Appropriateness in healthcare

Inappropriateness in healthcare is not only a Canadian problem, it is also a global issue.

It is estimated that around the world 30 to 40 per cent of patients do not get treatments of proven effectiveness as a result of underuse and/or misuse of health services, products and resources. At the same time, 20 to 25 per cent of patients receive care that is not necessary and/or potentially harmful.

Dr. Jeremy Grimshaw, who is a senior scientist at the Ottawa Hospital Research Institute, says the causes are many including lack of knowledge about the best evidence available to local standards of care that my not reflect recent evidence.

There is mounting evidence that some patients receive treatments that may not be best suited for their actual needs, resulting in less effective care for patients and a waste of precious healthcare resources. Spending on diagnostic imaging in Canada has increased significantly and now costs about $2.2 billion each year.

According to the Canadians Association of Radiologist, 30 per cent of these tests may be unnecessary. In fact, if eliminating unnecessary tests was realized, there would be an additional $220 million annually to improve access to needed care and especially reduce wait times.

Appropriateness of healthcare is a real challenge for health care systems wanting to optimise care, outcomes and costs. In July 2013, the mandate of the Health Care Innovation Working Group to place efforts on identification of priority areas for future work on appropri- ateness, in addition to diagnostic imaging. As a result, the Seniors Health Strategic Clinical Network in Alberta led the way in the Appropriate Use of Antipsychotics Project aimed at improving the quality of seniors’ health by reducing the antipsychotic medication use in long-term facilities.

The projects goal is not to eliminate the use of antipsychotics, but rather to encourage the appropriate use of these medications when they are necessary. There in our province we are making progress in adopting the guidelines and reducing the use by significant percentages.

There are a number of doctor leaders, like Dr. Raja Rumpersaud, who want to make a significant change in reducing or eliminating inappropriate care. Heisan Orthopaedic spine surgeon at the Toronto Western Hospital and says a major shift is needed to address a problem that 70 to 80 per cent of the population will experience low back pain. He used a move from rigid guidelines to a Shared Care Model that offered a more complete, patient–centered care pathway. His results with this model to improve care for low back pain are impressive.

The working group, with input from the Canadian Medical Association and others, have implemented the Choosing Wisely Canada campaign. To spark conversations between patients and physicians, leading specialty societies created evidence–based, plain language lists of specific tests and procedures that should not be pursued unless specific conditions are met. These lists of clinical best practices are brief and set out in lay persons language and are meant to initiate conversations between doctors and their patients about appropriate and necessary treatments. Since 2014, recommendations are being implemented across Canada, in hospitals, primary care clinics, long-term care homes and health regions.

Choosing Wisely Canada has also developed a six-point plan for 2016-2020, with an end goal of eliminating 10 million un- necessary tests, treatments and procedures in Canada by 2020. It will take a culture change to ensure sustainability over the long-term.

What I strongly like about the Health Care Innovation Working Group is that their focus on appropriate care is leading to better care. Stroke Services Nova Scotia is a provincial program responsible for improving stroke care for all our citizens. The Institute for Health Care Improvement designed a model of collaborative care that led to establishing dedicated stroke units with evidence-based best practices. This provincial approach has helped achieved significant improvements and successes, with noted reduction in mortality.

With our changing demographic, we must continue to explore and implement innovative approaches to provide high quality and sustainable health services. Every week, I hear and see real and substantive changes that are being realized.