Choosing Wisely Canada (CWC) and the Canadian Cardiovascular Society Blair O’Neill, MD, FRCPC, FACC CCS Immediate Past President Senior Medical Director, Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services
Objectives • To review “Choosing Wisely Canada” (CWC) – Background – Rationale • Review the draft CCS CWC statements – Why chosen? – Review process – Path forward Conflicts of Interest: None related to this presentation 2
Reassessing Cardiac Imaging/Chest Pain Pathway Initiative CV Health And Stroke Strategic Clinical Network AHS 3
Total health expenditures as a percentage of gross domestic product (1970-2011) 18 16 14 12 Germany 10 U.K. Canada 8 Japan 6 U.S. 4 2 0 1970 1980 1990 2000 2008 2011 OECD, 2013
Non-sustainable cost increases in Canada 34.2 M people 23.4M people 1975 to 2010 • Expenditure increases = 3.5 fold • Population increases = 1.5 fold
Are we getting the results? Life Expectancy in Canada vs Healthcare Expenditures Cost (2002$)
Costs for Cardiac Imaging, Alberta 2010-11 Modality Cost Cardiac Catheterization $3,906,280 Nuclear Medicine – Hospital $11,263,719 Nuclear Medicine – Community $13,610,912 Echo – Hospital $7,524,104 Echo – Community $14,996,776 CT – Hospital $199,767 MRI – Hospital $957,885 TOTAL $52,459,443 NOTES: Counts of tests in hospitals based primarily on CPEL codes. Cost per exam is based on Capital Health info in 2010/11, excluding Covenant Sites and also excluding service contracts. Costs are per modality and not necessarily cardiac-specific. Community-based costs based on fee tariffs for physician billings. 7 7
Rising Rates of Cardiac Procedures in the United States and Canada: Too Much of a Good Thing? Ayanian JA, Circulation. 2006; 113: 333 “…Canadian study reported that the total costs of noninvasive and invasive cardiac procedures nearly doubled in Ontario from 1992 to 2001”. This finding led Alter et al 2 to conclude that rising cardiac procedure rates and costs “ challenge the sustainability of Medicare in Canada .” “On the basis of the much higher US cardiac procedure rates reported by Lucas et al, 1 a similar inference could presumably be drawn for the Medicare program” in the US”. 1. Lucas FL, et al Circulation. 2006; 113: 374 – 379. Alter DA, et al. Circulation. 2006; 113: 380 – 387 . 2.
Environment • Cost containment returns to Canada – Ontario- $340M cuts later allocated disproportionately to DI, Cardiology, Ophthalmology • Cardiology hardest hit 12.8%- 3.4% of which later offset – New Brunswick FFS Billings capped at $425M/ a cut of $19M; salaried doctors 0% increase • CMA/CCS advocate Choose Wisely Canada
Definition of Appropriateness In the context of health care, appr propr opriat aten eness ess is the proper use of health services, products and resources. Inappr appropr priate iate care e refers to overuse, underuse and/or misuse of health services, products and resources. Appr propriat opriateness eness • determined by analyses of the evidence of clinical effectiveness, safety, economic implications, and other health system impacts. • qualified by (a) clinician judgment, particularly in atypical circumstances and (b) societal and ethical principles and values, including patient preferences .
Why a program targeted at physicians? Physicians determine and direct care: 1. Which patients are seen and how frequently 2. Which patients are hospitalized 3. Which tests, procedures and surgical operations are performed 4. Which technologies are used 5. Which medications are prescribed Emanuel EJ. JAMA . 2013.
Choosing Wisely Canada (CWC) A campaign to help physicians and patients engage in conversations about the overuse, waste and harm associated with unnecessary tests and procedures Support physician efforts to help patients make smart and effective care choices 12
Language is important • This is about overuse, waste and harm • This is not about cost savings (although that is likely to happen) 13
Language is important • This is about overuse, waste and harm • This is not about cost savings (although that is likely to happen) 14
Language is important • This is about overuse, waste and harm • This is not about cost savings (although that is likely to happen) 15
US First 9 – now 56 societies
ABIM – US: How the Lists Were Created • Societies were free to determine the process for creating their lists with the following requirements: • Each item was within the specialty’s purview and control • Procedures should be used frequently and/or carry a significant cost • Should be generally-accepted evidence to support each recommendation • Process should be thoroughly documented and publicly available upon request
www.consumerhealthchoices.org
Strategy in Canada US CWC strategy Medical Physician Consumer Media Schools Consumer groups Coordinated Societies develop to adapt Consumer release of lists lists Curriculum Report materials development (undergrad, Disseminate to postgrad, faculty) Disseminate physician leaders CCS – Goal – to add evaluation of impact of CWC
Expected Outcomes 1. Ongoing “appropriateness” strategy related to overuse and waste 2. Physician engagement and leadership in use of finite resources 3. Public awareness of why “more is not better” 4. Decreased test, procedure and treatment use, where not needed
Canada – lead by CMA Confirmed medical societies (first wave) • Canadian Cardiovascular Society • Canadian Association of Radiologists • CMA GP and Family Practice • Canadian Orthopedic Association • Canadian Society for Internal Medicine • Canadian Rheumatology Association • Canadian Geriatrics Society • Canadian Association of General Surgeons
CCS-What were we asked to do? • Working with a strong group of leading CCS members from multiple subspecialties across the country, the committee developed a list of five cardiology related "don'ts “ • Webinars used as part of the consultation process with CCS members • Regional Meetings to inform members 22
CMA Operating Principles for Professional Societies • Societies free to determine process for creating lists • Each item should be within the specialty’s scope of practice • Appropriate tests, treatments or procedures should: • be used frequently; and/or, • may expose patients to harm; and/or, • may contribute to stress and avoidable cost for patients; and/or, • create an increased strain on our health care system • There should be generally-accepted evidence to support each recommendation
Operating principles for societies (continued) • Development process should be thoroughly documented and publicly available upon request • If applicable, societies are asked to keep their provincial (especially Quebec) counterparts informed regarding their list development • Following the US Choosing Wisely model, begin each item on the list with “Don’t” or “Avoid” • Each list should include a total of five items
CCS WG Committee members - 10 Dr. Heather Ross, Chair, CCS VP, Toronto Dr. Blair O'Neill, CCS Past President, Edmonton Dr. Chris Simpson, CCS Council, CMA President elect, Kingston Dr. Normand Racine, Montreal Dr. Camille Hancock-Friesen, CCS Council Member, Halifax Dr. Ian Burwash, Canadian Society of Echocardiography President, Ottawa Dr. Michelle Graham, CCS Council, CCS Guidelines Chair, Edmonton Dr. Ross Davies, CCS Council member, Canadian Nuclear Cardiology Society President, Ottawa Dr. Bill Ayach, Trainee representative, Cleveland Dr. David Marr, Saint John 25
CCS CWC Process • Review the ACC list of "don'ts" – well received by both ACC members and patients alike in the US • Adopted and adapted the ACC 5 Don’ts – Discarded the non ACC Don’t # 5, in light of PRAMI study – Added an ECG Don’t # 5 • CCS Review – Review literature • ACC consulted for potential pitfalls • Up to date literature review – filling in gaps since ACC developed don’ts – Review within Canadian Context • Add CDN guidelines and expertise – Review provincial/national AUC • Any AUC developed that impact Don’ts 26
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CCS 5 Don’ts - #1 1. Don’t perform stress cardiac imaging or advanced non - invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. Asymptomatic, low-risk patients account for up to 45% of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or greater than 2 percent yearly risk for coronary heart disease events. Number of papers reviewed: 140 Please note: These will not be finalized until a full consultation process with CCS membership is complete. Official release date is April 2 nd 2014 30
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