Improving resource stewardship in post-pandemic primary care: Insights into choosing Wisely Canada guidelines.

ObjectivesRising health care costs and an increase in unnecessary testing have sparked interest in resource stewardship (RS) and subsequently the Choosing Wisely Canada (CWC) campaign. Currently, all Canadian medical schools have student representatives for CWC; however, the same is not true in other health professions. Interprofessional care learned through interprofessional education (IPE) can lead to better patient outcomes. This study assessed whether an IPE course for health profession students was effective in teaching undergraduate students both interprofessional competencies and CWC principles.MethodsAn approximately seven-hour-long, four-session course was administered to Dalhousie University health profession students (N= 30). A validated survey for IPE competencies and a general survey about CWC principles were administered to assess the course. Descriptive statistics were used to assess the general CWC views, and paired samples t-tests were employed to compare pre- and post-IPE competencies.ResultsThe full survey was completed by 25 (83%) students. Of these, 52% were female, within five health disciplines, and 13 (52%) had heard of CWC prior. Overall, the students agreed that CWC was important and relevant to their profession. They also reported significant improvements in multiple IPE competencies, including communication, collaboration, roles and responsibilities, patient-/family-centered care, conflict management/resolution, and team function.ConclusionParticipants in our pilot Choosing Wisely IPE course valued the importance of the CWC campaign and reported improvement in multiple IPE competencies. This adaptable, simple, and low-cost course may be an effective way to integrate RS teaching across multiple health professions.

Background: Many guidelines in neurology encompass the principles of Choosing Wisely Canada (CWC): resource stewardship, patient safety, and high value care. There are currently 49 medical societies with CWC recommendations excluding the Canadian Neurologic Society (CNS). Methods: A descriptive process for list generation is outlined. A review of the American Choosing Wisely recommendations was undertaken to generate an adapted list of ten recommendations. CNS board members vetted this list and an online survey was sent to each CNS member. Results: A short list of recommendations endorsed by the CNS membership at large will be presented according to the survey results. CWC promotion of the list will take place to reach specialists, primary care providers, and trainees to ensure high value neurological care delivery is the standard across Canada. Conclusions: The process to delineate CWC recommendations for neurology is outlined. Participating in the CWC movement is an important leadership initiative for the CNS. It demonstrates the commitment of Canadian neurologists to the principles of high value patient care in neurology.

Resource stewardship is being increasingly recognized as an essential competency for physicians, but medical schools are just beginning to integrate this into education. We describe the evaluation of Choosing Wisely Canada's Students and Trainees Advocating for Resource Stewardship (STARS) campaign, a student-led campaign to advance resource stewardship education in medical schools across Canada. We evaluated the campaign 6 months after its launch, in November 2015. STARS students were administered a telephone survey eliciting a description of the initiatives that they had implemented or planned to implement at their schools to promote resource stewardship, and exploring their perceptions of facilitators of and barriers to successful implementation of their initiatives. We used a mixed-methods approach to analyze and summarize the data. Twenty-seven (82%) of the 33 eligible students representing all 17 medical schools responded. In 14 schools (82%), students led various local activities (e.g., interest groups, campaign weeks) to raise awareness about resource stewardship among medical students and faculty. Students contributed to curriculum change (both planned and implemented) at 10 schools (59%). Thematic analysis revealed key program characteristics that facilitated success (e.g., pan-Canadian student network, local faculty champion) as well as barriers to implementing change (e.g., complex processes to change curriculum, hierarchical nature of medical school). This student-led campaign, with support from local faculty and Choosing Wisely Canada staff, led to awareness-building activities and early curricula change at medical schools across Canada. Future plans will build on the initial momentum created by the STARS campaign to sustain and spread local initiatives.

BACKGROUND: Overuse of investigations, treatments, and procedures contribute to rising health care costs and may cause patient harm. In an attempt to promote higher-value health care, the Choosing Wisely Canada campaign has encouraged professional societies to develop statements that are directly actionable by their members. Currently, there are variations in infectious diseases practice that lead some patients to receive therapies and investigations that lack benefit and are potentially harmful. METHODS: The Association of Medical Microbiology and Infectious Disease Canada (AMMI) Canada established its Choosing Wisely Canada top five list of recommendations using the framework put forward by Choosing Wisely Canada. Following an electronic survey of its members regarding low-value practices within infectious diseases, AMMI Canada convened a working group that developed a list of draft recommendations and ranked the top five recommendations by consensus. This list was shared with the AMMI Canada membership electronically and during a national open forum. Following revisions based on feedback received, the AMMI Canada Executive Council and Guidelines Committee endorsed the final list, which was disseminated online. RESULTS: The top five declarative statements on infectious diseases practices that physicians and patients should question include: do not routinely prescribe intravenous forms of highly bioavailable antimicrobial agents for patients who can reliably take and absorb oral medications; do not prescribe alternative second-line antimicrobials to patients reporting nonsevere reactions to penicillin when beta-lactams are the recommended first-line therapy; do not routinely repeat CD4 measurements in patients with HIV infection with HIV-1 RNA suppression for >2 years and CD4 counts >500/μL, unless virological failure occurs or intercurrent opportunistic infection develops; do not routinely repeat radiologic imaging in patients with osteomyelitis demonstrating clinical improvement following adequate antimicrobial therapy; and do not prescribe aminoglycosides for synergy to patients with bacteremia or native valve infective endocarditis caused by Staphylococcus aureus. CONCLUSIONS: The Choosing Wisely Canada statements in infectious diseases endorsed by AMMI Canada represent a starting point to engage AMMI Canada members in broader discussions related to resource stewardship within infectious diseases practice and to take action.

BackgroundMedical student investment in resource stewardship (RS) is essential as resource overuse continues among physicians, but it is unclear whether this is influenced by hidden curriculum. This study investigated medical student perceptions of Choosing Wisely Canada (CWC).MethodsCanadian Medical students completed a bilingual questionnaire. Chi-square and student’s T-tests were used to analyze Likert responses capturing student attitudes toward questions grouped by theme, including the importance of the CWC campaign, the amount of CWC represented in undergraduate medical curriculum, the application of CWC recommendations in medicine, and the barriers which exist to student advocacy for CWC in practice.ResultsThere were 3,239/11,754 (26.9%) respondents. While most students (n = 2,720/3,171; 85.8%) endorsed the importance of CWC, few students felt that their institution had sufficiently integrated CWC into pre-clerkship (47.0%) and clerkship (63.5%) curricula. Overall, 61.4% of students felt that it is reasonable to expect physicians to apply CWC recommendations given the workplace culture in medicine. Only 35.1% students were comfortable addressing resource misuse with their preceptor. The most common barriers included the assumption that their preceptor was more knowledgeable (86.4%), concern over evaluations (66.0%), and concern for their reputation (31.2%).ConclusionsCanadian medical students recognize the importance of CWC. However, many trainees feel that the workplace culture in medicine does not support the application of CWC recommendations. A power imbalance exists that prevents students from advocating for RS in practice.

Context: Choosing Wisely Canada (CWC) aims to engage healthcare providers to reduce unnecessary care. Reducing overuse of antimicrobials and antipsychotics in patients with dementia in primary care settings remains an ongoing challenge. Audit and Feedback (A&F) interventions can facilitate practice change but can be improved by understanding factors affecting the likelihood of uptake of the feedback. Objective: To assess the impact of A&F interventions to reduce unnecessary prescribing of antibiotics and antipsychotics use and evaluate whether practice changes remain stable over time. Design: Clustered randomized controlled trial. Dataset: The Manitoba Primary Care Research Network (MaPCReN), a practice-based network that includes a repository containing de-identified EMR data from over 288,000 Manitobans. Population: Primary care providers participating in MaPCReN were randomized to three A&F groups: 1) Information on the relevant CWC recommendations; 2) practice specific data along with general information regarding the CWC recommendations 3) No CWC information. Outcome Measures: Statistics demonstrating changes in target prescriptions. Multivariate regression assessed characteristics of providers with improved prescribing. Results: 182 primary care providers were evaluated, 86.3% decreased the number of target prescriptions. More providers decreased prescribing in group1 (88.9%) or group2 (94.0%) compared to the control group 3 (76.7%) (p-value 0.02). There was no statistically significant difference between practice specific feedback and generic CWC information. An average of 46 antibiotic medications per provider were prescribed for viral indications in 2014/2015. This dropped to 15 in 2016/17 and was 18 in 2018/19. An average of 3 antipsychotic medications were prescribed for patients with dementia in 2014/2015. This dropped 7% in 2016/17 and remained stable in 2018/19. There were no statistically significant provider characteristics when considering all providers with improved prescribing, but male, rural and fee for service providers were more likely to decrease prescribing greater than the mean. Conclusion: Both practice specific and generic A&F information sent directly to primary care providers by a trusted source reduced potentially unnecessary prescriptions. This supports ongoing engagement with primary care providers in practice-based research networks to improve care and promote sustained practice changes.

BackgroundResident doctors are integral to healthcare delivery in Canada. Engaging residents in resource stewardship is important for professional development, but also as they are drivers of healthcare resource use. To date, no national resident-specific resource stewardship guideline has been developed. Resident Doctors of Canada (RDoC) in collaboration with Choosing Wisely Canada (CWC) sought to develop an evidence-informed, consensus-based list of five recommendations to promote resource stewardship.MethodsRDoC convened a taskforce with diverse geographic and specialty representation to develop candidate recommendations targeting resident resource stewardship behaviours using a consensus-based process, supported by a literature review. Residents across the country provided feedback on the candidate recommendations via an online questionnaire. The taskforce used this feedback to finalize the list.ResultsThe taskforce prepared 28 candidate recommendations for consideration. A detailed literature review and consensus process narrowed this list to 12 candidate recommendations for consultation. A total of 754 residents (754/10,068 residents = 7.5%) representing all provinces and levels of residency training reviewed and ranked the candidate recommendations. The highest-ranked recommendations comprised the final list.ConclusionResident doctors are willing and able to demonstrate leadership in advancing resource stewardship by the development of a national resident-specific list of Choosing Wisely Canada recommendations.

Choosing Wisely Canada aims to reduce potentially harmful or unnecessary diagnostic investigations and practices in healthcare delivery. A committee of the Canadian Association of Physical Medicine & Rehabilitation surveyed the general membership seeking suggestions on new or revised Physical Medicine & Rehabilitation Choosing Wisely Canada recommendations. Draft recommendations were revised and refined with an emphasis on resource stewardship and alignment with the Choosing Wisely Canada mission. The updated 2023 Choosing Wisely Canada recommendations for physical medicine and rehabilitation are to avoid: (1) investigating and treating asymptomatic bacteriuria in patients with neurogenic bladder; (2) recommending more than a brief period of physical and cognitive rest after mild traumatic brain injury; (3) starting opioid treatment for chronic noncancer pain without exhausting other approaches; (4) ordering diagnostic imaging for low back pain in the absence of red flags; (5) repeating injections without evaluating patients' responses to them; and (6) recommending carpal tunnel release without first confirming nerve entrapment with electrodiagnostic studies or ultrasonography. We present unique implementation tools to equip practitioners with quality improvement strategies to adopt these recommendations into their practices. Future work will include developing recommendations that consider planetary health co-benefits, creating knowledge translation tools, and assessing the impact of recommendation adoption into clinical practice.

New research suggests Canadian physicians order more than 1,000,000 potentially unnecessary tests and treatments each year. Strategies to educate medical students about the CanMEDs Resource Stewardship directive and judicious testing practices can help the healthcare system manage fiscal stress and improve healthcare experiences for patients. This article outlines several strategies that can be implemented at the undergraduate medical education level through Choosing Wisely Canada’s Students and Trainees Advocating for Resource Stewardship (STARS) program. The educational strategies feature group-based learning, lecture integration, and supportive online modules. Educating medical students across the country about judicious testing can produce the generation of resource-conscientious doctors that healthcare’s increasingly tight budget demands.

Exploring Clinical Care Among Adults With Diabetes Mellitus: Alignment With Recommended Statin and Sulfonylureas Treatment.

What Is the Issue? Lab test overuse can contribute to further unnecessary follow-up and testing, negative patient experiences, potentially inappropriate treatments, and the inefficient use of health care resources. One review of lab testing in Canada found that around 22% of blood tests were likely unnecessary. One strategy to address lab test overuse is to establish minimal retesting intervals that can be implemented in medical laboratories to help identify and manage potentially inappropriate lab test requests. Minimum retesting intervals suggest the minimum time before a test should be repeated based on the biochemical properties of the test and the clinical situation in which it is used. They are intended to inform clinical decisions about repeat testing. The importance of lab resource stewardship is being addressed by Choosing Wisely Canada through Using Labs Wisely, a consortium of more than 150 hospitals committed to driving the appropriate use of lab testing in Canada. The hospitals participating in Using Labs Wisely identified a need for guidance on minimum retesting intervals for commonly used lab tests. What Did We Do? Choosing Wisely Canada and CADTH partnered to convene an independent time-limited advisory panel to develop consensus-based recommendations for minimum retesting intervals for 7 commonly used lab tests (antinuclear antibody [ANA], B-type natriuretic peptide [BNP] and N-terminal pro b-type natriuretic peptide [NT-proBNP], Hemoglobin A1C, lipase, lipid panel, serum protein electrophoresis [SPEP], and thyroid stimulating hormone [TSH]) in prespecified patient populations. The advisory panel included core and specialist members who were recruited from across Canada. The 7 core advisory panel members brought together expertise in laboratory medicine, family practice, and patient lived experience. Seven additional specialist members brought expertise in endocrinology, cardiology, pediatric cardiology, rheumatology, hematology oncology, gastroenterology, and general internal medicine. The Advisory Panel on Minimum Retesting Intervals considered patient group input, evidence from focused literature reviews, equity considerations, and clinical expertise. Through facilitated discussion, they reached consensus on the recommendations for minimum retesting intervals. Following external feedback, the recommendations for BNP and NT-proBNP and lipid panels were removed, and this document includes recommendations for minimum retesting intervals for 5 lab tests. These are not recommendations for repeat testing. They are recommendations that if testing is undertaken, it should not be repeated sooner than the indicated intervals. They are not intended to replace clinical judgment as there may be exceptions in which the recommendations do not apply. What Is the Potential Impact? The recommendations on minimum retesting intervals can support the hospitals participating in Choosing Wisely Canada’s Using Labs Wisely program in their effort to reduce unnecessary lab tests and their impact on patients, providers, health systems, and the environment. The recommendations may also be relevant to community and hospital lab stewardship efforts and may address the appropriate use of the 5 lab tests by enabling changes in lab test ordering in both inpatient and outpatient settings.

Context: Respiratory tract infection (RTI) is the leading cause of avoidable antimicrobial use in primary care. How the COVID-19 pandemic has impacted antibiotic prescribing practices across Canada is unknown. The purpose of this study was to examine rates of antibiotic prescribing for RTI in primary care during the first year of the pandemic (2020), compared to baseline in 2019. Study Design and Analysis: Cross sectional study. Dataset: Canadian Primary Care Sentinel Surveillance Network electronic medical record data from sites in British Columbia, Alberta, Manitoba, Ontario, Quebec, Nova Scotia and Newfoundland. Population Studied: Patients that met the case definition criteria for an RTI or a Urinary Tract Infection (UTI) in 2019, and in 2020. Outcome measures: We examined oral antibiotic prescribing for patients who were identified as having a primary care visit for RTI. The same analysis was repeated for urinary tract infection (UTI) as a tracer condition. The antibiotic use considered avoidable for RTI was defined by Choosing Wisely Canada. Results: A total of 1,692,876 patients with a valid birth year and sex and at least one visit to primary care in 2019 and 2020 were included. Patient visits for RTI decreased from 2.3% in 2019 to 1.6% in 2020 (p<.0001), as did patient visits for UTI (1.1% vs 0.7%, p<.0001). In 2019, 28.0% of patients visits for RTI were prescribed an antibiotic, and this proportion decreased significantly to 20.6% in 2020 (<.0001). The drop in antibiotic prescriptions for RTI was driven by a decrease in prescribing for common cold (13.6% vs. 11.3%, <.0001) and for acute bronchitis/asthma (15.2% vs. 7.3%, p<.0001). In comparison, antibiotic prescribing for visits related to UTI increased marginally between 2019 and 2020 (71.6% vs. 72.3%, p=0.007). Conclusions: A significant decrease in antibiotic prescribing for RTI across primary care was observed during the first year of the COVID-19 pandemic, likely related to the changes in epidemiology and care delivery models in primary care. CPCSSN can provide pan-Canadian surveillance of antibiotic prescribing practices in primary care that can be used for provider feedback and quality improvement.

BackgroundUrinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics.Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithmFigure 2: Patients included/excluded with exclusion criteriaMethodsInstitutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm.Figure 3: Run chart of urinary tract infection misdiagnosis rateFigure 4: Callback system - Percent patients contacted and antibiotics-days savedResultsFrom June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics.ConclusionImplementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning.DisclosuresOlivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)

Choosing Wisely Canada (CWC) is a national branch of a global campaign advocating for fewer unnecessary tests and for optimizing patient care. Professional societies representing physicians, pharmacists, and nurses participate by generating lists of recommendations meant to reduce patient harm and resource mismanagement in healthcare. The Canadian Neurological Society (CNS) plays an important role in advocating for quality patient care demonstrated by deriving specific recommendations. This process is described. The CNS Choosing Wisely task force adapted 10 recommendations for Canadian neurology practice. These were approved by the CNS board, and subsequently ranked by CNS members. Ten recommendations were brought forward and ranked in a survey completed by CNS members. Survey ranking is presented. The top five recommendations were selected and optimized, resulting in seven key recommendations. The recommendations set forth by the CNS will help with resource stewardship and patient safety in the delivery of neurological care by healthcare providers in Canada.

Evidence-based medicine is what clinicians strive for when caring for their patients. It is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."1 A key component of evidence-based medicine is the judicious use of tests and treatments. Choosing Wisely Canada (CWC) is a national campaign to help clinicians and patients make mutual decisions about appropriate management of health issues and to initiate discussions about unnecessary tests, treatments, and procedures. Since 2014, CWC has partnered with numerous professional medical organizations and associations representing several clinical specialties to generate lists of "Things Clinicians and Patients Should Question."2 The goal is to reduce the number of unnecessary tests, treatments, and procedures that occur in Canada which potentially expose patients to harm, create unnecessary stress for patients and families, lead to more testing to evaluate false positives, and consume time and limited resources. Partnering with Choosing Wisely Canada, the Canadian Academy of Sport and Exercise Medicine (CASEM) has generated a pediatric SEM list of "Eight Things Clinicians and Patients Should Question". This list was launched on April 12, 2022, on the Choosing Wisely and CASEM web sites.2,3 (EN: https://choosingwiselycanada.org/recommendation/sport-and-exercise-medicine/#pediatric-sport-and-exercise-medicine FR: https://choisiravecsoin.org/recommendation/medecine-du-sport-et-de-lexercice/#medecine-sport-pediatriques). WHY A PEDIATRIC SEM LIST? Musculoskeletal (MSK) complaints are common in the pediatric age group, accounting for up to 25% of primary care visits by adolescents.4 Two-thirds of all injuries in adolescents are related to sports participation and can result in hundreds of thousands of emergency room visits annually.5,6 Sport injuries in children and youth can have a significant negative impact on quality of life, sometimes requiring weeks to months of time away from sport and activity as well as physiotherapy or even surgery, particularly if these injuries are not appropriately identified and managed. These injuries can also result in school absence, negatively affecting academic achievement, and can cause children and adolescents to drop out of sports altogether, reducing physical activity levels in adolescence and into adulthood.7 Given the frequency of sport injuries in the pediatric age group, it is vital that all clinicians managing these issues in children and youth are aware of and apply the available evidence in their daily practices. Current lists on the Choosing Wisely Canada web site have very few pediatric-specific SEM or pediatric-specific MSK recommendations.2 CASEM has previously developed an SEM list but only one recommendation was specific to the pediatric population.8 We are addressing this gap with the new list. HOW THE LIST WAS DEVELOPED CASEM formed a small working group consisting of Drs Laura Purcell, Erika Persson, and Kristin Houghton, all pediatricians and sport medicine specialists, who identified a need to develop a list of recommendations specifically for pediatric SEM. This list was developed based on existing research, experience, and common practice patterns. We sought input from the Pediatric Interest Group of CASEM, as well as a pediatric orthopedic surgeon and a pediatric MSK radiologist at McMaster Children's Hospital. The general CASEM membership was also asked for their input by electronic survey. The Publications Committee of CASEM provided input before the list being approved by the CASEM Board. The list was then submitted to CWC, which approved it after their own internal review process. THE PEDIATRIC SEM LIST The Pediatric SEM list identifies investigations and practices commonly used in pediatric SEM/MSK assessments that are not supported by evidence and may expose patients to harm, unnecessary stress, and additional unnecessary testing, consuming time and constrained resources. The list includes 8 imaging and management recommendations for knee and shoulder injuries, back pain, scoliosis, distal radius buckle fractures, CT scans in minor head injuries/concussion, and management of chronic pain syndromes. The list can be accessed using the following links: EN: https://choosingwiselycanada.org/recommendation/sport-and-exercise-medicine/#pediatric-sport-and-exercise-medicine. FR: https://choisiravecsoin.org/recommendation/medecine-du-sport-et-de-lexercice/#medecine-sport-pediatriques. CONCLUSION Evidence-based medicine is what we aspire to in our daily practices. We encourage all clinicians who see pediatric patients—family physicians, pediatricians and pediatric subspecialists, orthopedic surgeons, and SEM doctors—to adopt these CWC pediatric SEM recommendations as part of routine practice to optimize care for children and youth and minimize the use of unnecessary investigations and treatments.