Overuse is a significant and long-standing issue within Canadian healthcare. Previous efforts to curb overuse have relied predominantly on top-down mechanisms to shape clinician behaviour. In 2014, the Choosing Wisely Canada campaign was launched, with a refreshing, grassroots approach premised on clinicians taking leadership on overuse. Five years later, and by many accounts, Choosing Wisely Canada has fulfilled that original mission, with significant penetration among clinicians. However, the overuse problem still persists and continues to be a challenge for clinicians, administrators, decision makers and patients. Although it is necessary for the clinician community to take leadership on overuse, this alone is not a sufficient condition for change. Many factors contributing to overuse are beyond what most individual clinicians can affect. These are system-level factors, including poorly designed information systems that drive overuse, lack of clinician feedback, outdated organizational processes, misaligned incentives and insufficient training within medical education and institutions on addressing overuse. This article proposes that it is time for a concerted approach to tackling overuse, one that is built on the foundation of strong clinician leadership, in combination with systemic actions to make it easier to do the right things at the front lines of care.
Five Years of Choosing Wisely Canada
Too much medicine, or overuse, can cause harm to individuals and healthcare systems. For individual patients, overtesting or unnecessary screening for disease can result in false positive results. Increasingly sensitive screening modalities can detect asymptomatic conditions or findings that have no clinical significance, yet treatment and further diagnostic tests can expose patients to harm (Moynihan et al. 2012). Overtreatment or unnecessary prescribing of medications can result in harmful side effects and dangerous medication interactions. For health systems, overuse increases wait times for those who really need care as well as wastes limited human and material resources. Overuse has powerful consequences for health systems; for example, overprescribing antibiotics contributes to an increase in antimicrobial-resistant organisms. In 2017, the Canadian Institute for Health Information (2010) found that up to 30% of healthcare services in Canada offered no clinical value to patients. Data from the Institute of Medicine in the United States suggest a similar amount of overuse.
Overuse has been described as an “intractable global quality problem with no quick fix” (Mafi and Parchman 2018). In the United States, overuse is understood to be influenced by the complex interplay between clinician factors (e.g., training, fear of lawsuit, time pressures, intolerance of uncertainty), patient factors (e.g., lack of knowledge or financial consequences) and healthcare system factors (e.g., institutional culture, pricing, fee-for-service payment models). Notwithstanding these complexities, the American Board of Internal Medicine Foundation launched the Choosing Wisely® campaign in the United States in 2012. This professionalism initiative was rooted in the evidence that physician decision making drives an estimated 80% of healthcare expenditures and that reducing overuse is imperative to improving quality of care (Cassel and Guest 2012).
Choosing Wisely Canada was launched in 2014 based on a similar formula: mobilize the physician community – through national societies representing different specialties – to take a stance on overuse by publishing evidence-based lists of unnecessary tests, treatments and procedures in their domain of practice that are common and can cause harm (Levinson and Huynh 2014). In the five years since launching, nearly 70 specialty societies have joined the campaign, publishing a total of more than 300 recommendations against such practices. These societies represent over 95% of all physicians in Canada; surveys show that nearly 90% of Canadian physicians are aware of the campaign and its recommendations, and over 40% use them in their daily practice (Canadian Medical Association 2016). More recently, the campaign has expanded to include other healthcare professionals, with recommendations for nurses, dentists, pharmacists and other clinicians.
Through the involvement of these partners, Choosing Wisely Canada has the potential to impact the practice of the majority of clinicians from coast to coast. This is a sizable and novel initiative in the Canadian healthcare environment, which has long struggled to engage clinicians, particularly physicians, in being stewards of system resources outside of the periodic wrangling of fee negotiations. In this sense, the campaign has been a success. In mobilizing significant swaths of the healthcare workforce to join, Choosing Wisely Canada has brought overuse to the forefront of healthcare improvement and refocused actions to where they should be – with patients on the front lines.
Yet the overuse problem persists and continues to be a challenge. This statement is qualified by numerous efforts to implement campaign recommendations across the country, with varying results – as high as 90% reduction in overuse in some settings, (Naugler et al. 2017) but more commonly in the 20–40% range overall (Leis et al. 2016; Lin et al. 2016). What has become clear from these localized efforts is that although it is necessary for clinicians to take leadership on overuse, that alone is not a sufficient condition for widespread change of the scale needed to make a dent in the 30% of tests, treatments and procedures that are potentially unnecessary. So what are the sufficient conditions to address overuse across the many complex drivers of this problem, and whose job is it to create them?
What we know
Medical training emphasizes the primacy of individual patients and their needs. Reducing overuse has been often been conflated by physicians with “rationing at the bedside,” which goes against their professional and ethical obligations. Choosing Wisely campaigns have developed an acceptable language for physicians to speak about reducing waste and harm, not as a cost-cutting or rationing approach but rather as a quality and patient safety initiative (Levinson and Huynh 2014). This framing has been vital to the uptake of the campaign among physicians.
Physicians also connect their ordering of unnecessary tests and treatments to defensive medicine. Clinicians’ behaviour of ordering tests when they are not clinically warranted is often justified by the need to mitigate perceived legal liabilities. This occurs, for example, in emergency departments, where physicians do not have continuity of care or ongoing therapeutic relationships with patients, coupled with significant time pressures.
Surveys suggest that physicians believe that the environment itself in which they practise is a barrier to Choosing Wisely. Increasingly, given the demands of electronic health records entry and documentation, time with patients is being squeezed and shortened (Sinsky et al. 2016).Given the pressures of increased complexity of patients, demands of practice and the need for shared decision making, it can be challenging for clinicians to think twice before ordering a test or taking the time to have a conversation with patients about an unnecessary medication. As such, changing medical culture has been identified as a priority to realize the promise of Choosing Wisely.
Medical training can influence overuse as habits, practice patterns and behaviours learned in training persist in practice. These patterns extend to overuse. A landmark study published in 1997 evaluated the long-term benzodiazepine prescribing patterns of graduates from four Québec medical schools. It was found that regardless of years after graduation, the prescribing rates of graduates from one school were significantly higher than the prescribing rates of graduates of the other three (Moneyite et al. 1997). These results suggest that prescribing patterns can be traced to influential faculty members or curricular content that de-emphasized the harms of benzodiazepines. The apprenticeship model of medical education asks trainees to provide more senior faculty and medical staff with patient information, profiles and differential diagnoses. Not only does this process reinforce modelling of faculty habits learned in practice, but it also tends to reward the demonstration of knowledge and thoroughness rather than restraint (Detsky and Verma 2012).
Yet there are signs that this is shifting. In 2015, the Royal College of Physicians and Surgeons of Canada introduced a revised CanMEDS framework to govern specialty training. This revised framework specifically includes “resource stewardship” within the “leader” role, whereby training programs are tasked to teach physicians to engage in resource stewardship, allocating resources for optimal care and, importantly, applying evidence and management to achieve cost-appropriate care (CanMEDS Framework 2015).
What Choosing Wisely Canada has done
The campaign has targeted shifting the medical culture through clinician engagement, training and education. Clinician engagement through medical professional societies and associations has emphasized raising awareness about recommendations and strategies to implement them in practice. The Canadian Medical Protective Association (CMPA) is a campaign partner and has communicated with members in support of the campaign. These communications are aimed at alleviating malpractice concerns that are often cited by physicians as a barrier to reducing overuse in practice.
Surveys have indicated that physicians want more tools to reduce overuse and to support conversations about unnecessary tests and treatments (Canadian Medical Association 2016). Choosing Wisely Canada has developed tools to be used in practice to avoid overuse, such as delayed and viral prescription pads for primary care physicians. The campaign has also collaborated with clinicians who have developed successful interventions to develop toolkits that include components of their intervention, such as decision aids, sample medical directives and order sets, that could be used elsewhere. In addition to tools, campaign partners have developed educational resources such as modules and continuing medical education courses to help individual clinicians improve shared decision-making skills (Wintemute et al. 2018). The Students and Trainees Advocating for Resource Stewardship (STARS) campaign has fostered medical student leaders who advocate for more curricular content and awareness about overuse during undergraduate training (Cardone et al. 2017).
What else is needed
Addressing system pressures of efficiency and accessibility is not within the realm of changes that Choosing Wisely Canada can deliver. Rather, the campaign has targeted influencing the medical culture and offering clinicians tools and support to help them choose wisely in practice when they are faced with such pressures.
There is significant heterogeneity across undergraduate medical education on overuse. Changing the culture begins in training, and there is more that medical schools and training programs can do to ensure that trainees have the knowledge and skills to meet the CanMEDS resource stewardship competencies. In addition, other professions engaged in the campaign need to be encouraged to embed resource stewardship knowledge and skills into training programs. To drive the culture change required to reduce overuse, Choosing Wisely needs to expand beyond a noun describing the campaign itself to a verb that clinicians can embody in their clinical habits and practice. Promoting Choosing Wisely Canada in medical education can help combat the “hidden curriculum,” which has tacitly encouraged overuse.
What we know
Research has shown that when appropriately informed of the risks and benefits of decisions, patients often choose less, not more. For example, research has found that shared decision-making strategies can lead to fewer unnecessary antibiotic prescriptions and screening tests (Stacey et al. 2017).
There are barriers to shared decisionmaking in practice, however. A 2015 Ipsos Reid of the Canadian public found that over 90% agreed that “patients need more support and/or tools to make decisions surrounding necessary healthcare” (Canadian Institute for Health Information 2017). But whose job is that? Clinicians generally cite limited time for conversations during hurried clinical encounters (Zikmund-Fisher et al. 2017). When compounded by the perception that many physicians have that patients will not be satisfied unless they get the tests or treatments they anticipated receiving, dialogue can feel impractical if not inconsequential.
The health literacy of patients and the public has been identified as a driver of overuse (Born et al. 2017). The risks and harms of aspects of overuse, such as antimicrobial resistance, and harms of incidental findings associated with unnecessary cancer screening, for example, are not well understood (Hoffmann and Del Mar 2015). There are many competing sources of health information. Canadians who access “Dr. Google” may find information that is incorrect and contradicts evidence-based advice from clinicians alongside reputable organizations and associations. Recent research has found that patients are influenced by such search engine results and can make harmful decisions about treatment based on this information (Pogacar et al. 2017).
Other forces driving healthcare decision making, and increasingly overuse, are new technologies and tools that are providing health information to Canadians. The advent of personalized medicine through new technologies, such as wearable health technologies and direct-to-consumer genetic testing, has been suggested as a driver for overuse and overdiagnosis (Diamandis and Li 2016). The coupling of forces of misinformation, technology, low health literacy and a lack of time for shared decision making can make it very challenging for clinicians and patients to choose wisely in practice.
What Choosing Wisely Canada has done
To counter such forces, Choosing Wisely Canada has developed a library of patient materials that it has disseminated through physician offices and online. Clinician leads have been active in connecting directly with the public through writing about the campaign on local and national editorial pages. These editorials aim to share campaign information in a practical and informative way, encouraging readers to talk to their doctors about overuse. But, admittedly, this is a drop in the bucket in a society awash in health content and advice, legitimate and otherwise.
What else is needed
Improving the health literacy of the public is a vital national goal to continue to advance healthcare system quality. This is a big job for governments and perhaps the public education system, but without some improvements in the general levels of health literacy, it will be increasingly difficult to have constructive conversations and shared decision making between clinicians and patients. This is being attempted elsewhere, with Choosing Wisely in Australia and England, for example, embarking on large-scale public education and information campaigns about the harms of overuse and encouraging shared decision making to combat this problem (Born et al. 2017).
Healthcare System Factors
What we know
Close to two decades ago, the Institute of Medicine (2000) broke the silence on medical errors when it released the ground-breaking report To Err Is Human. The lasting legacy of To Err Is Human lies in the powerful idea that safety incidents are shaped by systems rather than just individuals and that substantial improvements are possible by changing poorly designed and error-prone systems.
Similarly, overuse is often a product of antiquated systems that nudge people toward doing more than what is necessary. There are apt examples of this in lab ordering, for example, when tests are bundled together and part of outdated lab panels embedded within a hospital’s order entry system. In some hospitals, laboratory software may also automatically run both tests even if only one was ordered, embedding waste and overuse with no clinical indication or order (Fralick et al. 2017). For example, at many hospitals, “daily labs” appear as an option on admission order sets, making it too easy just to check off the box, which can lead to indiscriminate testing (Eaton et al. 2017). Historical practices that have, over time, become routinized and “baked” into the system set overuse on auto-pilot, taking decision making out of clinicians’ hands.
At the macro system level, information silos often result in tests being duplicated by different clinicians. For example, awareness of long patient queues to see certain specialists can put pressure on referring physicians to “proactively” run a barrage of tests to ensure that the wait is not further prolonged because of a missing piece of information. Information silos also, for example, exist in the inability to see data across institutions and regions. This means that clinicians who are providing care to the same patient in different settings do not have access to testing results and important clinical information, resulting in the repeat ordering of tests. Duplicative care is a common symptom of the absence of interoperable information technology systems to share important healthcare information across settings of patient care (Chang and Gupta 2015).
Another significant challenge to driving improvement is the lack of information or feedback physicians receive about their practice. There are rich administrative data sets in federal and provincial repositories, and many of the data can paint a picture of how an organization is performing. However, when it comes to the performance of individual clinicians, we are faced with the reversed situation of not having nearly enough. But these are technical issues that can be addressed by the many capable federal and provincial data organizations. The bigger challenge lies in the willingness to provide such feedback to clinicians, solicited or not. In Ontario, for example, since 2014, the province has developed individualized reports for physicians practising in primary and long-term care about their performance on a range of issues covering both overuse (e.g., opioid prescribing) and underuse (e.g., cancer screening). As of July 2018, only 32% of primary care physicians and 23% of long-term care physicians had signed up to receive these reports, largely because participation is voluntary (Office of the Auditor General of Ontario 2018).
Finally, models of remuneration can make it challenging for physicians to spend enough time with patients to discuss the pros and cons of certain tests and treatments, particularly those that benefit from shared decision making, such as certain types of cancer screening. Traditionally, most physicians were paid on a fee-for-service basis, but today there are many new and more nuanced ways to reimburse physicians for their services that prioritize goals other than productivity and volume. However, despite the gradual decline in the popularity of fee for service over the past couple of decades compared to alternate payment plans, it remains the major way physicians are paid. Although fee for service incentivizes procedures, productivity and volume, it does not, however, incentivize clinicians to spend time on shared decision making and relationship building with patients, which are evidence-based strategies to avoid overuse (Lyu et al. 2017). Ultimately, payment regimes are a product of policy priorities; if making time for shared decision making is an important goal, which we think it is, then there need to be more robust payment models that do not place a financial loss on physicians taking the time needed for shared decision making.
What Choosing Wisely Canada has done
Choosing Wisely Canada has helped raise awareness among providers and organizations that resource stewardship or reducing overuse is an important part of quality improvement. The campaign has worked with leading clinicians to develop and disseminate a suite of toolkits to help organizations identify processes and systems that drive overuse.
At the macro system level, this is challenging as each province and territory has its own unique structures, attributes and capabilities. For example, not all provinces/territories are capable of audit and feedback interventions, and for the ones that are, the responsibility typically rests with different groups that deal with this heterogeneity. Choosing Wisely Canada has established provincial/territorial campaigns to ensure that implementation strategies take into account the uniqueness of the respective healthcare systems.
What else is needed
Efforts to reduce overuse within healthcare systems need to be forward thinking and future oriented. Technology plays an increasingly important role in managing clinician workflow and influencing decision making. As such, it is imperative that technology vendors get engaged in the overuse issue. At the macro level, it is equally important that governments and planners minimize information silos that result in repeated tests simply because clinicians have no way of knowing if they have already been ordered. Finally, there is a need to re-examine the underlying incentive structures such that time for shared decision making is a valued aspect of the clinician– patient encounter. Payment schemes that are fee for service tend not to be very good at this.
A consideration of the broader context in which the Choosing Wisely Canada campaign operates, and the drivers of overuse at the individual clinician, patient and organizational levels, demonstrates the complexity of why overuse persists. Overuse continues to be a quality problem and challenge for clinicians, administrators, decision makers and patients. In the preceding sections, we summarized our observations about the nature of overuse in Canada based on the experience of Choosing Wisely Canada over the past five years. Like most quality problems in healthcare, the root causes of overuse are extensive, and addressing these requires a collaborative, team-based approach. Professional associations and societies need to continue to support their members to embed Choosing Wisely into practice through offering training, tools and continued leadership. Medical schools and sites for healthcare professional training need to take leadership and make resource stewardship a critical element of the curriculum. Administrators need to question the ways in which the microenvironments of care encourage and routinize over-ordering and over-treatment. Technology vendors need to build tools and products that make it easy for clinicians to do the right things. Policy makers need to revisit the incentive structures and all the subtle and not-so-subtle ways in which they nudge the system toward doing more. And collectively, we all need to step up to better educate patients and the public in engaging and meaningful ways to empower shared decision making to foster sound decision making in healthcare.
About the Author
Karen Born, MSc, PhD , Knowledge Translation Lead, Choosing Wisely Canada, Assistant Professor, Institute of Health Policy, Management and Evaluation University of Toronto, Toronto, ON
Tai Huynh, MDes, MBA, Campaign Director, Choosing Wisely Canada, Toronto, ON
Wendy Levinson, MD, OC, Chair, Choosing Wisely Canada, Professor, Department of Medicine, University of Toronto, Toronto, ON
Correspondence may be directed to: Prof. Karen Born, Choosing Wisely Canada, e-mail: email@example.com.
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