SGEM Xtra: High-Value Care Post Covid19 – Did you ever have to make up your mind?

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Date: May 28th, 2021

Guest Skeptics: Heather Logan is the executive Strategy lead for the Canadian Agency for Drug and Technologies in Health (CADTH). Dr. Wendy Levinson is the Chair of Choosing Wisely Canada (CWC) and a Professor of Medicine, University of Toronto

This SGEM Xtra is based on document created by CADTH and presented at Choosing Wisely Canada National annual meeting May 13, 2021. The title of the report is Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care.

We have discussed Choosing Wisely before on SGEM Episodes:

• SGEM#15: Choosing Wisely
• SGEM Xtra: CAEP Choosing Wisely
• SGEM Xtra: Right, You’re Bloody Well Right, You’ve got the Bloody Right to Care

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Choosing Wisely Canada (CWC):

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It is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices. Choosing Wisely Canada is led by a team of clinicians and staff based at St. Michael’s Hospital (Toronto), the University of Toronto, and in collaboration with the Canadian Medical Association.

Choosing Wisely Canada mobilizes and supports clinicians and organizations committed to embedding campaign recommendations into practice.

There are close to 350 documented quality improvement projects across the country that are building capacity for the spread and scale of Choosing Wisely.

These efforts are underway in hospitals, long-term care homes, and primary care clinics. Many of these innovative projects, including their evidence-based tools and methods, have been packaged into easy to follow toolkits that are broadly circulated in order to encourage widespread adoption. This has allowed Choosing Wisely Canada to foster a network for those looking to implement campaign recommendations into practice.

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Canadian Agency for Drug and Technologies in Health (CADTH):

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It is an independent, not-for-profit agency funded by Canadian federal, provincial, and territorial governments (except Quebec) to provide credible, impartial advice and evidence-based information about the effectiveness of drugs and other health technologies to Canadian health care decision-makers.

CADTH believes that credible, objective evidence should inform every important health care decision. When you want to know what the evidence says, ask CADTH.

Created in 1989 by Canada’s federal, provincial, and territorial governments, CADTH was born from the idea that Canada needs a coordinated approach to assessing health technologies. The result was an organization that harnesses Canadian expertise from every region and produces evidence-informed solutions that benefit patients in jurisdictions across the country.

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South Huron Hospital Association (SHHA) is known as the “Little Hospital that Does”. SHHA has been choosing wisely since 2012 selecting five items every three years.

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SHHA Choosing Wisely 2012

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1. Influenza shots for staff with privileges SGEM#20
2. Use Ottawa ankle and knee rules SGEM#3 and SGEM#5
3. No routine use of antivirals for Bell’s Palsy SGEM#14
4. No routine use of antibiotics for simple cutaneous abscesses SGEM#13
5. No routine use of proton pump inhibitors for upper GI bleeds SGEM#16

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SHHA Choosing Wisely 2015

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1. Utilize Canadian CT head rules to guide our decisions on getting CT heads SGEM#106
2. Utilize Canadian C-Spine rules to guide our decisions on obtaining plain film c-spine imaging SGEM#232
3. Do not do annual physical exams on asymptomatic adults with no significant risk factors
4. Do not screen women with Pap smears if under 21 years of age or over 69 years of age
5. Do not order echo cardiograms routinely

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SHHA Choosing Wisely 2018

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1. Only use supplemental Oxygen for STEMI patients that are hypoxic (saturations < 90%) SGEM#193
2. Use appropriate antibiotic selection for uncomplicated COPD exacerbation ie. Amoxicillin, Septra and Doxycycline
3. Do not start IV unless you are 80% sure that you are actually going to use the IV SGEM#204
4. Treat Chronic Pain utilizing non-pharmacological means before prescribing an opioid medication
5. Don’t place or leave in place a urinary catheter without reassessment

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Low-Value Care, Challenges of COVID19, High-Value Care and the Purpose of the CADTH Report

Slides from the Choosing Wisely Presentation – May 13th, 2021

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CADTH Four Step Approach

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Recommendations in Six Key Clinical Areas

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• Primary care: Seven recommendations span primary care, including avoiding unnecessary rural transfers, annual exams, and screening and imaging tests
• Specialty care: Four recommendations address low-value procedures, including chronic dialysis, colonoscopy for constipation, cardiac imaging without high-risk markers, and knee MRIs
• End-of-life care: Three recommendations emphasize the importance of advance care planning conversations for patients with serious illness and access to palliative care
• Hospital care: Two recommendations address low-value routine investigations and pre-operative testing in hospital care
• Long-term care: One recommendation addresses unnecessary hospital transfers from long-term care
• Blood products: One recommendation addresses the overuse of red blood cells transfusion in hemodynamically stable critical care patients.

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Nineteen Recommendations for High-Value Care

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Hospital Care:

• Routine Investigations: Don’t order routine investigations, including chest radiographs or blood tests, in critically ill patients except to answer a specific clinical question.
• Preoperative Testing: Don’t order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery

End-of-Life Care:

• Advance Care Planning Conversations: 
  • Don’t start or continue life-supporting interventions unless they are consistent with the patient’s values and realistic goals of care
  • Don’t delay advance care planning conversations
• Palliative Care:
  • Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment

Specialty or Outpatient Care:

• Nephrology: Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team
• Gastroenterology: Avoid performing a colonoscopy for constipation in those under the age of 50 years without a family history of colon cancer or alarm features
• Cardiology: Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present
• Orthopedics: Don’t order a knee MRI when weight-bearing X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis as the MRI rarely adds useful information to guide diagnosis or treatment

Long-Term Care:

• Transfer: Don’t send the frail resident of a nursing home to the hospital unless their urgent comfort and medical needs cannot be met in their care home

Blood Products:

• Red Blood Cells Transfusion: Don’t routinely transfuse red blood cells in hemodynamically stable ICU patients with a hemoglobin concentration greater than 70 g/L (a threshold of 80 g/L may be considered for patients undergoing cardiac or orthopedic surgery and those with active cardiovascular disease)

Oncology:

• Palliative: Don’t delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment

Primary Care: 

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Key Messages from the CADTH Report

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• Low-value tests, treatments, and procedures are an important health care quality problem in Canada and across the world because they provide little clinical benefit, may be harmful for patients, and waste limited resources.
• Due to the COVID-19 pandemic, health care systems face increased challenges of limited resources, reduced capacity, and a growing backlog of surgeries and other procedures. The pandemic has compelled health care professionals to make challenging decisions to prioritize health care services while coping with increased demand.
• As Canada emerges from the pandemic and health care systems rebuild and begin to address the backlog of delayed or cancelled services, there is an imperative to introduce lasting changes to reduce low-value care and ensure high-quality care is available to everyone.
• To help inform efforts for using health care resources wisely and to support decision-making, CADTH and Choosing Wisely Canada convened a 10-member multi-disciplinary panel of clinicians, patient representatives, and health policy experts to review areas of low-value care that can be reduced or limited. This panel reviewed, deliberated, and prioritized 19 recommendations of the more than 400 Choosing Wisely Canada recommendations, the implementation of which can help ensure high-value care after the pandemic.

You can also read the CADTH media release announcing the report.

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The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.

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REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

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