Choosing Wisely Champions

If you’re a Canadian over the age of 65, there’s a good chance your medicine cabinet is a little crowded. Approximately two thirds of Canadians aged 65 or older are taking five or more prescription medications, with more than a quarter being prescribed 10 different drug classes. In addition, one may be taking over-the-counter medications such as acetaminophen, ibuprofen or supplements.  These staggering numbers are one of the reasons why I’m passionate about optimizing medication use and managing polypharmacy through deprescribing.

Polypharmacy is generally defined as the simultaneous use of multiple drugs by a single patient to treat one or more conditions; more and more, we think of polypharmacy as using more drugs than are medically needed. The more medications a patient is on, the more potential there is for drug interaction and harmful side effects.

It’s a slippery slope. Polypharmacy can lead to prescription cascades, which is when the side effects of a drug are misdiagnosed as symptoms of a new condition leading to further prescriptions and potentially additional side effects. These adverse reactions to multiple medications increase the risk of falls, which can result in injuries, fractures and hospitalizations.

Adverse drug effects take a toll on the health care system, and more importantly on the patient and their support system. Polypharmacy is a prime example of how ‘more is not always better’ and how we can apply Choosing Wisely principles to improve health outcomes.

Fortunately, thanks to campaigns such as Opioid Wisely and Using Antibiotics Wisely, awareness around deprescribing is growing. Deprescribing is the planned and supervised process of safely reducing or stopping the use of medication that may be causing harm or is no longer providing a benefit to the patient.

It’s not an easy process. It’s a team effort that starts with a conversation between the health care provider and the patient. It’s important to involve the patient in the decision-making process and ensure that the patient’s goals and values are considered and their concerns are addressed.

While medications such as antibiotics and pain medication can be very beneficial to the patient and improve health outcomes, there’s clear evidence that the inappropriate use of medications hinders optimal health outcomes. It’s important for both patients and health care providers to routinely question whether a medication is needed or if there are alternative strategies that can be considered instead. The same applies every time a medication is renewed.

Education is key to creating this mindset. In my opinion Choosing Wisely is something that should be included in every health care curriculum. Any test, medication, or treatment requires a thoughtful, evidence-based decision, so the earlier we start embedding that concept in students, the better.

I’m passionate about antimicrobial stewardship because the evidence is strong: using antibiotics when you don’t need them increases the risk of antibiotic resistance, which renders antibiotics ineffective when you need them in the future. If we do not start changing our practice in antibiotic use now, we could be faced with a serious medical crisis. Our future depends on it, as well as the future of our kids and grandkids.

Antimicrobial stewardship is incredibly complex, which is why we must work as a team to find solutions. Fortunately, with Choosing Wisely and campaigns like Using Antibiotics Wisely, the antimicrobial stewardship movement is picking up steam and awareness is growing. For instance, Dr. Sergio Fanella and his team at Children’s Hospital – HSC Winnipeg implemented a very successful pilot project that reviewed the use of antibiotics for every child. Clinicians, specialists and pharmacists worked together to determine whether or not prescribing antibiotics would lead to better health outcomes. Eventually, reviewing and thinking about antibiotic prescribing became part of daily practice.

There are also some community-based projects, which are important since over 90 per cent of antibiotics are prescribed in the community setting. Dr. Ganesan Abbu championed antimicrobial stewardship in the Boundary Trails Health Centre in Morden/Winkler, and as a result local clinicians in the area are far more aware and far more conscientious about the appropriate use of antibiotics in their practice.

This progress is uplifting because if we are not stewards now and if we do not remain vigilant and diligent about how and when we are prescribing antibiotics, we are putting our patients at risk. If bacteria is repeatedly challenged, i.e. with antibiotics, science shows us that it will respond by developing a resistance against antibiotics as part of its natural course.

The serious implications of antibiotic resistance are the reason why I advocate for antimicrobial stewardship. As the co-chair of the Federal Antimicrobial Stewardship working group, we are working to move policy, education, and decision making at a higher level to effect change. Antimicrobial stewardship should be driven from the top. Choosing Wisely is a key component to this process because it provides evidence-based recommendations and tools for more than 15 different clinical specialties that can be integrated into every day practice.

Educating both clinicians and patients about the appropriate use of antibiotics is also critical in facilitating change and shifting social expectations. Another reason why Choosing Wisely is incredibly valuable is because it encourages patient engagement and supports healthy conversations between patients and their health care providers about appropriate antibiotic use. Not only do these discussions lead to better health outcomes, but they also help grow the antimicrobial stewardship movement.

Preparing Manitobans for surgery requires interdisciplinary collaboration. In addition to a surgeon, most surgical patients will also receive care from an anesthesiologist, a primary care provider and a preanesthetic clinic.  Historically, panels of blood work and other investigations like electrocardiograms and chest x-rays were ordered routinely.  They were intended to screen for asymptomatic abnormalities and/or to use normal results to demonstrate that the patient was ready for surgery and anesthesia. 

Just as in other areas of clinical care where Choosing Wisely recommendations have shown to add value to patient care, we’ve also learned that more is not always better when it comes to preoperative testing.  It is uncommon for asymptomatic patients to have abnormalities in their preoperative tests, and the abnormalities we do find rarely result in significant changes in clinical care. Conversely, false positive tests can lead to more invasive and unnecessary confirmatory testing that may have other adverse effects for the patient.  With no evidence to suggest that this screening improves outcomes, additional testing can lead to surgery delays, potentially causing stress to the patient and progression of the underlying disease.

Since 2015, our team has been working to help physicians and other caregivers choose preoperative testing wisely.  With support from Manitoba Health, the George and Fay Yee Centre for Health Care Innovation and leadership from all the disciplines regularly involved in preoperative care, we have successfully taken steps towards improving preoperative diagnostic testing .One of our first steps was to incorporate the Canadian Anesthesia Society’s Choosing Wisely recommendations on preoperative testing into a provincial preoperative testing guideline.  These recommendations have been shown to significantly reduce the amount of recommended laboratory testing prior to elective surgery compared to what has historically been obtained.  We also recognized that on its own, dissemination of this guideline would not be sufficient to significantly and sustainably change practice.  We were particularly aware that in the multidisciplinary preoperative environment patients and providers would continue to be inconvenienced by requests for unnecessary testing unless all team members consistently adhered to the guideline.  Furthermore, we were concerned that inconsistent adherence would lead to confusion between providers and a fall back to routine ordering of panels of preoperative lab work in a misguided attempt to more efficiently move the patient through the system.

Considering these challenges, our team has worked hard to ensure that anesthesiologists and preanesthetic clinics, as the last team members to see the patient before surgery, are up-to-date on this culture practice change.  In addition, we’ve created a variety of knowledge translation tools including an updated preoperative history and physical form, an online app with guideline content and template letters for communication of preoperative testing expectations and other information between surgeons and primary care providers. A recently completed chart audit has shown that these initiatives were associated with a 34% reduction in unnecessary testing, and an estimated savings of $32 per patient, or approximately $900,000 per year within the Winnipeg Regional Health Authority.  We’re optimistic that we can achieve further improvements in preoperative testing by further engaging stakeholders with additional knowledge translation strategies.

Choosing Wisely is important for the sustainability of health services, not just for my patients, but for all Manitobans.  We only have so many resources and I want to ensure we’re allocating tax dollars to the highest value services my patients really need. I am a witness to this on a daily basis, appraising my actions while advocating for the best care for my patients; so I feel a duty to “Choose Wisely” so my patients will get the care they really need, now and into the future.

Communication is critical in making this initiative a reality. Meeting the expectations of our patients needs to be managed in a socially accountable manner by educating and setting a behavioral standard at each clinical encounter. Any day that I can pass this information on to one of my patients is a good day in clinic.  Any day that they can carry that sentiment forward to others is an even better day!

Fortunately in my practice, I am starting to see patients who are becoming wise to unnecessary drugs and diagnostics. A great example is the work up for acute lower back pain. This is a great opportunity for a one on one discussion on the topic of unnecessary x-rays, CT’s and MRI’s.  I will often ask my patients about their expectations of the outcomes of a specific test. If they request a CT scan, do they worry about the radiation exposure, are they concerned about their condition worsening, what do they think the harm is in delaying an exam, what red flag symptoms should they be aware of? It gets us to the heart of their expectations, and often we can agree that we don’t need to do the test. We can then move onto a management plan, which gives a feeling of satisfaction.

Communication is also moving forward between our medical experts. During our CPD sessions, conversations about social accountability are occurring more frequently. Scientific planning committees are now integrating Choose Wisely tools at many of our educational events and physicians, both new and established, are utilizing these resources that will help support them in their daily clinical encounters. Unfortunately, we don’t get through to every patient, some still advocate for that test or prescription, but the tools that Choose Wisely Manitoba is developing can strengthen our role as “medical expert” and offer us a tool kit to draw from and allow us to further open up those conversations. We will, however need to move beyond the paper reference materials- utilize the waiting room for educating and leverage technology through social media and patient information resources. I believe we can educate on their terms and must influence on our terms.

I think Choosing Wisely matters to every patient I see as it refocuses me to think carefully when making treatment decisions.  As a physician, I accepted the obligation stated in the Hippocratic Oath to “do no harm” and fundamentally I think that is what Choosing Wisely is about.  If physicians provide unnecessary or extraneous care, we will eventually harm someone – no diagnostic test, procedure, or medical treatment is risk free.  Not only do we need to know when to do provide certain potentially life-saving tests and treatments, but equally important is knowing when not to perform those same interventions if doing so might actually harm the patient given different circumstances. Importantly, the Choosing Wisely campaign doesn’t try to tell us “never” do something, but rather encourages and supports us in using our clinical judgment and evidence-based patient centered rationale to make the best decisions. Typically medical education encourages us to be thorough, which is generally a good thing, but taken too far, we risk failing to be judicious when it is appropriate for our patients to do less.

I appreciate Choosing Wisely Manitoba for keeping us on top of the evidence and challenging us to question what we do. I think it’s useful that these recommendations are convenient, concise, peer-reviewed and evidence-based. In my practice, we’ve noticed that once you get engaged in thinking about the Choosing Wisely recommendations there is a collateral benefit – even if you haven’t memorized all the specific recommendations, you find yourself naturally questioning and more likely to modify your clinical practice for the patient in front of you. It also gets us thinking about other quality and efficiency improvements in our clinic that may be more “lean” than “choosing wisely”. One of the challenges or risks related to the advancement of the evidence-based medicine paradigm is that we seem to be encouraged to follow algorithmic protocols that can take discourage the heuristic interaction between patient and physician. Choosing Wisely encourages us to be judicious interpreters selecting the interventions that are right for our patients and being more cognizant of our role to treat each patient as an individual and not apply tests and treatments indiscriminately. Personally, I think it helps me be a more mindful doctor ensuring my care leads to truly beneficial outcomes in my patients.

Prescribing antibiotics is a good example; if we blindly dispense these powerful medications for every potential infection, we lose sight of what is best for each individual patient; perhaps I should not be worrying about the cough in a 5 year-old as much as an 70 year old with COPD.

My research and clinical work overlap in the clinic where I work. I’m privileged to work in a place that has been willing to change our practices based on our own EMR data and other benchmarks for some key indicators. Interestingly, it is giving us a new perspective on practice outliers and practice change, but also on how we need to make system changes that support us doing the right things, and help us avoid doing unnecessary things.

I’ve been involved with Choosing Wisely Manitoba since its beginning, and I’m pleased to be considered a Clinical Champion. Beyond each of the specific recommendations, we are encouraged as physicians to question the things we’re doing on a daily, patient-by-patient basis. We’re challenged to reflect on the evidence and ask ourselves if what we’re doing is appropriate – it builds an almost automatic reflex reaction to everything we do; after all, not everything we do is beneficial, and we should be questioning the real clinical needs and risks for our patients.

I’m particularly interested in choosing our therapies wisely and a few of my pet interests include: medications typically prescribed for long periods of time (such as proton pump inhibitors), polypharmacy, and the long term value versus negative impacts and side effects of all medications we prescribe for our patients.

In my own specific practice, I am keen to participate and encourage all my colleagues to take quarterly medication reviews seriously and am especially interested in over prescribing and long-term use of antipsychotics, sedatives and the multi-pharma cocktails many of our geriatric patients. I recall one particularly elderly patient on multiple medications, including 3 different antipsychotics – she was barely ambulatory and virtually comatose. After our team case review, we designed a step-down regimen that ended with 1 medium dose antipsychotic and many fewer drugs; she became more mobile and cognitive – the family couldn’t believe how it was like she had been returned to them.

Often our medical team and the family fear the impacts and risks of reducing these medications, but in one of our units we were able to free up nursing time by reducing the number of medication “passes” – reducing the cycle and frequency of medication distributions to patients, and offsetting the time they were able to spend with each patient and support step-down regimens. Knowing that their loved one will have more attention is very reassuring to families who really want their granny not to be medicated so heavily, but fear change even if granny could be returned to them because they think “she’s doing so well”.

Choosing Wisely Manitoba has challenged, encouraged, and enabled us to examine many of our clinical practices – and I believe we are improving quality, improving the health system, delivering better care, and ultimately reducing wait times and saving health care dollars.