Unnecessary Care in Canada
In healthcare, more does not necessarily mean better. Unnecessary tests and treatments are not helpful and they potentially expose patients to harm, lead to more testing to investigate false positives and cause unwarranted anxiety to patients and their families. Unnecessary care also wastes system resources and contributes to longer wait times.
There are many possible drivers of unnecessary care (Morgan et al. 2017), including:
- Practice habits are traditionally difficult to change, even in the face of new evidence.
- Patients might demand tests and treatments they are misinformed about.
- Lack of time for shared decision-making between clinicians and patients.
- Outdated decision-support systems encourage over-ordering.
- Payment systems reward doing more.
Over the years, there have been many efforts to address the concerns of unnecessary care in Canada. For example, the Saskatchewan Surgical Initiative (http://www.sasksurgery.ca/sksi/surgicalinitiative.html), established in 2010, aimed to improve surgical care and experience for patients. A key component of the initiative was to streamline care processes to ensure patients are receiving appropriate and timely care.
As part of a global movement to reduce unnecessary care, Choosing Wisely Canada (CWC) was launched in 2014. CWC is a national, clinician-led campaign designed to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures, and supports physician efforts to help patients make smart and effective choices to ensure high-quality care. CWC has engaged more than 90% of all Canadian medical specialty societies to develop lists and has published over 250 recommendations in partnership with them. The campaign marks a point where physicians, patients and government all agree on the need to reduce unnecessary care. CWC collaborates with many national, provincial and regional organizations to bring together stakeholders to help accelerate improvement initiatives.
To fulfill the measurement and evaluation objectives of the campaign, the Canadian Institute for Health Information (CIHI) collaborated with CWC to measure eight Choosing Wisely recommendations. The recommendations selected for this study have provincial interest and value, align with international interest and span several areas of the healthcare system: primary care, specialist care, emergency care and hospital care. The report, Unnecessary Care in Canada (CIHI 2017), released in April 2017, found that up to 30% of patients covered by these recommendations received potentially unnecessary care. Furthermore, substantial variation exists among regions and facilities in terms of the number of unnecessary tests and procedures performed – pointing to an opportunity to improve.
The report also details success stories – from national- and facility-level organizations as well as from individual clinicians across the country – of using the recommendations to identify and reduce unnecessary care.
Highlights from the report are provided in Table 1.
|Table 1. Highlights from the report|
In 2014–2015, the rate of chronic benzodiazepine use among seniors varied across the country from 5% in Saskatchewan to 25% in New Brunswick.
In most provinces, the rate had fallen since 2011–2012; however, there were steady increases in three provinces: Newfoundland and Labrador, Prince Edward Island and New Brunswick.
Variation across provinces may be because of several factors, such as public drug program design, physician prescribing practices and patient socio-demographic factors.
Both prescription practice and the discontinuation of sedative hypnotics while a patient is in hospital can have a substantial impact on long-term use. Non-pharmaceutical-based therapy, such as behavioural therapy, or following a benzodiazepine withdrawal program has proven effective in discontinuing use.
In Ontario, Saskatchewan and Alberta, endoscopy and ophthalmology were the most common types of low-risk surgeries.
In all three provinces, endoscopy patients had lower rates of pre-op tests than ophthalmology patients did; however, patients with other (less frequent) procedures had the highest rate of pre-op tests.
Electrocardiogram (ECG) was the most common type of preoperative test: 64–80% of patients undergoing low-risk procedures had at least one ECG.
CIHI's analysis of facilities in Alberta and Saskatchewan found wide variation among providers, even within the same facility. While it is difficult to decouple the facility rate from the physician rate, we do see wide variation, with preoperative test rates ranging from 1% to 95%. Physicians who did fewer procedures tended to order more preoperative tests which can end up delaying surgery.
Almost 50,000 patients aged 18–64 visited emergency departments in Ontario and Alberta for minor head trauma (with no red flags) in 2015–2016 – roughly 75% of all reported head trauma cases in this age group.
Almost one in three had a potentially unnecessary head scan, 98% of which were computed tomography (CT) scans. This is the equivalent of more than 15,000 potentially unnecessary scans.
Patients who were male, older or living in lower-income neighbourhoods were more likely to receive potentially unnecessary head scans. The variation among facilities (0–68%) was even greater than the regional variation. Emergency departments with high trauma volumes (not only head trauma) had higher percentages of potentially unnecessary head scans. The decision to order a scan may be influenced by many factors, such as availability of diagnostic machines on site, physician training program and patient expectations.
A better understanding of all these factors may facilitate collaboration among clinicians and health system leaders to ultimately reduce potentially unnecessary imaging.
In 2013–2014, risk-adjusted red blood cell transfusion (RBCT) rates among elective hip replacement patients varied from 16.3% in Prince Edward Island and Alberta to 7.7% in Manitoba. The variation for elective knee replacement patients was from 11.5% in Alberta to 5.1% in Manitoba.
The variation in RBCT rates was greater across facilities than across geography. Among facilities with at least 100 elective hip replacements, RBCT rates ranged from 2% to 33%. As for facilities with at least 100 elective knee replacements, RBCT ranged from 0% to 27%. Providers who had 0% use of RBCTs still conducted 100 or more procedures. This might point to where improvements have been made and/or practices have been influenced by clinical guidelines.
Please refer to Unnecessary Care in Canada report (https://www.cihi.ca/en/unnecessary-care-in-canada) for more detailed findings on all eight recommendations and improvement efforts of partner organizations across the country.
Along with the full report, there is an accompanying technical report, as well as data tables that are publicly available.
About the Author
Katerina Gapanenko, PhD, is the manager of the Health System Research team at the Canadian Institute for Health Information (CIHI), Toronto, ON. She oversees the development and production of a variety of CIHI's analytical reports.
David Lam is senior project coordinator at CIHI, Toronto, ON.
Michelle Parker was a program lead at CIHI, Toronto, ON.
Jennifer D'Silva is the manager of Emerging Issues at CIHI, Toronto, ON.
Tracy Johnson is the director of Health System Analysis and Emerging Issues at CIHI, Toronto, ON.
Canadian Institute for Health Information (CIHI). 2017. Unnecessary Care in Canada. Ottawa, ON: Author. Retrieved August 31, 2017. <https://www.cihi.ca/en/unnecessary-care-in-canada>.
Morgan, D.J., A.L. Leppin, C.D. Smith and D. Korenstein. 2017. "A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient–Clinician Interaction." Journal of Hospital Medicine 12(5):346–51. Retrieved August 31, 2017. <http://www.journalofhospitalmedicine.com/jhospmed/article/136487/hospital-medicine/practical-framework-understanding-and-reducing-medical>.
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