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Will Reducing Low-Value Care be a Pandemic Silver Lining?

by: Dr. Wendy Levinson

Choosing Wisely Canada has released Not Necessary. Policy Ideas for Limiting Low-Value Care in Canada. The document includes five policy ideas to address in the short, medium, and long-term to limit low-value care in Canada during the pandemic and beyond.

The COVID-19 pandemic has changed our professional and private lives in so many ways. Front line providers are feeling this hardship acutely with new and sustained stressors. Yet, there are some silver linings.  I am reading more books that I previously never had time to read. I am cooking some nicer meals with my husband and learned to bake bread (much easier than I thought). These are silver linings for me and I hear from many friends and colleagues that they are finding similar silver linings as well during this challenging time.

Another silver lining of the pandemic has been a heightened awareness from the public as well as our profession about how important it is to use our health care resources wisely.

In my role as chair of Choosing Wisely Canada, I have been working with physician leaders from national societies and federal, provincial, and territorial associations to advance awareness of overuse and drive changes to practice. While Choosing Wisely is firmly based on grassroots clinician leadership to reduce overuse, many of the drivers of overuse are outside of the control of individual doctors. There are health care system structures and policies that can drive overuse; these policies can be resistant to change. Yet in the COVID-19 pandemic, governments rapidly made changes like adding virtual care billing codes to ensure that physicians could continue to offer high-quality care.

The enormous financial impact of the pandemic means that governments and decision makers will have to seek ways to ensure that health care systems can deliver high-quality care as efficiently as possible. It is critical that as physicians we provide leadership to ensure quality of care for our patients AND work with governments to use health care resources wisely.

Choosing Wisely Canada is uniquely positioned because we are clinician-led with recommendations based on scientific evidence.  We have developed a policy document for policy makers with ideas for how to decrease low-value care in Canada in the COVID-19 era based on physician expertise and our commitment to protecting patients. These ideas can be a silver lining of the pandemic to advance health care system quality and sustainability. A number of the policy ideas suggest system changes that remove barriers for us that drive overuse. These include issues around redesigning processes of care that sometimes embed wasteful practices.

The first policy idea addresses a consequence of COVID-19, cancelled elective surgeries and subsequent backlogs. Recent estimates suggest it will take approximately a year and a half to clear this backlog. Pressures like a surgical backlog call for new approaches and ensuring that we optimize surgeons’ time as well as resources.  Reducing unnecessary preoperative testing, leveraging virtual care during the perioperative pathway and redesigning surgical queues to prevent bottlenecks are just some strategies that this document presents.

Similarly, COVID-19 has added new pressures on laboratories to process tens of thousands of COVID-19 tests in a timely way. This pressure is introduced to already stressed laboratory services. Yet, we know that there is significant variation in lab ordering appropriateness. The rise of standardized order sets and laboratory requisition forms have built in over-testing and overordering. To change this, regional and provincial decision makers need to be engaged and partner with doctors to reduce unnecessary laboratory test ordering. Our policy report also highlights unnecessary imaging, which is driven by many of the same factors as unnecessary laboratory tests. Efforts to retool order sets and avoid unnecessary or redundant imaging can help reduce wait lists for those patients who really need imaging tests.

COVID-19 has drawn our attention to how important it is to conserve supplies of limited health care resources —like personal protective equipment— are, and how judicious management strategies are important to conserve these resources. We propose policy ideas to conserve the precious resource of blood products and components. Canada is fortunate to have a coordinated blood supply and management model, but how hospitals use blood products is often not clear and more transparency and benchmarking is needed to ensure these precious resources are being used wisely.

Finally, the report suggests ways to choose wisely at the end of life. Canada lags behind other industrialized countries in our ability to support our patients end-of-life wishes to die at home. Improving this is even more important now that necessary policies to restrict outside visitors to hospital settings mean that patients are dying alone and with less support from loved ones.  A silver lining to the COVID-19 pandemic could be helping more Canadians die at home or in community settings. Fulfilling these wishes cannot be done by good will alone and doctors need more resources and appropriate remuneration to do this work.

Since the Choosing Wisely Canada campaign launched in 2014, we have partnered with 85 physician societies and other professional associations (such as nursing, pharmacy, dentistry). This grassroots community has made a major impact on awareness of overuse and also on innovative ways to tackle this problem.

COVID-19 presents a window of opportunity to line up our goals of high-quality care and using resources wisely with policy makers interest in optimizing resources and sustainability. Physicians have demonstrated their leadership and now its time for policy makers to invest in smart strategies to help use resources wisely. Read the full report ‘Not Necessary: Policy Ideas for Limiting Low-Value Care in Canada’.

 

This article originally appeared in the Medical Post published on September 17, 2020. 

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