Our turn to Choose Wisely.

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Healthcare spending has been a hot topic recently. While the focus in Ontario (and subsequently spreading to other provinces as well) these days has been on curbing physician fees, let us not forget another big piece of the puzzle: over-spending on unnecessary investigations and treatments. In the U.S. alone, up to one-third of the $2 trillion of annual healthcare costs goes towards unnecessary hospitalizations and tests, unproven treatments, ineffective drugs and futile end-of-life-care.


We are not much better north of the border.

A recent report summarizes the poor value we are getting out of the healthcare dollars we spend:

Canada is the fifth-highest spender on health care on a per capita basis and the sixth-highest in terms of spending as a percentage of GDP among industrialized countries. Despite such investments in health care…In 2008 and 2009, Canada ranked last out of 30 countries in terms of value-for-money spent as reflected in the Euro-Canada Health Consumer Index. In 2010, Canada’s ranking moved to 25th place out of 34 countries (with the United States excluded from the study). The scorecard released by the Commonwealth Fund ranked Canada sixth out of six countries on the value-for-money dimension

Some of you may have heard of the Choosing Wisely campaign launched in the U.S. last year, an initiative spearheaded initially by the American Board of Internal Medicine that aims to trim down that chunk of excessive and unnecessary healthcare costs. Its major thrust is to provide information, in the form of “lists”, to the general public that helps them understand what current evidence-based recommendations are for when to obtain/avoid certain investigations or treatments.

The premise is of course, that physicians are pushing for and offering unnecessary investigations/treatments that might even be harmful, especially in a private healthcare system where the more a provider does, the more he/she gets paid. Others accuse physicians in the U.S. of “defensive” medicine, where over-investigations tend to occur in the face of high litigation rates and a tort system in need of reform. While the intention of lowering excessive costs is good, some healthcare providers are feeling the negative consequences of such a campaign – see this one prominent Family Physician blogger’s response as an example.

The question for Canadians, is whether there is a role for a similar Choosing Wisely effort in a public healthcare system. Although provider-driven demand for services is not much of an issue, we are still clearly wasting healthcare dollars on unnecessary items; some of this excess utilization must therefore be patient-driven. Personal experience working in the emergency room have shown me that patients often present to healthcare providers with very clear expectations of what tests and/or treatments they believe should be performed/given – and often, expectations that are not based on evidence or the physicians’ clinical impressions.

I have lost count of the number of times I’ve had to convince a patient that antibiotics is not necessary for a viral pharyngitis, or the times I’ve had to convince a patient an xray or MRI is not indicated for various ailments. It is almost like patients no longer believe a physician’s clinical impressions, and only want “objective” bloodwork/imaging, despite the fact that they still need to trust the very same healthcare providers to interpret those tests.

In that sense, a similar Choosing Wisely campaign in Canada would help educate the public on when certain investigations/treatments are indicated and when they are not. At the very least, it should open up channels of communication between providers and patients and facilitate a shared-decision making approach to healthcare services utilization.

My only reservation on the actual success of such a campaign is that neither the providers nor the patients immediately feel the financial effects of pursuing unnecessary investigations, hospitalizations, etc.. In the U.S., where they must convince their insurance providers to pay (or cough up the cash out of their own pockets) for services, the Choosing Wisely campaign has much more bite in making patients more hesitant in pursuing extravagant and ineffective tests/treatments. In Canada, where an individual does not immediately feel the cost of getting an MRI or getting admitted into a hospital bed, it is extremely easy for both physicians and patients (and families/friends!) to default to over-investigate and over-treat, “just in case”.

It will be interesting to see whether the Choosing Wisely effort will make a significant impact over the next few years. Their experience might provide a useful lesson for how we might want to tackle our own inefficient utilization of healthcare dollars, beyond cutting healthcare provider fees.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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