent on healthcare goes to waste. As part of a 'high value care' exercise, we studied if estimating CD4 cell counts and HIV viral load in hospitalized patients with a known diagnosis of HIV led to any meaningful change in HAART regimen and discharge diagnosis.

METHODS

Retrospective chart review for all patients admitted with a known diagnosis of HIV from January 1, through December 31, 2017.

RESULTS

A total of 83 patient encounters were reviewed during the period. The mean age was 54.1 ± 16.4 years, 64.1 % of patients were males. 75 patients (90.3%) were already on highly active antiretroviral therapy (HAART). The median hospital length of stay (LOS) was 3 days (IQR 2.0 - 5.0). The mean turnaround time for CD4 counts and HIV viral load assay was 2.9 days (95% CI 2.1 - 3.7) and 3.9 days (95% CI, 3.2 - 4.6), respectively. A CD4 count estimation led to no change in HAART regimen. HIV viral load assay testing had no impact on a change in treatment or a change in diagnosis.

CONCLUSIONS

In our study, testing CD4 counts and HIV viral load for inpatients did not confer any benefit in altering the diagnosis or HAART regimen. We believe that our study identifies a systems level opportunity to add to the concept of 'Choosing Wisely.'

Routine Chest X-Rays Are Inaccurate in Detecting Relevant Intrapulmonary Anomalies During Medical Assessments of Fitness to Dive

Introduction: Intrapulmonary pathology, such as bullae or blebs, can cause pulmonary barotrauma when diving. Many diving courses require chest X-rays (CXR) or high-resolution computed tomography (HRCT) to exclude asymptomatic healthy individuals with these lesions. The ability of routine CXRs and HRCT to assess fitness to dive has never been evaluated.

Methods: Military divers who underwent yearly medical assessments at the Royal Netherlands Navy Diving Medical Center, including CXR at initial assessment, and who received a HRCT between January and June 2018, were included. The correlations of CXR and HRCT results with fitness to dive assessments were analyzed using Fisher's exact tests.

Results: This study included 101 military divers. CXR identified bullae or blebs in seven divers, but HRCT found that these anomalies were not present in three subjects and were something else in four. CXR showed no anomalies in 94 subjects, but HRCT identified coincidental findings in 23 and bullae or blebs in seven. The differences between CXR and HRCT results were statistically significant (p = 0.023). Of the 34 subjects with anomalies on HRCT, 18 (53%) were disqualified for diving.

Discussion: Routine CXR in asymptomatic military divers does not contribute to the identification of relevant pathology in fitness to dive assessments and has a high false negative rate (32%). HRCT is more diagnostic than CXR but yields unclear results, leading to disqualification for diving. Fitness to dive tests should exclude routine CXR; rather, HRCT should be performed only in subjects with clinical indications.

Are Continued Efforts to Reduce Radiation Exposures from X-Rays Warranted?

There are pressures to avoid use of radiological imaging throughout all healthcare due to the notion that all radiation is carcinogenic. This perception stems from the long-standing use of the linear no-threshold (LNT) assumption of risk associated with radiation exposures. This societal perception has led to relentless efforts to avoid and reduce radiation exposures to patients at great costs. Many radiation reduction campaigns have been launched to dissuade doctors from using radiation imaging. Lower-dose imaging techniques and practices are being advocated. Alternate imaging procedures are encouraged. Are these efforts warranted? Based on recent evidence, LNT ideology is shown to be defunct for risk assessment at low-dose exposure ranges which includes X-rays and CT scans. In fact, the best evidence that was once used to support LNT ideology, including the Life Span Study data, now indicates thresholds for cancer induction are high; therefore, low-dose X-rays cannot cause harm. Current practices are safe as exposures currently encountered are orders of magnitude below threshold levels shown to be harmful. As long as imaging is medically warranted, it is shown that efforts to reduce exposures that are within background radiation levels and that are also shown to enhance health by upregulating natural adaptive protection systems are definitively wasted resources.

The Canadian Dermatology Association's Top Five Choosing Wisely Canada Recommendations

INTRODUCTION

In this article, we present the Canadian Dermatology Association's (CDA) Choosing Wisely Canada (CWC) list of top "Five Things Physicians and Patients Should Question in Dermatology" and the evidence in support of each recommendation.

METHODS

Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019.

RESULTS

The top five recommendations are as follows: (1) Don't routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don't routinely prescribe topical combination corticosteroid/antifungal products; (3) Don't routinely use topical antibiotics on a surgical wound; (4) Don't prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don't use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy.

DISCUSSION

This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology.

CONCLUSIONS

This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

BACKGROUND

The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation.

METHODS

Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed.

RESULTS

A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction.

CONCLUSIONS

Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.

Antibiotic prescribing in patients who presented to the emergency department with dog bites: A descriptive review of current practice

OBJECTIVE

To describe the current practice of prophylactic antibiotic prescribing for patients presenting to the ED with a dog bite, and compare management against existing guidelines.

METHODS

We performed a descriptive retrospective study on all consecutive patients who presented to one tertiary teaching hospital and one regional district hospital in Southeast Queensland between 1 July 2017 and 30 June 2018 with a presentation of a dog bite. Data on demographics and management were collected from the electronic medical record using a standardised data collection tool. Risk factors supporting prophylaxis were taken from the electronic Therapeutic Guidelines.

RESULTS

Of the 336 patients included for analysis, 299 received antibiotics, of which 23 were for established infection. A total of 276 (82% of overall cohort) received a prescription for prophylactic antibiotics, either in hospital (ED or admitting ward) and/or on discharge. Of the 178 patients who received prophylactic antibiotics in hospital, 91 (51.1%) received intravenous antibiotics. Of the patients who presented to ED without a previously established infection 271 (86.6%) received prophylactic antibiotics on discharge. Over one quarter (27.5%) of patients who were given prophylactic antibiotics did not meet any high-risk factors as outlined in guidelines.

CONCLUSION

Prophylactic antibiotics are extensively used for patients with dog bites. There is scope to rationalise antibiotic use and route of antibiotic administration in patients with dog bites.

Monitoring the Use of Telemonitor: A Resident-run Quality Improvement Initiative Decreases Inappropriate Use of Telemonitor in a Community Hospital

Background Cardiac telemetry is an important tool to detect life-threatening conditions in hospitalized patients but is used widely and inappropriately. We sought to assess current usage and improve the appropriate use of telemetry in a community hospital. Methods We conducted a quality improvement project on patients who were admitted on telemetry floors between January and March 2017 (pre-intervention). The indication(s) and duration of telemonitor use, event(s) recorded on telemonitor and outcome of the event(s) were documented. A six-month educational intervention was undertaken and the effect of intervention was assessed among patients admitted between December 2017 and February 2018 (post-intervention). Results In the pre-intervention group, 329 patients qualified for the study, with a median age of 78 years. The post-intervention group had 383 qualified patients with a median age of 77 years. Mean duration of telemonitor use was four days in both groups. In the pre-intervention group, 54% had class I, 32% had class II, and 14% had class III indications. In post-intervention group, 46% had class I, 42% had class II, and 12% had class III indications. The educational intervention resulted in a trend towards less inappropriate use of telemetry, particularly in teaching service. Telemonitor events were recorded in 22 (7%) of the pre-intervention patients and 13 (4%) of the post-intervention group. Two patients died in the pre-intervention group and one in the post-intervention group from non-cardiac causes. Conclusion Our results highlight that change in practice requires sustained education interventions.

A Patient-focused Information Design Intervention to Support the Minor Traumatic Brain Injuries (mTBI) Choosing Wisely Canada Recommendation

Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states: "Don't order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule)". In order to provide patients with information on the risks and benefits of computed tomography (CT) scans in minor traumatic brain injuries (mTBI) and to encourage discussions between patients and their doctor, we designed a patient-focused mTBI infographic for the emergency department (ED). Methods Stakeholders worked with content experts to co-design the infographic, which was posted in two emergency department (ED) waiting rooms. A survey was administered to evaluate whether the infographic influenced patient beliefs about the risks and benefits of CT scans and to gauge patient willingness to have a discussion with their doctor about the necessity of a scan. Results One hundred fifteen patients completed the survey. Prior to participating, 38% of patients thought a CT after an mTBI was always a good idea and 60% thought it was sometimes a good idea. After viewing the poster, 87% of respondents stated they better understood when a CT scan may be appropriate, 93% felt they better understood the risks of CT scans, and 76% understood that their doctor can often rule out serious illness without a CT scan. Only 19% of patients still felt that a CT was always necessary after an mTBI. Conclusions The mTBI infographic changed patient perceptions regarding the need for CT scans and increased awareness of the indications and risks of CT scans. This study demonstrates that targeted patient education materials can help support CWC recommendations.

Association of Adverse Drug Events with Broad-spectrum Antibiotic Use in Hospitalized Patients: A Single-center Study

Objective The importance of antimicrobial stewardship is increasingly highlighted in this age of antimicrobial resistance. A better comprehension of adverse drug events (ADEs) can promote the appropriate use of antibiotics. We aimed to quantify the incidence of ADEs associated with broad-spectrum systemic antibiotics in a hospital setting. Methods We conducted a six-month prospective, observational study at Osaka University Hospital to describe the incidence of ADEs in patients hospitalized in general wards undergoing treatment with broad-spectrum antibiotics [carbapenems, piperacillin/tazobactam (PIPC/TAZ), and anti-methicillin-resistant Staphylococcus aureus agents]. The occurrence of ADE was defined as any cardiac, gastrointestinal, hepatobiliary, renal, neurologic, hematologic, dermatologic, or musculoskeletal manifestation after 48 hours or more of systemic antibiotic therapy. Results The 3 most frequently prescribed antibiotics were PIPC/TAZ (242 cases), meropenem (181 cases), and vancomycin (92 cases). Of 689 patients, 118 (17.1%) experienced ADEs, including gastrointestinal (6.4%), hepatobiliary (4.2%), dermatologic (2.5%), and renal (2.3%) manifestations. Patients treated with PIPC/TAZ, meropenem, doripenem, vancomycin, daptomycin, and teicoplanin developed ADEs at rates of 20.7%, 16.0%, 15.4%, 19.6%, 11.8%, and 10.9%, respectively. Conclusion Our study provides a quantitative value for the incidence of ADEs associated with broad-spectrum antibiotics in clinical practice. To optimize patient safety, clinicians need to be aware of the risks associated with antibiotic administration.

Inappropriateness of Repeated Laboratory and Radiological Tests for Transferred Emergency Department Patients

Background: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. Methods: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. Results: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. Conclusion: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.

Would You Be Surprised if This Patient Died in the Next 12 Months? Using the Surprise Question to Increase Palliative Care Consults From the Emergency Department

BACKGROUND

There is a growing movement to increase palliative care consults from the emergency department (ED) to reduce healthcare costs and improve quality of life. The surprise question is a screening tool that emergency medicine physicians may be able to use towards achieving this goal.

OBJECTIVE

The objectives of this study were to increase awareness of hospice and palliative care medicine (HPM) among emergency medicine (EM) providers and to evaluate whether this heightened awareness increased palliative care consults among participating emergency medicine providers.

METHODS

We conducted an anonymous convenience sample survey and two educational interventions about HPM including the surprise question among emergency medicine resident and attending physicians at a large urban public academic quaternary care center from July to November 2018. A report of palliative care consults ordered between August 1, 2017 and January 1, 2019 was generated from the electronic health records used by the hospital. The number of palliative care consults made before and after the educational intervention was compared.

RESULTS

After the first educational intervention centered on the surprise question, palliative care consults from the ED increased from an average of 2.25 per month (range 0 to 8, SD: 2.38) to 12.67 per month (range 9 to 19, SD: 4.01, p < .001).

CONCLUSION

Educating EM physicians about the surprise question can increase the number of palliative care consults from the ED, thereby potentially improving patient care and decreasing costs by avoiding unwanted healthcare interventions.

Utility of calcium, magnesium and phosphate testing in the emergency department

OBJECTIVE

To determine how frequently calcium (Ca), magnesium (Mg) and phosphate (PO₄ ) tests change ED patient management.

METHODS

We undertook a retrospective observational study in an Australian tertiary referral ED. We enrolled adult patients (aged ≥18 years) who presented between 1 January and 30 June 2017 and who had a serum Ca, Mg or PO₄ test ordered and completed during their ED stay. Patient symptoms, medical history, electrolyte levels and ED management changes were extracted from the electronic medical record.

RESULTS

Of the 33 120 adults presented during the study period, 1716 (5.2%, 95% confidence interval [CI] 5.0-5.4) had at least one Ca, Mg or PO₄ test completed in the ED. This included 4776 individual electrolyte tests, of which 776 (16.2%, 95% CI 15.2-17.3) were abnormal. Fifty-six (7.2% [95% CI 5.5-9.3] of patients with abnormal tests, 1.2% [95% CI 0.9-1.5] of all tests) tests were associated with a change in ED management. Twenty-six out of 1683 (1.5%) Ca levels were low with six (23.1%) management changes; 203 (12.1%) were high with 10 (4.9%) management changes. One hundred and twenty-eight out of 1579 (8.1%) Mg levels were low with 33 (25.8%) management changes; 30 (1.9%) were high with no management changes. Two hundred and twenty-five out of 1514 (14.9%) PO₄ levels were low with six (2.7%) management changes; 164 (10.8%) were high with one (0.6%) management change. Fifty (2.9%) patients had management changes despite normal electrolyte levels.

CONCLUSION

Ca, Mg and PO₄ testing is common. However, the yield of clinically significant abnormal levels is low and patient management is rarely changed. Testing of these electrolytes needs to be rationalised.

Choosing anesthesia options for cataract surgery in patients with dementia

Background and Aims

Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of "Choosing Wisely" initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery.

Material and Methods

A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the "Choosing Wisely" based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed.

Results

One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6-7, and regional anesthesia (RA) for GDS stages 1-5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA.

Conclusions

The authors found a reduced requirement for GA when "Choosing Wisely' initiative was used based on the GDS stage.

Choosing Wisely: Bedrest-A Panacea for All That Ails the Gravida?

Bedrest has been frequently prescribed for various high-risk conditions during pregnancy. A common indication cited is concern regarding increased risk of spontaneous preterm birth, known to be associated with gestations with twins or higher-order multiples, polyhydramnios, presence of preterm contractions with or without evidence of cervical change, sonographic cervical shortening, presence of a dilated cervix with bulging membranes, or preterm premature rupture of membranes. In some cases, there is concern that excessive movement may increase the risk of antepartum hemorrhage, as may be with placenta previa, with or without a higher risk of a morbidly adherent placenta or a vasa previa. It is also thought that improved splanchnic perfusion with bedrest may enhance blood supply to the uterus with possible benefit in conditions such as preeclampsia (or gestational hypertension) or fetal growth restriction. However, there is no evidence of any benefit of bedrest or reduced activity during pregnancy for either of these conditions. On the contrary, there is evidence of harm, in addition to the fact that exercise is known to be beneficial in pregnancy.

[The Role of Pharmacists in Antimicrobial Stewardship]

Antimicrobial resistance (AMR) has been declared a global public health emergency, necessitating the involvement of the whole of society to address this increasingly serious threat. AMR causes prolonged illness, greater risk of infection spread, increased morbidity, and higher mortality rates, which result in increased expenses to the government, healthcare services, and individuals. Inappropriate use of antimicrobials has been indicated as the primary cause for the global expansion of AMR. Under these circumstances, various countries have formulated suitable national action plans to curb AMR. In Japan, the national action plan on AMR was announced in April 2016. Our previous study clarified that orally administered antimicrobials accounted for approximately 90% of total consumption: oral third-generation cephalosporins, macrolides, and fluoroquinolones accounted for approximately 77% of oral consumption. Therefore pharmacists must extend their support for the appropriate use of antimicrobials prescribed by attending physicians to not only hospitalized patients but also outpatients. "Choosing wisely," a US-based health education campaign, warns against unnecessary use of antimicrobials. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to other medicines, implement further interventions, and evaluate them. In this article, we present data on use of antimicrobials in Japan, and mention how pharmacists should be involved in enabling physicians choose antimicrobials wisely.

Reduction of routine radiographs in the follow-up of distal radius and ankle fractures: Barriers and facilitators perceived by orthopaedic trauma surgeons

RATIONALE, AIMS, AND OBJECTIVES

Studies suggest that routine radiographs during follow-up of distal radius and ankle fractures result in increased radiation exposure and health care costs, without influencing treatment strategies. Encouraging clinicians to omit these routine radiographs is challenging, and little is known about barriers and facilitators that influence this omission. Therefore, this study aims to identify barriers and facilitators among orthopaedic trauma surgeons that might prove valuable towards the design of a deimplementation strategy.

METHODS

A mixed-method approach was used. First, interviews were conducted with orthopaedic trauma surgeons and patients (n = 16). Subsequently, a questionnaire was developed. This questionnaire was presented to 228 orthopaedic trauma surgeons in the Netherlands. Regression analyses were performed in order to identify which variables were independently associated to the decision to stop performing routine radiographs 6 and 12 weeks after trauma if proven not effective in a large randomized controlled trial.

RESULTS

In total, 130 (57%) respondents completed the questionnaire. Of these, 71% indicated they would stop ordering routine radiographs if they were proven not effective. Three facilitators were independent predictors for the intention to omit routine radiographs: This will "lead to lower health care costs" (Odds Ratio [OR]: 5.38 and 4.38), the need for "incorporation in the regional protocol" (OR: 3.66 and 2.66), and this will "result in time savings for the patient" (OR: 4.84).

CONCLUSIONS

We identified three facilitators that could provide backing for a deimplementation strategy aimed at a reduction of routine radiographs for patients with distal radius and ankle fractures.

Active change interventions to de-implement low-value healthcare practices: a scoping review protocol

BACKGROUND

There is recognition that the overuse of procedures, tests and medications strains the healthcare system financially and can cause unnecessary stress and harm to patients. In recent years, several initiatives have targeted the reduction or elimination of low-value practices in healthcare. Research suggests that passive interventions, such as the publication of guidelines, are often not sufficient to change behaviour and that active change interventions - interventions which actively implement strategies to change practices - are required to effect significant, sustained practice change. The purpose of this scoping review is to identify and characterise studies of active change interventions designed to reduce or eliminate low-value healthcare practices.

METHODS

We will conduct a review of MEDLINE, EMBASE, CINAHL and Scopus databases from inception. Building on previous research, 40 key terms will be used to search literature. The screening process will be conducted separately by two researchers, with discrepancies resolved by a third. Empirical studies of active change interventions used to reduce or eliminate low-value practices will be included. Descriptive statistics and thematic analysis will be used to categorise the characteristics of the studies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study. This scoping review will provide insights into the impact of several characteristics of active change interventions, including the number of interventions (single-faceted or multifaceted) and the level of implementation (individual or organisational). These results can provide guidance and direction for future research in de-implementation. The results will be disseminated through presentations at national and international conferences and the publication of a manuscript.

Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010-2014)

OBJECTIVE

To examine the prevalence, costs and trends (2010-2014) for 21 low-value inpatient procedures in a privately insured Australian patient cohort.

DESIGN

We developed indicators for 21 low-value procedures from evidence-based lists such as Choosing Wisely, and applied them to a claims data set of hospital admissions. We used narrow and broad indicators where multiple low-value procedure definitions exist.

SETTING AND PARTICIPANTS

A cohort of 376 354 patients who claimed for an inpatient service from any of 13 insurance funds in calendar years 2010-2014; approximately 7% of the privately insured Australian population.

MAIN OUTCOME MEASURES

Counts and proportions of low-value procedures in 2014, and relative change between 2010 and 2014. We also report both the Medicare (Australian government) and the private insurance financial contributions to these low-value admissions.

RESULTS

Of the 14 662 patients with admissions for at least 1 of the 21 procedures in 2014, 20.8%-32.0% were low-value using the narrow and broad indicators, respectively. Of the 21 procedures, admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value (1607-2956; 44.4%-81.7%).Seven low-value procedures decreased in use between 2010 and 2014, while admissions for low-value percutaneous coronary interventions and inpatient intravitreal injections increased (51% and 8%, respectively).For this sample, we estimated 2014 Medicare contributions for admissions with low-value procedures to be between $A1.8 and $A2.9 million, and total charges between $A12.4 and $A22.7 million.

CONCLUSIONS

The Australian federal government is currently reviewing low-value healthcare covered by Medicare and private health insurers. Estimates from this study can provide crucial baseline data and inform design and assessment of policy strategies within the Australian private healthcare sector aimed at curtailing the high volume and/or proportions of low-value procedures.

To Choose or Not To Choose: Evaluating the Effect of a Choosing Wisely Knowledge Translation Initiative for Imaging in Low Back Pain by Emergency Physicians

Introduction: We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC)-EM recommendations. We then assessed whether a structured knowledge translation (KT) initiative affected awareness, knowledge, and practice patterns for imaging in low back pain.

Methods: We completed a two-center, before and after practice evaluation study. Physicians working in two Canadian emergency departments (EDs) were asked to participate in a survey before a KT initiative, and were surveyed again at a six-month follow up period post-intervention. The primary outcome of physician practice was determined by analyzing the frequency of lumbar X-ray imaging for back pain.

Results: A total of 37 physicians were asked to complete the pre- and post-intervention survey. Awareness of the CWC-EM recommendations increased following the intervention (63%; 95%CI: 43-79 at baseline vs. 86%; 66-96 post-intervention). Knowledge increased with 58% (39-76) of physicians responding correctly initially, and 86% (66-96) after the intervention. Despite increases in awareness and knowledge of the guidelines, the lumbar X-ray imaging rate increased from a baseline of 12% (9.9-14.5) to 16.2% (13.6-19.2; p = 0.023) following the intervention.

Conclusion: We demonstrated some improvements in physician awareness and knowledge of the CWC-EM recommendations following our intervention. Despite these improvements, our KT intervention was associated with an increased frequency of imaging for low back pain, contrary to our expectations.

Limited utility of routine chest X-ray in initial evaluation of neutropenic fever in patients with haematological diseases undergoing chemotherapy

BACKGROUND

Routine chest X-ray (CXR) is recommended for neutropenic fever (NF) management however its role is relatively understudied in haematology patients.

AIM

To investigate the utility of CXR in the diagnosis and management of patients with haematological conditions complicated by NF.

METHODS

Retrospective, single-centre analysis of haematology patients admitted with NF between January 2011 and December 2015. Baseline demographics, treatment details and outcomes were collected from electronic patient records. CXR underwent independent radiology review. Primary endpoints were a proportion of NF episodes in which CXR detected a probable chest infection in the absence of respiratory symptoms/signs and/or resulted in a change in antibiotic management.

RESULTS

Four hundred and thirty-five episodes were identified; CXR was performed in 75% of patients (65% within 2 days of NF). In 4 of 164 (2.4%) asymptomatic patients, CXR was consistent with infection, in contrast to 19 of 119 (16%) patients with clinical signs of respiratory infection. Only 3 of 283 (1.1%) CXR resulted in a change to antibiotics. CXR consistent with infection was not associated with increased mortality or increased admission length, although there was an association with intensive care unit admission (odds ratios: 7.61, 95% confidence interval: 2.04-28.31).

CONCLUSION

In haematology patients with NF, CXR rarely detected chest infection or changed management in patients with no respiratory symptoms or signs. CXR in our institution is no longer part of routine assessment of NF in the absence of these features.

Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

Objectives

The Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients.

Methods

Data was retrospectively collected from patients, ages 18–50 and Canadian Triage and Acuity Scale (CTAS) codes 2–5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging.

Results

Data from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues.

Conclusion

Considerable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.

Lean Management to support Choosing Wisely in healthcare: the first evidence from a systematic literature review

Purpose

Choosing Wisely (CW) is an emergent approach to identify and reduce unnecessary care, such as tests and treatments that do not add value for patients and may even cause harm. The purpose of this paper is to investigate whether and how Lean Healthcare Management (LHM) can support CW objectives, focusing on customer needs and on waste elimination.

Data sources

A systematic literature review has been performed in Scopus, PubMed and Web of Science.

Study selection

Peer reviewed articles published in English language have been selected. Papers were considered if they regarded LHM and its possible support for achieving CW objectives. Data extraction. The links between the LHM purposes of adoption and the pursued CW objectives were investigated. Moreover, LHM tools, practices and interventions to support CW were grasped.

Results of data synthesis

Sixteen articles were included in the analysis. Links between the identified LHM purposes of adoption and CW objectives were discovered: through process understanding, optimization, evaluation and control, LHM contributes to the reduction of overuses in healthcare, but also to the delivery of a more effective and evidence-based care (EBC). Moreover, it provides an objective approach useful for choosing the most cost-effective solution among different alternatives.

Conclusions

Results highlight how LHM, and with which tools and practices, can be adopted to enhance the healthcare appropriateness pursued by CW, paving the way for interesting future research about this emerging topic.

Choosing wisely in oncology: necessity and obstacles

In the last decades, the survival of many patients with cancer improved thanks to modern diagnostic methods and progresses in therapy. Still for several tumours, especially when diagnosed at an advanced stage, the benefits of treatment in terms of increased survival or quality of life are at best modest when not marginal, and should be weighed against the potential discomfort caused by medical procedures. As in other specialties, in oncology as well the dialogue between doctor and patient should be encouraged about the potential overuse of diagnostic procedures or treatments. Several oncological societies produced recommendations similar to those proposed by other medical disciplines adhering to the Choosing Wisely (CW) campaign. In this review, we describe what was reported in the medical literature concerning adequacy of screening, diagnostic, treatment and follow-up procedures and the potential impact on them of the CW. We only marginally touch on the more complex topic of treatment appropriateness, for which several evaluation methods have been developed (including the European Society for Medical Oncology-magnitude of clinical benefit scale). Finally, we review the possible obstacles for the development of CW in the oncological setting and focus on the strategies which could allow CW to evolve in the cancer field, so as to enhance the therapeutic relationship between medical professionals and patients and promote more appropriate management.

ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services

OBJECTIVES

Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse.

STUDY DESIGN

Survey analysis.

METHODS

We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest).

RESULTS

Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care.

CONCLUSIONS

In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye

BACKGROUND:

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies.

METHODS:

Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature.

RESULTS:

We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery.

DISCUSSION AND CONCLUSION:

Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Choosing wisely after publication of level I evidence in breast cancer radiotherapy

Background

Recent trials in early-stage breast cancer support hypofractionated whole-breast radiotherapy (WBRT) as part of breast-conserving therapy (BCT). Evidence also suggests that radiotherapy (RT) omission may be reasonable for some patients over 70 years. Among radiation-delivery techniques, intensity-modulated RT (IMRT) is more expensive than 3-dimensional conformal RT (3DCRT). Based on this evidence, in 2013, the American Society for Radiation Oncology (ASTRO) recommended hypofractionated schedules for women aged ≥50 years with early-stage breast cancer and avoiding routine use of IMRT for WBRT. To assess response to level I evidence and adherence to ASTRO recommendations, we evaluated the pattern of RT use for early-stage breast cancer at our National Comprehensive Cancer Network institution from 2006 to 2008 and 2011 to 2013 and compared the results with national trends.

Methods

Data from a prospective database were extracted to include patients treated with BCT, aged ≥50 years, with histologic findings of invasive ductal carcinoma, stage T1-T2N0M0, estrogen receptor-positive, and HER2 normal. We retrospectively reviewed the medical records and estimated costs based on 2016 Hospital Outpatient Prospective Payment System (technical fees) and Medicare Physician Fee Schedule (professional fees).

Results

Among 55 cases from 2006 to 2008, treatment regimens were 11% hypofractionated, 69% traditional schedule, and 20% RT omission (29% of patients were aged >70 years). Among 83 cases from 2011 to 2013, treatment regimens were 54% hypofractionated, 19% traditional schedule, and 27% RT omission (48% of patients were aged >70 years). 3DCRT was used for all WBRT treatments. Direct medical cost estimates were as follows: 15 fractions 3DCRT, $7,197.87; 15 fractions IMRT, $11,232.33; 25 fractions 3DCRT, $9,731.39; and 25 fractions IMRT, $16,877.45.

Conclusion

Despite apparent resistance to shorter radiation schedules in the United States, we demonstrate that rapid practice change in response to level I evidence is feasible. Wider adoption of evidence-based guidelines in early-stage breast cancer may substantially lower health care costs and improve convenience for patients without sacrificing oncologic outcomes.

Choosing Wisely - An international and multimorbid perspective

Some medical diagnostic and therapeutic interventions are non-beneficial or even harmful. The Choosing Wisely campaign has encouraged the generation of "top five" lists of unnecessary low-value services in different specialist areas. In the USA alone, where the campaign was launched, these lists include a total of 450 evidence-based recommendations. Medical scientific societies in further countries such as Canada, Australia, New Zealand, England, Switzerland and Germany have since initiated Choosing Wisely campaigns. Besides implementing top five lists, these aim to change attitudes, expectations and practices in the culture of medicine. The field of internal medicine has initiated change in Switzerland (Swiss Society of General Internal Medicine: Smarter Medicine) and Germany (German Society of Internal Medicine: Klug entscheiden). Formulating Choosing Wisely principles in managing complex patients with multiple concurrent acute or chronic diseases, i. e., multimorbidity (MM), will present a particular challenge. Research is needed to determine the primary sources of overuse in specific combinations of diseases (i. e., MM clusters) and spearhead corresponding recommendations. National Choosing Widely campaigns may serve as a forerunner to a more global initiative.

Determinants of Computed Tomography Head Scan Ordering for Patients with Low-Risk Headache in the Emergency Department

Background

Many specialty societies have found that neuroimaging in headache is a low-value intervention for benign presentations. This study describes factors that influence Emergency Room (ER) physicians’ adherence to Choosing Wisely (CW) recommendations for low-risk headache patients presenting to Calgary’s Emergency Departments (EDs). Emergency medicine has yet to address imaging in headache as a CW topic; however, this study may inform that decision.

Methods

Data were retrospectively collected for all patients presenting to Calgary EDs with headaches from April 1, 2014 to March 31, 2016. Patients were deemed low-risk by virtue of discharge home from the ED, age < 50, and no lumbar puncture (LP), trauma, neurology, or neurosurgery consult or red flags on history. The primary outcome was computed tomography (CT) ordering rates with an eye to medical doctor (MD) practice variation. Patient, physician, and environmental factors were analyzed to compare patients who did and did not receive a CT.

Results

Two thousand seven hundred and thirty-four headache patients met the eligibility criteria. A total of 117 Calgary ER physicians were included, all of whom had seen 10 or more headache patients over the study period. Physician practice variation was vast, with a mean ordering rate of 38.0% and a range of 0% to 95% (M = 39.0%, IQR = 21.0%). CTs were ordered more often in males than females (39.9%; 34.1%; p = 0.002) and in patients presenting during the day and evening (38.1%; 39.0%) compared to the night (29.7%; p < 0.001). Patients were divided into quartiles by age, with the oldest group (41.6 - 50 years) receiving significantly more head CTs (45.1%) than the other quartiles (34.9%; 34.9%; 27.5%; p < 0.001). Longer triage-to-discharge times were associated with an increase in CT ordering rates (12% for < 2.95 hours; 35% for > 4 hour wait; p < 0.001). Lastly, patients who did not have a CT were more likely to revisit the ED within seven days compared to those who did (6.9% vs 4.0%; p = 0.003), but their seven-day admission rate was unaffected (0.6% in the group that got CTs and 0.3% in the group that did not get a CT). Time to assessment, the day of the week, physician gender, years of experience, and training program did not influence CT ordering practices.

Conclusion

To our knowledge, this is the first study to assess how patient, physician, and environmental factors relate to the use of CT scans in low-risk headaches presenting to the ED. CW guidelines are not optimally adhered to, and the findings in this study findings may inspire new ideas for maximizing the judicious use of healthcare resources.

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

Purpose of review:

The purpose of this review is to contribute to the Choosing Wisely Canada campaign and develop a list of 5 items for nephrology health care professionals and patients to re-evaluate based on evidence that they are overused or misused.

Sources of information:

A working group was formed from the Canadian Society of Nephrology (CSN) Clinical Practice Guidelines Committee. This working group sequentially used a multistage Delphi method, a survey of CSN members, a modified Delphi process, and a comprehensive literature review to determine 10 candidate items representing potentially ineffective care in nephrology. An in-person vote by CSN members at their Annual General Meeting was used to rank each item based on their relevance to and potential impact on patients with kidney disease to derive the final 5 items on the list.

Key messages:

One hundred thirty-four of 609 (22%) CSN members responded to the survey, from which the CSN working group identified 10 candidate-misused items. Sixty-five CSN members voted on the ranking of these items. The top 5 recommendations selected for the final list were (1) do not initiate erythropoiesis-stimulating agents in patients with chronic kidney disease (CKD) with hemoglobin levels greater than or equal to 100 g/L without symptoms of anemia; (2) do not prescribe nonsteroidal anti-inflammatory drugs for individuals with hypertension or heart failure or CKD of all causes, including diabetes; (3) do not prescribe angiotensin-converting-enzyme inhibitors in combination with angiotensin II receptor blockers for the treatment of hypertension, diabetic nephropathy or heart failure; (4) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team; and (5) do not initiate dialysis in outpatients with CKD category G5-ND in the absence of clinical indications.

Limitations:

A low survey response rate of both community and academic nephrologists could contribute to sampling bias. However, the purpose of this report is to generate discussion, rather than study practice variation.

Implications:

These 5 evidence-based recommendations aim to improve outcomes and individualize care for patients with kidney disease, while reducing inefficiencies and preventing harm.

[Medical Overuse in Switzerland: How Frequent is Preoperative Chest Radiography?]

Zusammenfassung. Hintergrund: Präoperatives Thorax-Röntgen bei Patienten ohne Verdacht auf intrathorakale Pathologie wird auf der Top-5-Liste der «Smarter Medicine»-Initiative aufgeführt. Diese Studie untersucht den Anteil unnützer präoperativer Röntgenthorax-Aufnahmen in der Schweiz. Methoden: Sekundäranalyse von Abrechnungsdaten von hospitalisierten Patienten in der obligatorischen Krankenpflegeversicherung. Die Häufigkeit präoperativer Thorax-Röntgen wurde stratifiziert nach Soziodemografie und den chronischen Erkrankungsgruppen «kardiovaskuläre Erkrankung» und «Atemwegserkrankung» untersucht. Ergebnisse: Von 47 215 hospitalisierten Individuen erhielten 6 121 (13 %) ein ambulantes präoperatives Thorax-Röntgen. Es zeigte sich erhebliche interkantonale Variation. Diskussion: Unsere Untersuchung ergab keine Hinweise auf einen übermässigen Einsatz von unnützen präoperativem Thorax-Röntgen in der Schweiz. Die interkantonalen Schwankungen könnten auf unerwünschte Varianz hinweisen. Die Studie liefert Argumente, zukünftige Top-5-Listendaten aus der Versorgungsrealität miteinzubeziehen.