2. Choosing Wisely
Bottom up clinician led effort to identify and reduce low value health care
Premised on the balance of benefit versus potential harms
May reduce cost but that is not an explicit goal
Recent but now international
CWC recommends – CWNL implements

3. Choosing Wisely - Happy Video

4. Why Are We Involved?
NL SUPPORT aims to increase Patient Oriented Research
We were doing studies of healthcare utilization in various settings
The initial thought was to produce reports and dashboards to inform decision making
Then we realized it takes more to induce change

14. How We Work Identify who to contact based on utilization data
Not limited to Family Practice – specialists and hospital practice are also involved
Goal is a provincial reach
Some interventions need public involvement, others just clinicians
Will work with clinicians to facilitate change, non-coercive, personal data remains confidential
Interventions are chosen based on the issues

15. Use of Blood Urea in General Practice
1 July – 31 December 2015

16. First Campaign
Blood urea testing in non-urgent care Limited impact on the system but Allowed us to test how we could reach clinicians with a message Used Eastern health data from last half of 2015 so limited to Eastern Health family doctors Goal was to reduce use of a test which is rarely needed in this setting

17. Practice Points
Blood urea is not necessary to evaluate stable kidney function
eGFR should not be used to evaluate acute deterioration in Kidney function
In acute deterioration, blood urea may be increased by decrease in blood volume, hypercatabolism, or by bleeding retained in the body.

18. Tests results separately, 1 July – 31 December 2015
In general practice, blood urea is usually ordered with serum creatinine, and is unnecessary in stable patients.

19. eGFR vs Urea, 1 July – 31 December 2015:
*High blood urea with normal eGFR in stable patients creates unnecessary diagnostic confusion

20. Blood Urea in Patients with normal eGFR

21. Top 20 general practitioners who submitted Urea test the most:

22. Number of Urea Tests submitted by General Practitioners:

23. First Campaign: Reduce Urea Testing In Family Practice
Summary slide an from NLMA: 300 active doctors
Click to obtain personal utilization data: 1/3
Required information by paper 43: 1/8

24. Use of Antibiotics A bigger target with public involvement – helped develop communications strategy

29. Second Campaign: Antibiotic use
and education slides
Decision aids by post
Peer comparison in 3 months

30. First Public Campaign: Antibiotic use
Press release: TV x 3, Radio x 4
Slides on website
Video
Twitter and Facebook

31. Third Campaign Use of carotid imaging
We had utilization data from the Vascular lab at SCMH – targets Fam Med and Specialists
There is an issue with overuse of US but
The bigger issue is likely the underuse in a timely manner for those with TIA or minor stroke
Need for a provincial intervention targeting the under use of imaging in this context – US or CT angiography of carotids

32. The Problem Secondary Stroke rate in NL as % of total Strokes
Secondary stroke occurs after a warning event such as TIA or very mild stroke

33. The Problem Most secondary strokes: Are disabling or fatal
Occur within 48 hrs-2 weeks
Are PREVENTABLE with rapid management
Are often the result of high grade carotid artery disease ;

34. The Solution
Rapid Carotid Endarterectomy (CEA) substantially lowers risk of stroke in symptomatic patients

35. Carotid Territory TIA is a medical emergency!
Rapid onset symptoms include:
Unilateral weakness of face/arm/leg
Speech disturbance (aphasia and/or dysarthria)
Monocular visual loss (Amaurosis Fugax), or loss of one visual field (Homonymous Hemianopia)
Immediate work-up required
CT head
Carotid studies

36. Current Utilization at St. Clare’s Vascular Lab 2007-15
What’s happening here?
Current Utilization at St. Clare’s Vascular Lab
Carotid artery studies
17,600
Indicated based on symptoms
40%
Not indicated based on symptoms
60%
Test result shows high-grade stenosis
33%
Most requests arrive too late after symptoms onset
Access to urgent testing is diminished by a waitlist for tests that are not indicated

37. Choosing Wisely Recommendations
Don’t order a procedure that will not change the patient’s clinical course
Carotid Studies are not indicated for:
Syncope
Headache
Dizziness
Tinnitus
Carotid bruit
Pain
Generalized weakness

38. What you can do!
Arrange urgent carotid imaging for patients with rapid onset of carotid territory symptoms
When referring, provide type and timing of symptoms, ensure referrals are legible and transmit urgently.

39. Ranking of Doctors by Total Number of Referrals for Carotid Artery Testing (2007-2015)

40. Ranking of Doctors by Percentage of Tests Indicated (2007-2015)

41. Ranking of Referring Physicians by Percentage of Test Results Showing High Grade Stenosis ( )

42. Warning signs of stroke

43. Upcoming Campaigns Peripheral vascular disease testing
LDH and Troponin testing in the community
Ferritin testing
Colonoscopy
Antibiotics in Nursing Homes
Low back pain imaging
Antipsychotics in Nursing Home