Low-Value Health Care in Canada — Dr. Wendy Levinson and Dr. Janet Reynolds

Avis Favaro

The COVID-19 pandemic has caused major disruptions to the Canadian health care system. Resources have been stretched thin, with long waits in the ER and wait-lists for other care. Is it possible to help this strained system work better by doing less? Fewer tests and procedures that may not be really needed?

Wendy Levinson

I think more now than ever, we need to decrease low-value care and protect our health care system.

Avis Favaro

Today’s podcast is about how to choose wisely, a global campaign to stop low-value medical tests and treatments that may not really help patients and could, potentially, even cause them harm, and why the pandemic may be a great time to make these changes.

Janet Reynolds

I think you could frame some of the work and the recommendations of Choosing Wisely as sort of life jackets. They’re our little life jackets that can help make small change in this crisis situation.

Avis Favaro

Hello, and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation, where we look at our health system, the data, and an eye on problems and solutions.

Note the opinions expressed here don’t necessarily reflect those of CIHI.

But it is a free and open discussion, and this one is about the overuse of tests and treatments, the campaign to curtail them, and what 4 questions patients can ask to get the best care at the lowest risk.

Joining us today, Dr. Wendy Levinson, a professor of medicine at the University of Toronto and the Chair of Choosing Wisely Canada. Welcome, Wendy.

Wendy Levinson

Thanks for having me.

Avis Favaro

And Dr. Janet Reynolds, a family physician who supports the Choosing Wisely practice in her work in Calgary. Hello, Janet.

Janet Reynolds

Good morning. Thanks for having me.

Avis Favaro

So let’s start with you, Wendy. I was surprised to learn this fact, that over a third of medical tests and procedures, like some blood tests and X-rays and some medications, may not really be of benefit to patients and may even cause harm. How did we get here?

Wendy Levinson

Yeah. It’s a bit surprising to hear that fact, but it’s being replicated, that number, in many countries in the world, not just Canada. And it’s because a lot of things get baked into our system, just done routinely, and we don’t necessarily question them. And some things we do can lead to harm; for example, drugs that can lead to side effects or tests that lead to what we call false positives. So it’s important for patients to know that they — that more is not always better in health care.

Avis Favaro

And is this part of the training, Janet, is that you’re just told this is what you need and nobody ever questions it?

Janet Reynolds

Sometimes, these tests get started with early evidence, and we get stuck with the old evidence and don’t stay modern, and we don’t keep up with changing evidence. So what seemed like a good idea or it sounded like a good thing to do 10 years ago, but as the literature changes, we need to stay caught up. And it takes us a long time to change our practice.

Avis Favaro

Choosing Wisely Canada started in 2014 and, Wendy, you were a key reason that it began. What was it — why was this important to you?

Wendy Levinson

Well, I think that overuse has been kind of invisible in our system. I agree with Janet that we learn these things in — in our education and they stay with us through our practice. But it was obvious to me that these things can be harmful to patients, and they also harm the health care system because we can’t afford, especially after the pandemic, to waste resources. We need to put them into high-quality care for the most patients.

So it just was obvious to me we needed to have this discussion, but we needed the profession itself to lead this discussion because, I think, patients trust doctors, as they should, and doctors know when there are things that we’re doing that aren’t based on excellent science, that are just old habit.

Avis Favaro

With Choosing Wisely and the Canadian Institute for Health Information, you started looking at a number of procedures and tests back in 2014. So now, we’re looking at data that compares where we were to where we are now. And this is in this new report, and CIHI’s posting it on the website so people can check out the data.

So, Wendy, to you. Where have we gone over the last 8 years in terms of dealing with these tests?

Wendy Levinson

Well, first of all, it’s excellent that CIHI has more data now so that we can examine trends over time. And the key findings in this report are, number one, that we have made progress on 8 of 12 indicators in Canada, showing at least a 10% decline in overuse in these 8 indicators. So that’s the good news story.

Secondly, there are some provinces or territories that do better than others on one or another of these indicators. And that’s also a good news story because that means we can learn from one another. So I think those are 2 really key findings.

Avis Favaro

I picked out 5 areas, and you can bring up other ones. But we looked at preoperative tests, blood transfusions, seniors and medication, antibiotics, and low back pain. And I’m going to start with that one because I imagine, Janet, you get a fair amount of people coming in with low back pain. And a lot of them expect to get a CT scan, an X-ray, an MRI for that. But Choosing Wisely has said, you should be careful when you use it. So —

Janet Reynolds

I think you’re right. We’ve known for a long time that that imaging doesn’t often give you the answer you’re looking for or change the management. So explaining to patients, after a good conversation with the patient and examining them, what the next steps might be to manage that pain, and then encouraging the follow-up. So if things aren’t progressing the way you’d expect, you’d want to reevaluate.

Avis Favaro

Mm-hmm. So what you’re saying is, most patients with back pain don’t need these images?

Janet Reynolds

Correct.

Avis Favaro

And what do patients say, if they want one, and you say, don’t need it?

Janet Reynolds

It takes a bit of practice to have that conversation, if the patient has a strong expectation. Often, it is a bit of a negotiation and keeping the door open for that return visit or return conversation. And most often, they get better with the plan that you come up and they don’t come back for an X-ray.

Avis Favaro

So, Wendy, when you looked at the data, where were we in 2014 when you started Choosing Wisely? And where did we — where are we, roughly, now with this?

Wendy Levinson

Well, Avis, that is one of the indicators we haven’t made a lot of progress on. Up to 30% of patients were getting an X-ray that was potentially unnecessary, when we started doing this, but we only had one province. Now we have multiple provinces showing their data, and it looks like between 25 and 30%, again, of patients are getting one of these imaging tests. So I think it’s an area, actually, that points to we need to do more work here, but it is a complicated one to work on, partly for the reasons that you talked about with Janet.

In my experience, I would just add to Janet, often patients are worried there’s something really wrong. And when a doctor listens, takes a thorough history, and explains, often that reassurance is what replaces — makes people feel better and makes them feel reassured that they don’t need an X-ray. I often say a request for a test is a marker for a worry. And if you understand what the patient is worried about, often, the request for the test becomes kind of moot and not necessary, so.

But we have more work to do on this one. This is one that we haven’t made a lot of progress on.

Avis Favaro

All right. But if I’m a patient and I say, I have back pain, what’s the harm in doing an X-ray? What’s the harm in doing a CT scan?

Wendy Levinson

First of all, X-rays and CTs are radiation, and we know that radiation, over time, can increase people’s risk of cancer.

Secondly, and probably more commonly, often what happens is you do an X-ray and you find something we say is incidental. By incidental, I mean you weren’t expecting it. It’s just sort of something that you notice and that might be irrelevant. But it leads to another X-ray, and then a follow-up X-ray, and then maybe a biopsy, and then that can lead to a complication. We call this the downstream cascade of more and more tests.

Janet Reynolds

Further to that, patient anxiety, when they have those incidental findings, gets quite high. And their worry often doesn’t go back to normal, knowing they’ve had this finding, it’s been investigated, and it’s normal in the end. So you sort of medicalize or turn a healthy person into a patient without necessarily needing to.

Avis Favaro

You’ve seen that happen?

Janet Reynolds

I’ve seen that. Yeah. Often, patients, if they tend to be anxious or have health anxiety, they’ll start looking for other things, and you — the perspective of something must be wrong with me. I had that X-ray and it showed something. Even though it was normal, now I’m worried about the next thing.

Avis Favaro

So next thing that I want to talk about is the antibiotics. That’s a huge problem. It’s been recognized by the World Health Organization, too many antibiotics used improperly can lead to antibiotic resistance and superbugs that then defy treatment.

So where — Wendy, let’s go to you on this one. I see from the report that it’s an 11% decline over 8 years. Something, but it’s not enough. Is it?

Wendy Levinson

Yes. I think that you’ve said that exactly correctly. It’s something, but it’s yet not enough. And one of the things that we know helps in the outpatient setting is to give doctors feedback. So often, I might not know as a doctor that I’m prescribing more antibiotics than my colleagues. But when we review individual physicians, and we give them information about how they’re performing compared to their peers — so if Janet’s doing better than me, I want to know what she’s doing and make my practice better. We call that audit and feedback, and that’s a powerful mechanism to decrease antibiotics.

Avis Favaro

Let me go to Janet because I know that you must be under incredible pressure, especially from families with young kids, too, please, just give me something, antibiotics or whatever. How bad is the pressure on you?

Janet Reynolds

So the pressure can be there. We have a bunch of tools that have been created through Choosing Wisely with reviews on the literature about maybe a delayed prescription for antibiotics. So again, letting the patient know, right now it doesn’t seem like they need an antibiotic, but here’s one you could fill within 48 or 72 hours, if these things happen, or your symptoms progress in this way. We know a lot of those don’t end up getting filled, so that’s one strategy.

So to Wendy’s point earlier, often, patients just need some reassurance and want to know they don’t need an antibiotic. I do hear that.

Before I answer your question, I just want to go back to the population issue around antibiotic overuse and, also, those potential harms. We often see complications from antibiotics with excessive diarrhea, for example, rashes, allergies, those things that were potentially avoidable. And so we do always want to avoid harm, and that’s bringing it down to the individual person a little bit more than just us all worried about the whole population.

Avis Favaro

You’ve bought into the concept of using the tools when most necessary and beneficial. When you look around at your colleagues at walk-in clinics, do you worry?

Janet Reynolds

I do worry. I think there is a perception it takes more time to not prescribe antibiotics, and we know that’s not really true. It takes another couple of minutes. And I think the setup around a walk-in clinic, where it’s very episodic care, it does kind of — it puts you at risk for taking treatments and tests that are unnecessary because you don’t have context or that ongoing relationship with a patient.

Avis Favaro

Let’s move to another area that I found really interesting, was preoperative testing. I, personally, was really surprised to learn that some patients get chest X-rays and cardiac stress tests if they’re having an eye procedure or endoscopy. I mean, why would you need these tests for that?

Wendy Levinson

Sometimes what happens is things become routine in the hospital. They just become part of what we call an order set. Whenever a person comes in to have a surgery or a cataract surgery, they get the following tests. Nobody actually really orders them. They just appear because they’re part of routine things that are just done almost automatically. And so those things just — no one questions whether they’re needed or not. They just happen for everyone.

And so, if you can start to examine those things and say, well, maybe for these patients we need it. But these low-risk patients, like having a hernia repair in a young person, they don’t need any tests. Or a cataract in a person — an older person. So these things can then be avoided in the low-risk patient. We’re not saying you don’t need them at some point with some people, but you don’t need them routinely on everyone.

Avis Favaro

I see the data that there was a 17% decline in the rate over the 2 measurements. How would you rate that, Wendy?

Wendy Levinson

Well, I think that’s good progress. I mean, there’s still more to be done, but I think we’ve started to have the conversation in the medical community about unnecessary preoperative tests. And so specialties like anesthesia and surgery and internal medicine, that might order these or be involved in them, might be reexamining their old habits and trying to reduce unnecessary care.

Avis Favaro

Okay. Next one, seniors. Very hot topic, discussed for many years, is the overuse of benzodiazepines, sedatives, anti-hypnotics for them, and the risk that it will lead to falls and hip fractures and hospitalizations, and even death. So where were things when you started tracking the practice, Wendy?

Wendy Levinson

Well, this is probably one of my favourite indicators because I always say that we do more harm than good when we prescribe these drugs on an ongoing basis in seniors. We lead to the things you mentioned: falls, memory problems, car accidents. I mean, these are drugs that people think they’ll help me go to sleep, or they’ll help me relax, but actually, we hurt more people than we help. So they’re very important drugs to reduce in the elderly.

But I was shocked when we started this work that 1 in 10 Canadians, when we started our work, were on these drugs chronically. And in some provinces, it was 1 in 4 Canadians. So it’s like, whoa, what are we doing here? And fortunately, this is again an indicator where we’ve made some progress, but we have a lot of work to do because we’ve reduced it from 1 in 10 Canadians to 1 in 12, and so that’s good.

Avis Favaro

It doesn’t sound like much.

Wendy Levinson

It’s progress. We’re probably preventing some people falling and fracturing their hip and everything. But we have a lot of work to do on this. And we’re also out of line in the world. There are other countries that do much better on this than we do. So we have to roll up our sleeves. And it’s a hard work. I mean, Janet, you might talk about what it’s like to try and stop someone who’s kind of used to taking them.

Avis Favaro

That’s de-prescribing. Yeah. So do you ever get a new patient, and you look at the rundown of medications and say, whoa?

Janet Reynolds

Well, you know what? It’s a new patient, and it’s even existing patients, where you take the opportunity to look at their medication list with them in a different way. De-prescribing is one of my favourite things to do. We certainly know that it’s usually successful. Very little harm happens from getting rid of a medication that’s not necessary.

But it takes time. And when someone’s been on a benzodiazepine for a long time, it’s definitely the tortoise and the hare. You want to navigate it very slowly with the patient. Most of them are motivated, once they understand their potential harms. Nobody wants to lose their independence, fall and break a hip, and not be able to go live in their home and age in place.

Avis Favaro

That’s a good incentive, right, if a stay in their home. But why hasn’t this one moved more?

Wendy Levinson

One of the things that we notice, too, in some of our work is that these drugs get started in the hospital. So a patient might get admitted, and the orders will say give one of these drugs at night, as needed, for sleep. And then the person gets discharged on that medication. So some of the work that’s been happening around the country is to decrease the initiation of these drugs in the hospital setting so that we don’t contribute to people being on them chronically.

Avis Favaro

Now the last one is the blood transfusions in hospitalized patients, Wendy. So how and why would anyone overuse a blood transfusion? And what’s the risk here?

Wendy Levinson

So what happens is we learn in medical — in our education to practice a certain way. So I will put up my hand and say, my entire career, I ordered 2 units of red blood cells, whenever a patient needed blood. I thought that you were not supposed to order one; you ordered 2 automatically. I can see Janet laughing. This is how we trained. Right? But now I realize, because of the literature, that you should order one unit and reassess and decide if you need a second unit.

And the second thing is that I also learned to give blood when the hemoglobin, the blood level, really wasn’t low enough to require it. And the research shows that you can decrease this significantly without any harm to the patient.

And the reason this is important is, one, it’s a precious resource that society donates. Two, there are side effects from blood. In fact, 1 in 100 patients will have something. We call it overload syndrome. They get too much fluid onboard.

And third, it’s very expensive. Canada spends $1 billion on purchasing blood.

And then I’d actually add a fourth, which is it has an environmental impact because we waste a whole lot of plastic, we have transport blood. So if we, as health care providers, also protect the environment so that it doesn’t harm our patients. So I’d say that decreasing blood has multiple benefit: precious resource, decreasing harm, decreasing cost, and protecting the environment. A win-win-win-win.

Janet Reynolds

I was just going to highlight a shout-out in the subgroup of the orthopedic surgeons with hip and knee replacements and the magnitude of change in blood transfusions that hasn’t impacted anybody’s health in a negative way. I think from the — I can’t remember the number, Avis, but it was 10 or 30 — 10 or 20% down to 3% of patients requiring blood, with a concerted effort.

Avis Favaro

That’s quite impressive. I notice that the red blood cell transfusion rate in hospitalized patients declined by 11%, to just 6%. So that’s almost half.

Wendy Levinson

We set benchmarks that were appropriate for a hospital, and now there are almost 250 hospitals in Canada engaged in using blood wisely, where they measure their blood use against these criteria that have been set, that I just discussed a bit, and they try to improve it. And so we’ve tried to really get hospitals onboard here so that we decrease unnecessary blood.

Avis Favaro

Before we leave the data, health equity. Did you look at whether the overuse of tests and treatments were different in different communities? So, for example, one of the findings suggested that older adults who used benzodiazepines and other sedatives were more likely to live in lower-income communities.

Wendy Levinson

Yes. This is a very important part of the CIHI report and something we need to do more work on. We were able, with the CIHI work, to look at several different issues, whether someone was in a rural area or an urban area, their age, and also their socioeconomic status, based on postal codes. And so this allowed us to look at whether there are subgroups that have more overuse than others. And, of course, this has an implication for how we can improve things.

So as you mentioned, a very good example is, again, the benzodiazepines, where we know a few things. We know that women get them more than men and that they get them more as they age. In fact, in women in their 90s, over 17% of women in their 90s are on chronic benzodiazepine. So given what we just talked about, about the falls and broken hips, that is not where we want to be.

Avis Favaro

So I want to move to the idea of talking about reducing the use of certain medical procedures and tests in a pandemic. Everybody’s under stress. Hospitals are just struggling to give people basic care. Is this the right time to be talking and telling people not to do things? When people are, you know, health workers are struggling to do things?

Wendy Levinson

I think everyone listening to this podcast knows that our health care system really is stressed. So we need that system to be healthy and resilient. And if we reduce things that don’t add value for patients, we can invest that in things that do add value. So I think more now than ever we need to decrease low-value care and protect our health care system.

Janet Reynolds

I think we have to find the quick wins, and some of it actually reduces my workload. If I don’t order a test, I don’t have to review a test. So that turning it, flipping it around a little bit, makes it easier to do the right thing or to get rid of that low-value care.

Avis Favaro

So do you think it could ease pressure on frontline staff in emergency units and hospitals?

Wendy Levinson

Yes. I think — let’s give the example of CTs for head for minor concussion, minor head trauma. Really the data show that in minor head trauma you don’t need them. But if you do one, you have to wait for it to be done. The patient is in the queue, that backs up a bed. You have to read the results. So you made your workload more than if you had given the patients proper instructions for follow-up and what to watch for and then not done the CT scan.

So these are examples. They don’t seem intuitive. They seem a little bit counterintuitive. But if you think them through, they decrease workload.

Avis Favaro

Yeah. That was the thought that I had. It seems counterintuitive to ask hospitals, at this point —

Janet Reynolds

I think you could frame some of the work and the recommendations and the tool kits through Choosing Wisely as sort of life jackets. They’re our little life jackets that can help make small change in this crisis situation that then we can build on.

Avis Favaro

Mm-hmm. In an average week, by implementing these ideas, Janet, what do you think it cuts down on your workload? Five percent?

Janet Reynolds

So interesting, it’s hard to quantify because other works fill the space. There’s, you know, if I don’t have to review this test, it means I have more time to talk to the patient about their end-of-life care. So it’s hard to know exactly, but I would — it frees up space to do more important work or the higher-value work.

Avis Favaro

I’m just going to bring up one example, and then we’ll go to the conclusion here. But there was an interesting point where Choosing Wisely stepped up in the pandemic regarding the blood tubes and overuse of blood tests. Wendy, what did you do? And how did it work?

Wendy Levinson

There was this international problem with not enough blood tubes to do blood testing. And so we — actually, we had the Society of Clinical Biochemists (sic) [Chemists] come to us and say, we have a problem here. And so they helped go through all our recommendations and pulled out ones where we had highlighted unnecessary blood work. And then we put them out during the pandemic with, I think, a really wonderful little thing which was after each one it said, do you know that?

And I learned a lot about unnecessary blood tests. For example, a test I order frequently, called a sed rate, takes an hour for a laboratory technician to do and uses a blood tube. So it’s like, wow, I just didn’t know this.

Janet Reynolds

And I think the bundle that came out of that blood tube shortage really resonated with people and showed you where you fit in the big system. I think I’m one doctor with one patient, but actually me ordering that test might take a blood tube away from someone who is getting cancer treatment and really needs a blood test. So it really was a bit of a — maybe a silver lining.

Avis Favaro

All right. My last question, I guess is, is there anything patients can do in terms of questions they can ask, if they’re going to the hospital or going to see a physician?

Wendy Levinson

Well, we really encourage patients to ask 4 questions. Do I really need this test or treatment? Are there downsides? Are there simpler, safer options? And what if I do nothing? And in all the work we do, we try to embed those 4 questions so people feel empowered and enabled to ask doctors about whether a test or treatment is right for them, or whether they should not have it.

Janet Reynolds

In my world in family medicine, it’s about our relationship with our patients over time. So allowing the patient to ask those questions, really, often, for me, it’ll say, oh my goodness, you’re right. Maybe we could wait another day or 2. And those are welcome conversations.

Avis Favaro

All right. Well, I’ve really enjoyed this discussion because it’s — in a way, it’s low-hanging fruit in the health system, that if you get it out of the way, you free up space for other therapy.

I thank you both. Janet, thank you so much. And, Wendy, thank you. Really appreciate you being here.

Wendy Levinson

Our pleasure.

Janet Reynolds

Thanks very much, Avis.

Avis Favaro

Low-value medical tests and treatments consume precious hospital resources and may not really benefit patients. And there are ways to curb overuse, with the pandemic being the right time to take a hard look at what’s needed and what isn’t.

Thank you for joining our discussion. Our executive producer is Jonathan Kuehlein. Special thanks to Aila Goyette and to Alya Niang, host of our French CIHI podcast.

And if you want to read the new Choosing Wisely report done with CIHI, please go to cihi.ca — that’s C-I-H-I-dot-C-A — and subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.