Is Canada’s health-care system making wise choices?

One of the most important campaigns in Canada has nothing to do with politics. Choosing Wisely Canada is an initiative that aims to curtail the unnecessary tests and treatments in our health care system.

Started in 2014 by a team from the University of Toronto, Canadian Medical Association and St. Michael’s Hospital, Choosing Wisely is part of a global movement that first began in the United States by the American Board of Internal Medicine Foundation. It now spans 20 countries across five continents and includes the majority of medical societies and associations, including those in Canada.

The evidence to support a reduction in wasteful diagnostic and therapeutic resources is clear and uncontroversial. The Canadian Institute for Health Information estimates that 30 per cent of health care, or nearly one million tests and treatments annually, is unnecessary.

This is a staggering figure, and especially worrisome given Canada’s growing health care expenditure, which totalled $228 billion — or 11 per cent of its gross domestic product — in 2016. A national effort to curb unnecessary testing and treatment not only makes medical sense, but is also economically prudent in the context of ballooning health care utilization.

Choosing Wisely hopes to achieve its goals through grassroots advocacy by publishing a series of practice recommendations for physicians based on international peer-reviewed research.

Interestingly, many of the studies used to guide these recommendations did not collect data or outcomes on minority populations. In studies that did, most of the patients analyzed were Caucasian. It asks the question, is Canadian health care choosing wisely or merely choosing whitely?

This is why it matters. In the past, the medical community has experienced the perils of ignoring large segments of the population in its research initiatives.

For example, scientists have recently lamented that our general understanding of how disease affects women is extremely poor because most of the information previously collected was on middle-aged men.

Similarly, studies have shown that a patient’s race plays a significant role in disease screening, diagnosis and management. Unfortunately, research on minority populations has been scarce and eclipsed by studies that favour the inclusion of patients with high socioeconomic status who are often Caucasian.

This research bias is hard to shake because research is notoriously hard to conduct. It first involves identifying a clinical question, generating a hypothesis, developing an experimental protocol and securing funding.

Subsequently, researchers need to navigate the important but Byzantine institutional review processes before addressing the challenges associated with subject recruitment, data collection and analysis.

Ideal patients are those who have the luxury of time and who are able to travel to downtown research hospitals for repeated evaluation. It is easy to see how this is unlikely to include a minority single mother working multiple jobs in Scarborough.

Canada’s minister of science, Kirsty Duncan, recently introduced the Equity, Diversity and Inclusion Action Plan in order to address the chronic underrepresentation of women, First Nations, visible minorities and persons with disabilities among Canada research chairs. This laudable effort should also dovetail with the minister’s insistence that taxpayerfunded medical research focus on all communities represented in our country and not just select groups.

In an era that will be increasingly dominated by big data genomics, artificial intelligence and personalized medicine, our society will migrate away from a one size fits all health care paradigm.

Choosing Wisely will continue being an essential and vital initiative in helping to reduce unnecessary tests and streamline medical care in this country.

Future iterations of its recommendations, along with any practice guidelines created, should endeavour to more comprehensively apply to and represent the great diversity of Canada.