Taking Action on Overuse

In 2018, Ontario introduced Rapid Access Clinics for Low Back Pain, where primary care providers can send patients with lower-back pain to a multidisciplinary team for timely care. Rather than waiting more than 6 months to be assessed by a spine surgeon — with the great majority receiving an MRI while they waited — patients are assessed by specially trained providers in less than 4 weeks, on average. A study found that in more than 30% of cases, an MRI was not needed and only 10% of patients were candidates for surgery. In addition to reducing imaging overuse, the clinics also provide education and evidence-based self-management plans, which help improve patient experience and outcomes.

Similar to Ontario’s clinics, Saskatchewan’s Spine Pathway Program ensures that patients experiencing back pain get the care they need quickly. The program is designed around an evidence-based care pathway that starts in primary care. If there’s no improvement, the patient is referred to a Spine Pathway Clinic in Regina or Saskatoon. From there, only those who would benefit from surgery are referred to surgeons. Imaging is typically not warranted until the final step in the pathway, which helps cut down overuse.

The Alberta Back Care Pathway Program is a research study through the University of Alberta to address low back pain symptoms while reducing inappropriate interventions in family practice.

BC Patient Safety and Quality Council’s Essential Imaging Initiative provides tools and resources designed to accelerate change for appropriate medical imaging for low-back pain and other clinical areas. Resources include coaching and support for participating teams, as well as a webinar series.

Quality of Care/Choosing Wisely NL undertook an investigation of the magnitude of unnecessary low-back imaging in the province, and a framework on communication behaviours and tools was described in an education article to support shared decision-making in primary care.

Choosing Wisely Manitoba has developed an educational poster for patients, advising of the risks of unnecessary imaging for lower-back pain, and when to connect with a doctor.

All provinces and territories co-created Canada’s Action plan for the elimination of cervical cancer in Canada, 2020–2030, which outlines steps to reduce cervical cancer, including the transition towards primary HPV screening and self-sampling. Several provinces across the country have initiated planning or transition to HPV primary screening and/or self-sampling and momentum continues to build.

The Canadian Partnership Against Cancer (The Partnership) is providing $1.4 million in funding to support planning and implementation of HPV screening as the primary test to replace the Pap test in seven provinces (BC, SK, MB, NB, PEI, NS, NL). The Partnership has also developed a number of resources to improve cervical cancer screening practices including conducting routine environmental scans to highlight cervical cancer screening guidelines, strategies, and activities across Canada and internationally.

The Canadian Strategy for Cancer Control is a roadmap to improve equity and quality cancer care and includes a focus on sustainability. The Partnership is working with jurisdictions to monitor progress towards the Strategy, including optimizing screening and appropriate follow-up.

Each jurisdiction is a member of the Pan-Canadian Cervical Screening Network, a community of practice hosted by the Partnership to support improved quality, equity, and delivery of population-based cervical screening services across Canada.

The Task Force has developed a suite of knowledge translation materials which support reducing cervical cancer screening outside of the recommended age guidelines. Materials include algorithms and frequently asked questions for clinicians and patients.

The BC clinical trial, HPV FOCAL, found that over a 4-year period the HPV test was a better screening tool for reducing the likelihood of cervical cancer compared to the Pap test. These results may help to inform improvements and efficiencies in cervical cancer prevention.

Using Antibiotics Wisely is a national campaign that encourages conversations about unnecessary antibiotic use in different practice settings. The primary care campaign works with the College of Family Physicians of Canada to engage family physicians through continuing medical education and has partnered with the Canadian Primary Care Sentinel Surveillance Network in providing prescriber-feedback reports. 

CPCSSN is studying ways to decrease inappropriate antibiotic use in primary care patients with viral respiratory tract infections and urinary tract infections. Using audit and feedback, physicians are provided antibiotic prescribing reports and provided education to improve practice.

Among Canadian jurisdictions, British Columbia has had the most success in reducing antibiotic use, with consistently lower rates year over year. The Do Bugs Need Drugs? program in British Columbia and Alberta includes education for prescribers and offers educational outreach to the public through schools, daycares and community care facilities and through campaigns ranging from transit ads to social media.

In December 2018, the highest-prescribing primary care providers in Ontario were sent a letter comparing their antibiotic prescribing rates to provincial norms, as well as information on how to limit overuse. Compared with high-volume prescribers who were not sent a letter, there was an 8.1% reduction in prolonged-duration prescriptions and a 6.1% reduction in antibiotic drug costs (both were statistically significant).

The EMPOWER cluster-randomized trial engaged patients at their pharmacy when they were renewing prescriptions for benzodiazepines and other sedative–hypnotics. In the intervention group, patients were given a pamphlet by the pharmacist on the harm versus benefits of benzodiazepines and other sedative–hypnotics, with a tool for tapering off using them. 27% of people given the pamphlets discontinued using sedatives compared with 5% in the group that was not given the pamphlet. This study showed that patients who are given direct information about risks and benefits may choose to stop taking medications with a risk of harm. 

The MD Snapshot-Prescribing Profile developed by the College of Physicians & Surgeons of Alberta provides physicians with a personalized report of how many benzodiazepines they have prescribed to their patients. More than half of physicians involved indicated they planned to make changes to their prescribing based on the profile and two-thirds of respondents found the information in the prescribing profile useful. 

SaferMedsNL is a provincial campaign that brings together patient advocates, health professionals and academics to raise public awareness about the risks of sedative–hypnotic drugs.

Nova Scotia’s Prescription Monitoring Program tracks and reports on controlled drugs from community pharmacies, including benzodiazepines. Feedback is provided to prescribers when concerns about a patient’s medication use are identified.

New Brunswick’s Prescription Monitoring Program includes monitoring of the benzodiazepine, Ativan, among other drugs and is built into the Electronic Health Record software to support prescribers and pharmacists in identifying at-risk patients.

The Deprescribing.org initiative provides online patient and provider information on deprescribing and supports information exchange for new approaches. Tools include an antipsychotic deprescribing guideline, algorithm, and infographic, as well as resources specific to long-term care.

Healthcare Excellence Canada’s Appropriate Use of Antipsychotics program was designed to find alternatives to antipsychotics for managing responsive behaviour associated with cognitive impairment and encourage the appropriate use of medications. Interprofessional teams work with residents and families to review care plans, including the use of antipsychotics. These medications are appropriately discontinued or reduced if they’re no longer needed, lowering the risk of harms and improving patient care and safety. This approach started through a national collaborative, and continued with provincial collaboratives in New Brunswick, Newfoundland and Labrador, Prince Edward Island and Quebec, supporting more than 300 long-term care homes. In New Brunswick, for example, a 2-year study in 58 nursing homes demonstrated a reduction of more than 50% in the use of antipsychotics.

BC Patient Safety and Quality Council’s CLeAR (Call for Less Antipsychotics in Residential Care) Initiative supports long-term care homes with behavioural care planning and management in effort to reduce the use of unnecessary antipsychotics to address responses behaviours. Primary interventions included education and capacity-building for leaders and clinicians, as well as medication review plans.

This 2021 article provides guidance on avoiding chest X-rays for typical bronchiolitis and potential quality improvement strategies for eliminating their use, including clinician education and family engagement.

Alberta Health Services has a clinical education resource on bronchiolitis management in emergency and inpatient departments. It includes best practice and evidence-informed clinical guidance on avoiding chest X-rays for bronchiolitis and supportive clinical management considerations.

The National Institute for Health and Care Excellence (NICE) in the U.K. implemented a quality improvement project to reduce inappropriate use of chest X-rays in children with bronchiolitis. To support bronchiolitis guidelines, NICE offered education, including raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff. Chest X-rays for bronchiolitis were reduced from 20% to 4% in a comparison of winter 2014–2015 and winter 2015–2016 pre- and post-implementation of the NICE bronchiolitis guideline. 

Holding monthly webinars, and conducting audits and providing feedback in 21 American hospitals helped to reduce unnecessary care in hospitalized children under the age of 2 with bronchiolitis. Chest X-rays decreased by 44% in a comparison of January, February and March data from 2013 and 2014.

The Checklist for Head Injury Management Evaluation Study is based on the Canadian CT Head Rule (a validated clinical decision rule to determine the need for head CTs in adult emergency department patients with minor head injuries). The checklist was developed and implemented in the emergency department of University Health Network in Toronto. Because patient expectations are an important factor in overusing CT scans, the team also created a patient handout adapted from CWC’s materials. The intervention reduced head CT use by 14% at 3 months and by 8% at 16 months.

A targeted patient-education infographic was posted in 2 emergency department waiting rooms in Calgary and was found to increase patient understanding of the risks and appropriate use of CTs for minor head trauma. In a survey on whether the infographic influenced patient beliefs about CT risks and benefits, 87% of respondents stated they better understood when a CT scan is appropriate, 93% felt they better understood the risks and 76% understood that their doctor can often rule out serious illness without a CT scan.

A data dashboard for audit and feedback was developed for emergency room physicians in Calgary, reporting on CT use. This was thought to be a potential driver in reducing CT use in Calgary for minor traumatic brain injury.

Choosing Wisely Yukon is currently monitoring head CT use patterns for various conditions including head trauma. Planned interventions include an educational component for clinicians and the public about the benefits, harms, and appropriate indications for head CTs.

The original randomized controlled trials showing the limited benefit of knee arthroscopy were conducted more than 2 decades ago and studies since concur. In addition to this growing body of evidence, calls to end the practice include a 2017 position statement from the Arthroscopy Association of Canada and a 2018 Choosing Wisely Canada recommendation. Governments have tried to discourage the procedure by changing fee schedules — in 2019, for example, Ontario’s Ministry of Health ended coverage for knee arthroscopies under the Ontario Health Insurance Plan for most patients with arthritis.

Known by its acronym QUARISMA, this cluster-randomized, controlled trial of a multi-faceted 1.5-year intervention at 32 hospitals in Quebec found a significant but small reduction in the C-section rate for women with low-risk pregnancies. The intervention included audits of C-section indications, feedback to health professionals on their rates of doing the procedure and the introduction of best practices.

The Better Outcomes Registry & Network (BORN) Ontario is Ontario’s perinatal, newborn and child registry. Its role is to facilitate quality care for families across the province. BORN Ontario helps health providers such as doctors, nurses and midwives track care for pregnant individuals and newborns on the Maternal Newborn Dashboard, which allows comparison with the rest of the province and established standards. The implementation of BORN Ontario’s Maternal Newborn Dashboard was associated with a significant decline in the rate of elective repeat Caesarean delivery in low-risk women prior to 39 weeks.

The California Maternal Quality Care Collaborative uses research, quality improvement toolkits, state-wide outreach collaboratives and its Maternal Data Center (providing hospitals with access to timely benchmarking data) to improve health outcomes for mothers and infants. In 2016, it published a Toolkit to Support Vaginal Birth and Reduce Primary Caesareans, which contributed to a decline in the C-section rate from 26.0% in 2014 to 22.8% in 2019.

Launched in 2020 by Choosing Wisely Canada and Canadian Blood Services, Using Blood Wisely is a quality improvement program that helps hospitals compare how they use red blood cell transfusions with national benchmarks for appropriateness. A hospital that meets and maintains benchmarks is designated a Using Blood Wisely Hospital. More than 240 hospitals have participated, and 110 hospitals are designated. 

In this multi-pronged intervention involving 15 hospitals across Canada where sites adopted standardized red blood cell guidelines, staff education and the screening of transfusion orders increased the proportion of clinically appropriate orders and single-unit orders by 12% and 22%, respectively.

Saskatchewan has developed clinical decision-making tools, recommendations, guidelines, algorithms and videos to support red blood cell transfusion stewardship.

Since 2020 and in light of the pandemic context, enhanced communications around the judicious use of blood transfusion products were sent to clinicians in Quebec. This included Using Blood Wisely resources from Choosing Wisely Canada to promote awareness regarding proper use in the event of a shortage. Since then, five hospitals from CHU Québec-Université Laval have been designated as Using Blood Wisely Hospitals.

This is a partnership between Shared Health/Soins Communs, Manitoba and the George & Fay Yee Centre for Healthcare Innovation. Starting in 2015, a multidisciplinary team did an extensive review of preoperative practices in Manitoba. Using findings to develop consensus among stakeholders, the team removed cues for preoperative testing from various forms, standardized surgical and primary care letters to reflect evidence against testing, added decision-support tools to electronic medical records and provided physician-level performance data as part of an audit and feedback scheme. The initiative resulted in a 38% reduction in preoperative diagnostic testing.