How hospital staff can improve patient outcomes and stop wasting healthcare resources in the process
By Karen Born and Wendy Levinson
Each year, there are at least one million unnecessary tests, treatments and procedures done in Canadian healthcare settings, including hospitals.
What is ‘unnecessary care’?
Unnecessary care is medical care that offers no value to patients and can in fact be harmful. This could be a prescription drug, diagnostic test or medical procedure that is not needed, does not improve a patient’s health outcomes and is not backed by the best available evidence. It may also involve risks and harmful side-effects.
A recently released report from the Canadian Institute for Health Information (CIHI) in partnership with Choosing Wisely Canada demonstrates how pervasive unnecessary care is across the country and highlights several key examples where changes could be made to benefit patients and the health system.
So, what are we better off without? And how can hospital staff help to curb unnecessary care?
Unnecessary imaging has consequences
The report says about 30 per cent of patients visiting Ontario and Alberta emergency departments for minor head injuries have CT scans. CT scans deliver strong x-ray radiation. Exposure to this radiation can increase lifetime cancer risk. Yet evidence shows there are good alternatives to CT scans for investigating head injuries. Emergency department staff are trained to use clinical decision rules to assess the severity of a head injury, and decide if further diagnostic testing is warranted. Not only does this reduce harm associated with unnecessary imaging to patients, but it also reduces wait times for those who truly need imaging.
Unnecessary medications have side-effects
The report estimates that one in 10 Canadian seniors regularly uses sleeping pills, known as benzodiazepines, and other sedative hypnotics, on a regular basis. Benzodiazepines are often prescribed for hospitalized seniors who are having difficulty sleeping, and are intended for short-term use. The long-term use of these medications outweighs benefits and increases the risk of falls causing injuries and car accidents in seniors. It is worth asking yourself – are there non pharmaceutical based therapies that can be used instead of these powerful medications?
Seniors are not the only population where there is unnecessary and potentially harmful medication use. The report shows a disturbing 300 percent increase in dispensed prescriptions for the powerful antipsychotic quetiapine for insomnia in children and youth in Manitoba, Saskatchewan and British Columbia. Other options for treating insomnia should be considered first, such as behavioral changes and ensuring good sleep hygiene. Quetiapine is not recommended for children or youth and has a long list of harmful side-effects, including obesity, high blood sugar and cholesterol, even if given in low doses.
Unnecessary care wastes valuable resources
Blood is a vital, and limited resource. Choosing Wisely Canada recommendations highlight where blood transfusions are wasteful, and don’t improve patient care. Reactions to blood transfusions are common, and can increase morbidity and mortality in very ill in patients. Yet, the rates of blood transfusions vary across provinces with patients with similar diseases and treatments having different blood transfusion rates. For example, transfusions for hematology patients in Canada vary from 13 to 54 per cent depending on the hospital where they are receiving care.
Some hospitals profiled in the report are working to reduce unnecessary transfusions, and to conserve limited blood products by introducing new transfusion orders that reminder providers of Choosing Wisely Canada recommendations around using blood resources wisely.
Variation in practices demonstrates opportunities to reduce unnecessary care
An important finding of the report that should cause Canadians to take notice is wide variation across regions and between provinces. Variation means major differences in medical practice, some of which are not evidence-based and can be potentially harmful to patients.
Reducing variation improves quality for all Canadian patients and can reduce waste. A good example of this is pre-operative testing. In Ontario, nearly one in three patients having eye surgery had a preoperative test, compared to one in five in Alberta.
Medicine has evolved and so has medical practice. It used to be standard that patients needed to undergo a battery of tests to ensure that they were ‘fit for surgery’. However, as surgical and sedation practices have improved, this is no longer needed for certain low-risk surgeries, like hip or knee replacements or cataract surgery, pre-operative tests would be done to ensure that a patient was fit for surgery. These tests could include blood work, electrocardiograms and chest x-rays. Research shows that preoperative tests before low-risk surgeries do not improve patient care and that results of these tests waste resources and cause needless anxiety to patients.
So what can you do?
The national conversation about unnecessary care has started to spark changes. The report provides several examples of how health care providers are working hard to put in place better practices or protocols to reduce waste, which may also harm patients. For example, with preoperative tests, a simple change to pre-surgical checklists or order sets can help to reduce unnecessary tests.
We know patients are aware of this problem too. Ipsos Reid survey data shows that one in four Canadians say they personally have experienced unnecessary care in the past year: 67 per cent of Canadians surveyed believe patient demand is also responsible for unnecessary care, rather than decisions made by health care providers alone. Nearly half (42 per cent) of Canadians surveyed said they expect a test ordered, or a prescription written, when they visit a doctor’s office.
But the vast majority (92 per cent) of Canadians surveyed also said they need more information to help make decisions and ask the right care questions.
Choosing Wisely Canada, a national, clinician led campaign has over 220 recommendations of ‘things clinicians and patients should question.’
The campaign emphasizes that patients and clinicians need to together question whether that test, treatment or procedure is really necessary. There are four key questions that a patient can ask, or a clinician can introduce, to help start a conversation about unnecessary care: Do I really need this test, treatment or procedure? What are the downsides? Are there simpler, safer options? What happens if I do nothing?
Karen Born, PhD is the Knowledge Translation Lead, Choosing Wisely Canada and Assistant Professor, Faculty of Medicine, University of Toronto and Wendy Levinson, MD, OC is the Chair, Choosing Wisely Canada and Professor of Medicine, University of Toronto.