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The Globe and Mail

When it comes to tests, more is not always better

The number of laboratory tests ordered for ER patients is down 31 per cent since September, 2014.

The number of lab tests ordered in the pre-operative clinic has dropped 38 per cent since February, 2015.

The number of mobile chest X-rays done in the intensive care unit has fallen 12 per cent since January, 2015.

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With eye-popping numbers like that, it's no wonder that North York General Hospital has become the poster child for Choosing Wisely Canada. The CWC campaign has a startlingly simple goal: To identify and promote care that is evidence-based, not duplicative, free of harm, and truly necessary.

In other words, to help physicians and patients engage in conversation to eliminate procedures – tests, surgery and prescriptions – that are unnecessary, wasteful and harmful.

Choosing Wisely began by asking physician groups to identify unnecessary procedures in their area, and for each specialty group to come up with five things physicians and patients should question.

The initiative, launched by the U.S. National Physicians Alliance in 2012, came to Canada two years later thanks to a small group of researchers at the University of Toronto. To date, more than 175 Canadian recommendations have been published and there are more to come, as it expands to get more input from other practitioners like nurses and pharmacists and, importantly, to patients.

Choosing Wisely Canada also encourages institutions and practitioners to look beyond the lists and embrace the philosophy that, in medicine, more is not always better, that not testing is often as important as testing, that not doing surgery is as valid a choice as doing it, and that deprescribing is as important as prescribing.

In short, health practitioners and patients should be willing to turn an old admonition on its head and say: "Don't just do something, stand there." North York General embraced Choosing Wisely early and decided to focus first on lab tests and imaging because they are ubiquitous.

"A lot of tests are done by routine, or because we've always done them, not because they're helpful," says Dr. Donna McRitchie, vice-president of medical and academic affairs at the hospital.

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So, committees of staff members sat down and reviewed more than 800 order sets (pre-packaged lists of tests to be done for certain conditions) to weed out procedures and prescriptions that were being done by rote, not out of necessity.

For example, every time a patient was prescribed an opioid-based painkiller (which can cause constipation), an automatic order went in for laxatives, even though it was common knowledge they were largely ineffective and patients didn't take them. That simple adjustment to a common order set saved the hospital tens of thousands of dollars – a reminder that, given high patient volume, small changes can have a big impact.

A mid-sized hospital like North York General gets about 100,000 ER visits a year and 42 per cent of patients were getting at least one test (and often a battery of tests). After the review, that number dropped to 31 per cent, and the top 10 tests performed all dropped significantly in numbers. The result: Shorter ER wait times and savings of more than $150,000.

There were similar results in the pre-operative clinic. For every two visits, one less test was done, and many patients didn't need any tests at all so they avoided the visit altogether – along with inconveniences like time off work and parking charges.

One can assume too that not too many patients complained about less poking and prodding, and fewer stool samples, X-rays and blood tests.

Dr. McRitchie says many other hospitals have approached North York to know their secret, and she says it's simple: "The staff is engaged. Choosing Wisely wasn't imposed, it was embraced."

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For example, physicians were not just satisfied with knowing how overall test numbers changed, they also wanted individual scorecards to compare their practice to that of colleagues.

In the ICU, where Dr. McRitchie works, there were large variations in how antibiotics were prescribed, "so we sat down and talked about it."

Ultimately, she says, that's what Choosing Wisely is all about: "It's a conversation between physicians, and it's a conversation between physicians and patients.

"If you do enough iterations of this, it becomes part of everyday practice and, every day, our practice will be a little better."

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