ChangingStatusQuo

Changing the status quo: Has the disruption of the pandemic provided opportunities for re-thinking established medical tests and practices?

OVERVIEW

The COVID-19 pandemic dictated that difficult decisions be made to postpone thousands of scheduled surgeries across the country. These decisions were taken to limit contact and reduce the possible spread of COVID-19 as well as ensure capacity to respond to the prospect of massive spikes in COVID-19 hospitalizations.

The scope of the cancellations has been daunting, with as many as 400,000 elective surgeries deferred by mid-June 2020 with experts estimating then that each week would see nearly 33,000 additional cancellations.1

A Canadian Medical Association study released in the fall of 2020 identified the most common procedures delayed as being:2

  • CT and MRI scans
  • Hip and knee replacements
  • Cataract surgeries
  • Coronary artery bypass graft

Although hospitals and health regions across the country ramped up efforts to address the backlog of postponed surgeries, these deferred procedures caused significant anxiety, inconvenience and hardship to patients and their families. The pandemic presented further complications by isolating patients from usual support structures. To reduce COVID-19 transmission risk, patients were forced to advocate for themselves without caregivers and loved ones. There is significant supporting evidence for the important role that family caregivers play in improving patient care, safety and outcomes, and the Canadian Foundation for Healthcare Improvement has released policy guidance for their re-integration.

Surgical cancellations have also led to adverse outcomes and very difficult situations for many patients including delayed diagnoses. Both patients and providers now find themselves having to make increasingly tough decisions regarding care. Yet, for other patients, some experts are asking how many of the above-mentioned tests and procedures are truly necessary.

Canadian and International data indicate that nearly 30% of tests, treatments, and procedures routinely conducted show no benefit to patient outcomes. Even though medical professionals have redoubled efforts to clear surgical backlogs, a full return to pre-pandemic processes has not been possible in all parts of the country. Further, the Canadian healthcare system has long been plagued by queues and wait-times. With these challenges in mind, Choosing Wisely Canada is urging all levels of government and healthcare systems to look more closely at unnecessary medical tests, particularly in several key areas.

ENCOURAGING EVIDENCE-BASED PRACTICE AND EFFICIENCY

Since 2014, Choosing Wisely Canada (CWC) has worked with clinician groups and specialty societies to identify opportunities for streamlining medical practices and reduce low-value care. CWC collaborates with professional societies, medical schools, patient groups, and providers to promote evidence-based medical practices and significantly reduce the use of inefficient tests and procedures. While incredibly challenging, the COVID-19 pandemic and ensuing disruptions in healthcare also present an opportunity to bring long-lasting and sustainable change to the health care system.

Choosing Wisely Canada contends3 that implementing changes in five specific policy ideas will greatly simplify processes and save time:

  1. Streamline the perioperative pathway for scheduled surgeries and procedures to manage increasing demands for surgery. This includes reducing unnecessary pre-operative testing, redesigning surgical queues, and investing in virtual care (please see HealthCareCAN’s brief on digital health to learn more) to improve efficiency and minimize physical contact across the perioperative journey.
  2. Reduce low-value laboratory testing that leads to additional downstream testing and ties up resources that could otherwise be used to provide high-value services. This includes retooling lab requisition processes at the provincial/territorial and organizational levels with built in appropriateness considerations, as well as investing in audit and feedback strategies.
  3. Reduce low-value imaging that increases wait times and can expose patients to unnecessary harm. This includes investing in inter professional programs to assess and manage imaging-intensive conditions such as back pain and implementing appropriateness criteria for common imaging requisitions.
  4. Reduce overly aggressive life-sustaining measures at the end of life. This includes a concerted and adequately resourced approach to advance care planning, as well as improved palliative care capacity in the community.
  5. Sustain the national supply of blood components and products. This includes establishing national appropriateness benchmarks and directing hospitals to measure their performance against benchmarks, as well as exploring whether alternative funding models that could strengthen incentives for hospital blood conservation efforts. Hospitals interested in knowing if they are using blood wisely can visit: https://usingbloodwisely.ca

Expanding on these ideas through partnerships with policymakers, health providers, and patient groups will strengthen the Canadian healthcare system’s ability to provide timely, accessible, and evidence-based care. More information on the policy ideas from Choosing Wisely Canada can be found in their report.