SGEM Xtra: High-Value Care Post Covid19 – Did you ever have to make up your mind?

Date: May 28th, 2021
Guest Skeptics: Heather Logan is the executive Strategy lead for the Canadian Agency for Drug and Technologies in Health (CADTH). Dr. Wendy Levinson is the Chair of Choosing Wisely Canada (CWC) and a Professor of Medicine, University of Toronto
This SGEM Xtra is based on document created by CADTH and presented at Choosing Wisely Canada National annual meeting May 13, 2021. The title of the report is Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care.
We have discussed Choosing Wisely before on SGEM Episodes:
SGEM#15: Choosing Wisely
SGEM Xtra: CAEP Choosing Wisely
SGEM Xtra: Right, You’re Bloody Well Right, You’ve got the Bloody Right to Care
Choosing Wisely Canada (CWC):
Dr. Wendy Levinson
It is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices. Choosing Wisely Canada is led by a team of clinicians and staff based at St. Michael’s Hospital (Toronto), the University of Toronto, and in collaboration with the Canadian Medical Association.
Choosing Wisely Canada mobilizes and supports clinicians and organizations committed to embedding campaign recommendations into practice.
There are close to 350 documented quality improvement projects across the country that are building capacity for the spread and scale of Choosing Wisely.
These efforts are underway in hospitals, long-term care homes, and primary care clinics. Many of these innovative projects, including their evidence-based tools and methods, have been packaged into easy to follow toolkits that are broadly circulated in order to encourage widespread adoption. This has allowed Choosing Wisely Canada to foster a network for those looking to implement campaign recommendations into practice.
Canadian Agency for Drug and Technologies in Health (CADTH):
Heather Logan
It is an independent, not-for-profit agency funded by Canadian federal, provincial, and territorial governments (except Quebec) to provide credible, impartial advice and evidence-based information about the effectiveness of drugs and other health technologies to Canadian health care decision-makers.
CADTH believes that credible, objective evidence should inform every important health care decision. When you want to know what the evidence says, ask CADTH.
Created in 1989 by Canada’s federal, provincial, and territorial governments, CADTH was born from the idea that Canada needs a coordinated approach to assessing health technologies. The result was an organization that harnesses Canadian expertise from every region and produces evidence-informed solutions that benefit patients in jurisdictions across the country.
South Huron Hospital Association (SHHA) is known as the "Little Hospital that Does". SHHA has been choosing wisely since 2012 selecting five items every three years.
SHHA Choosing Wisely 2012
Influenza shots for staff with privileges SGEM#20
Use Ottawa ankle and knee rules SGEM#3 and SGEM#5
No routine use of antivirals for Bell’s Palsy SGEM#14
No routine use of antibiotics for simple cutaneous abscesses SGEM#13
No routine use of proton pump inhibitors for upper GI bleeds SGEM#16
SHHA Choosing Wisely 2015
Utilize Canadian CT head rules to guide our decisions on getting CT heads SGEM#106
Utilize Canadian C-Spine rules to guide our decisions on obtaining plain film c-spine imaging SGEM#232
Do not do annual physical exams on asymptomatic adults with no significant risk factors
Do not screen women with Pap smears if under 21 years of age or over 69 years of age
Do not order echo cardiograms routinely
SHHA Choosing Wisely 2018
Only use supplemental Oxygen for STEMI patients that are hypoxic (saturations < 90%) SGEM#193
Use appropriate antibiotic selection for uncomplicated COPD exacerbation ie. Amoxicillin, Septra and Doxycycline
Do not start IV unless you are 80% sure that you are actually going to use the IV SGEM#204
Treat Chronic Pain utilizing non-pharmacological means before prescribing an opioid medication
Don’t place or leave in place a urinary catheter without reassessment
Low-Value Care, Challenges of COVID19, High-Value Care and the Purpose of the CADTH Report
Slides from the Choosing Wisely Presentation - May 13th, 2021
CADTH Four Step Approach
Recommendations in Six Key Clinical Areas
Primary care: Seven recommendations span primary care, including avoiding unnecessary rural transfers, annual exams, and screening and imaging tests
Specialty care: Four recommendations address low-value procedures, including chronic dialysis, colonoscopy for constipation, cardiac imaging without high-risk markers, and knee MRIs
End-of-life care: Three recommendations emphasize the importance of advance care planning conversations for patients with serious illness and access to palliative care
Hospital care: Two recommendations address low-value routine investigations and pre-operative testing in hospital care
Long-term care: One recommendation addresses unnecessary hospital transfers from long-term care
Blood products: One recommendation addresses the overuse of red blood cells transfusion in hemodynamically stable critical care patients.
Nineteen Recommendations for High-Value Care
Hospital Care:
Routine Investigations: Don't order routine investigations, including chest radiographs or blood tests, in critically ill patients except to answer a specific clinical question.
Preoperative Testing: Don’t order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery
End-of-Life Care:
Advance Care Planning Conversations: 
Don’t start or continue life-supporting interventions unless they are consistent with the patient’s values and realistic goals of care
Don’t delay advance care planning conversations
Palliative Care:
Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment
Specialty or Outpatient Care:
Nephrology: Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team
Gastroenterology: Avoid performing a colonoscopy for constipation in those under the age of 50 years without a family history of colon cancer or alarm features
Cardiology: Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present
Orthopedics: Don’t order a knee MRI when weight-bearing X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis as the MRI rarely adds useful information to guide diagnosis or treatment
Long-Term Care:
Transfer: Don’t send the frail resident of a nursing home to the hospital unless their urgent comfort and medical needs cannot be met in their care home
Blood Products:
Red Blood Cells Transfusion: Don’t routinely transfuse red blood cells in hemodynamically stable ICU patients with a hemoglobin concentration greater than 70 g/L (a threshold of 80 g/L may be considered for patients undergoing cardiac or orthopedic surgery and those with active cardiovascular disease)
Oncology:
Palliative: Don’t delay or avoid palliative care for a patient with metastatic cancer because they are pursuing disease-directed treatment
Primary Care: 
Rural Transfer: Don’t send a patient for a specialist visit that requires several hours of transport if the visit can be done virtually or by a local physician
Annual Examinations: Don’t do annual physical exams on asymptomatic adults with no significant risk factors.
Unnecessary Screening Tests: Don’t perform population-based screening for 25-OH-vitamin D deficiency.
Unnecessary Imaging:
Don’t order screening chest X-rays and ECGs for asymptomatic or low-risk outpatients
Don’t do imaging for lower back pain unless red flags are present
Don’t do imaging for uncomplicated headache unless red flags are present
Don’t order a CT scan for uncomplicated acute rhinosinusitis
The official CADTH report with all 19 recommendations and additional information  can be downloaded as a PDF.
Key Messages from the CADTH Report
Low-value tests, treatments, and procedures are an important health care quality problem in Canada and across the world because they provide little clinical benefit, may be harmful for patients, and waste limited resources.
Due to the COVID-19 pandemic, health care systems face increased challenges of limited resources, reduced capacity, and a growing backlog of surgeries and other procedures. The pandemic has compelled health care professionals to make challenging decisions to prioritize health care services while coping with increased demand.
As Canada emerges from the pandemic and health care systems rebuild and begin to address the backlog of delayed or cancelled services, there is an imperative to introduce lasting changes to reduce low-value care and ensure high-quality care is available to everyone.
To help inform efforts for using health care resources wisely and to support decision-making, CADTH and Choosing Wisely Canada convened a 10-member multi-disciplinary panel of clinicians, patient representatives, and health policy experts to review areas of low-value care that can be reduced or limited. This panel reviewed, deliberated,...