Choosing Wisely Manitoba is focused on initiatives where there is an opportunity, specific to Manitoba, to improve the appropriate use of tests, treatments and procedures overwhelmingly shown by evidence to provide no benefit to a patient.
Improving Preoperative Diagnostic Testing
In Manitoba, many patients presenting for low-risk surgery were receiving full preoperative assessments despite the fact that these assessments did not improve outcomes. In 2014 a multidisciplinary team was formed to restructure the way preoperative assessment is carried out in Manitoba. The goal was to ensure that all Manitobans receive the necessary and appropriate preoperative diagnostic testing for minor surgeries through the sustainable implementation of a standardized, evidence-informed clinical practice guideline.
This project started with an examination of the barriers and facilitators to guideline adoption and implementation including further analysis of audit results, stakeholder consultations and a literature review. The results of this work were then used to develop and implement a new Routine Preoperative Lab Test Guideline. A series of interventions were then developed aiming first to reduce unnecessary testing in cataract surgery and then to reduce unnecessary testing in other types of surgery.
The implementation of a revised Cataract Surgery History and Physical (H&P) Form emphasized that tests are not usually required for cataract surgery and eliminated cuing for unnecessary preoperative tests. At the same time a Red-Green project eliminated preoperative History and Physicals for ~60% of cataract surgery patients. Pre and post-implementation audits showed a 77.5% reduction in patients undergoing preoperative testing from pre to post-implementation.
Building on what we learned through the cataract project, on July 11, 2016, five revised documents were implemented to help reduce cues that prompt unnecessary testing for all other types of surgery. The revised documents were implemented in eight surgical sites across Winnipeg.
Our primary outcome, to reduce preoperative diagnostic testing by 25%, was evaluated through retrospective chart reviews of two random samples of surgical patients during typical weeks in the WRHA. The results demonstrated a significant (p<0.0001) 35% reduction in preoperative diagnostic testing.
In order to review adherence to the guidelines and to support implementation by providing feedback and supporting materials, we have conducted approximately 10 audits of surgeons in each of the 8 surgical sites in Winnipeg (excluding cataract and pediatrics). The results revealed that the majority of surgeries were compliant with the guidelines (60%) but that there is a large range in the number of unnecessary tests ordered between surgical specialties from 24% of tests ordered are unnecessary to 72% are unnecessary. Based on these results our next step is to provide feedback to individual surgeons including supporting materials to increase adherence to the guidelines.
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Tissues for Disposal
Human tissues removed during a biopsy or surgical procedure are typically sent to a pathology laboratory for diagnostic examination and testing. Under the framework of Choosing Wisely Manitoba, and with the support of Orthopedic Surgeon and Clinical Champion, Dr. Eric Bohm, DSM conducted a retrospective review of approximately 300 orthopedic surgery cases (representing one surgeon’s annual caseload) to correlate pathology findings with the original diagnostic imaging report. As evidence and experts had suggested, the results of the review supported the case that pathology testing on tissues removed from the body during orthopedic procedures do not provide additional clinical data making the original diagnostic imaging report clinically sufficient. With no value added to patient care, these tissues are now recommended for exemption from requiring pathological review and instead recommended for immediate disposal.
New standard operating procedures to eliminate testing from elective hip and knee replacement surgeries were developed and implemented at Concordia Hospital, Grace Hospital and Boundary Trails Health Centre. Once fully implemented at all provincial orthopedic surgery sites, disposal of these tissues is anticipated to free pathologists’ for other important work. On average pathology testing was reduced from 204 tests per month to 13 tests per month (April – December, 2017). That represents a 93% reduction in pathology testing following the implementation of the new standard operating procedures. Ongoing collaboration with surgeons will ensure the development of processes to facilitate immediate disposal and improve workflow and efficiencies. Related clinical practice changes can be found here (November 2017, August 2017, July 2017, June 2017, June 2017).
Reducing Unnecessary Prostate-Specific Antigen (PSA) Testing
The PSA blood test is a test for prostate cancer, the most common cancer among men in Canada. The test has been used widely for early detection of the disease despite the fact that it does not significantly decrease overall prostate cancer mortality. Further, PSA testing can lead to a high number of false-positives, leading to over diagnosis, over treatment, and a potential decrease in quality of life. PSA levels may be elevated for many reasons and most men with high PSAs don’t have prostate cancer. Usually when prostate cancer is detected these cancers grow slowly and have a good prognosis, even without treatment.
Many provinces in Canada along with the Canadian Urology Association, Canadian Cancer Society, Canadian Task Force on Preventive Health Care and Prostate Cancer Canada have recommendations around when men should have a PSA test to screen for prostate cancer. Most recommendations limit testing to within certain age parameters and risk factors. An initial review of the current state of PSA testing in Manitoba revealed that every year thousands of tests are carried out on men who are not at high risk of life threatening prostate cancer. Choosing Wisely Manitoba is working with key stakeholders to examine current guidelines that reinforce appropriate testing parameters and clinical indications for PSA testing in Manitoba. In addition we are studying ways to educate patients and support physicians in engaging in healthy conversations about PSA testing.
Activated Partial Thromboplastic Time
The suboptimal utilization of aPTT testing has been identified as a prevalent problem across all health regions in Manitoba. As part of Choosing Wisely Manitoba and as per the aPTT testing recommendations issued by Choosing Wisely Canada, DSM’s Hematology discipline provided direction and new guidelines for the ordering of aPTT testing. Following this clinical practice change in October 2015 aPTT test requests have decreased provincially by an estimated 20,000 per month. It is anticipated that more than $57,000 will be saved in supply costs, allowing reinvestment within other areas of Hematology. Related clinical practice changes can be found here (September 2015).
Resource Stewardship in Medical Curriculum
Resource stewardship is a central focus of the Choosing Wisely initiative and an important concept to reinforce early in medical education as its principles can be carried throughout a physician’s career. Funded through DSM’s Summer Studentship Program, a project to better emphasize this concept within the University of Manitoba’s undergraduate medical education program (UGME) was funded through DSM’s 2016 Summer Studentship program. Following a review of Manitoba’s pre-clerkship medical curriculum, a variety of learning materials, including readings, interactive lectures, team-based learning sessions and online modules were developed, incorporating Choosing Wisely Canada recommendations. The impact of these changes on students’ knowledge and attitudes regarding resource stewardship are currently being assessed following the 2016-2017 academic year. Article: DSM Funds Student Project to Integrate Resource Stewardship into Medical Curriculum & Why Students Should Choose Wisely
ESR and CRP Testing
C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) testing generally offer the same information on a patient, looking for evidence of inflammation in the body. Often, physicians order both of these at the same time, not understanding that they both provide the same information except in special circumstances. In collaboration with Infectious Disease specialists and Rheumatologists, DSM has established that we can safely not provide both tests to general practitioners unless they have the approval of a Hematologist or Hematopathologist. This has resulted in a 25% decrease in combined testing. In addition, since this test is not needed as a stat test, DSM was able to consolidate the number of sites where this test is performed, adding to province-wide efficiencies. Related clinical practice changes can be found here (September 2017 and July 2017).
Appropriate Use of FOBT
In the absence of a national Choosing Wisely recommendation on Fecal Occult Blood Testing (FOBT), CWMB has assumed a leadership role in engaging DSM and Gastroenterology specialists to conduct research and present the evidence on appropriate use for FOBT in our province. The guaiac FOBT was designed to detect hidden blood in stool, making it an effective screening tool for colorectal cancer screening. However, the test is also commonly used (off-label use) in hospitalized patients to detect gastrointestinal bleeding in the investigation of anemia. In March a practice change was issued to support the recommendation that use of the guaiac FOBT should be restricted to the approved indication of screening for colorectal cancer in asymptomatic patients and should not be performed on hospitalized patients for investigation of anemia. CWMB has adopted this as its first “made in Manitoba” recommendation and hopes to lead other provinces in moving toward enforcing the appropriate use of this test. Related clinical practice changes can be found here (February 2017).
Improving the Appropriate Use of MRI for Lower Back Pain
Lower back pain is very common and 50-90% of people will experience lower back pain at some time in their lives. Patients wanting to pursue all options for diagnosis, treatment and recovery, are large drivers of inappropriate MRI and other medical imaging. This unnecessary testing can lead to more tests and in some cases, patients undergo surgeries that they do not need. In the absence of red-flag symptoms, MRI is not recommended for lower back pain. Patient education materials have been developed as a first step in the pilot project taking place at Boundary Trails Health Centre. These materials will be further supported by clinical guidelines, a provincial roll-out, and additional public awareness. Further physician resources can be found here.
Appropriate Vitamin D Testing
Vitamin D (25(OH)D) deficiency testing in Manitoba has increased exponentially over the last eight years, from approximately 5,000 in 2006 to 50,000 completed tests in 2015/16. Evidence based guidelines advise against routine testing, however it is estimated that approximately 90% of these tests have been completed on patients without medical indication, representing up to $800,000 that could be redirected to other critical diagnostic areas.
CWM implemented new ordering criteria and a new requisition (supported by Choosing Wisely Canada and Manitoba Endocrinologists) in early 2016 with initial data already showing a significant improvement within only a month’s time. Manitoba continues to see a decrease in ordering of this test, which is improving service delivery for medically indicated and priority tests as well as making way for a redirection of resources to other diagnostic areas of need. Related clinical practice changes can be found here (Jan 2016). Related clinical practice changes can be found here (February 2016). Further patient resources can be found here.
A Growing Momentum for Choosing Wisely
The Effective use of Blood and Blood Products and Imaging for lower back pain will be significant focuses for the upcoming fiscal year. Other current and future planned CWM projects include D-Dimer/Imaging for Deep Vein Thrombosis and pulmonary embolism, imaging for headache and head pain and fecal occult blood tests. Related clinical practice changes can be found here (May 2017, June 2017).
Work and collaboration continues with priority preoperative groups as well as within other pre-op specialties and within other medical disciplines to explore new Manitoba appropriate initiatives. Thanks to the support of Manitoba’s medical community more than 40 new champions and 20 new initiatives have been identified for further exploration.