Choosing Wisely Canada (CWC) and the Canadian Cardiovascular Society - - PowerPoint PPT Presentation

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

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Conflicts of Interest: None related to this presentation

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Reassessing Cardiac Imaging/Chest Pain Pathway Initiative CV Health And Stroke Strategic Clinical Network AHS

Total health expenditures as a percentage of gross domestic product (1970-2011)

2 4 6 8 10 12 14 16 18 1970 1980 1990 2000 2008 2011 Germany U.K. Canada Japan U.S.

OECD, 2013

Non-sustainable cost increases in Canada

1975 to 2010

• Expenditure increases = 3.5 fold
• Population increases = 1.5 fold

23.4M people 34.2 M people

Are we getting the results? Life Expectancy in Canada vs Healthcare Expenditures

Cost (2002$)

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Costs for Cardiac Imaging, Alberta 2010-11

7 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.

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 al2 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. 2. Alter DA, et al. Circulation. 2006; 113: 380–387.

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

• f $19M; salaried doctors 0% increase
• CMA/CCS advocate Choose Wisely Canada

Definition of Appropriateness

In the context of health care, appr propr

• priat

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

• priateness

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.

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

Choosing Wisely Canada (CWC)

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Language is important

• This is about overuse, waste and harm
• This is not about cost savings (although

that is likely to happen)

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Language is important

• This is about overuse, waste and harm
• This is not about cost savings (although

that is likely to happen)

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Language is important

• This is about overuse, waste and harm
• This is not about cost savings (although

that is likely to happen)

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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

Physician

Societies develop lists Disseminate to physician leaders

Consumer

Consumer groups to adapt Consumer Report materials Disseminate

Media

Coordinated release of lists

Medical Schools

Curriculum development (undergrad, postgrad, faculty)

US CWC strategy

CCS – Goal – to add evaluation of impact

• f CWC

Expected Outcomes

• 1. Ongoing “appropriateness” strategy related

to overuse and waste

• 2. Physician engagement and leadership in use
• f 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

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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

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• 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

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CCS CWC Process

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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 2nd 2014 30

CCS 5 Don’ts - #2

• 2. Don’t perform annual stress cardiac imaging or

advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact

• n patients’ outcomes. An exception to this rule would be for patients more

than five years after a bypass operation. Number of papers reviewed: 18

Please note: These will not be finalized until a full consultation process with CCS membership is complete.

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CCS 5 Don’ts - #3

• 3. Don’t perform stress cardiac imaging or advanced

non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non- cardiac surgery.

Non-invasive testing is not useful for patients undergoing low-risk non- cardiac surgery (e.g., cataract removal). These types of tests do not change the patient’s clinical management or outcomes and will result in increased costs. Number of papers reviewed: 11

Please note: These will not be finalized until a full consultation process with CCS membership is complete.

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CCS 5 Don’ts - #4

• 4. Don’t perform echocardiography as routine follow-up

for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

Patients with native valve disease usually have years without symptoms before the onset of deterioration. An echocardiogram is not recommended yearly unless there is a change in clinical status. Number of papers reviewed: 1,099

Please note: These will not be finalized until a full consultation process with CCS membership is complete.

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CCS 5 Don’ts - #5

• 5. Don’t order annual electrocardiograms (ECGs) or any
• ther cardiac screening for low-risk patients without

symptoms.

Don’t obtain screening ECG testing in individuals who are asymptomatic and at low risk for coronary heart disease. In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with electrocardiography does not improve patient outcomes. Number of papers reviewed: 967

Please note: These will not be finalized until a full consultation process with CCS membership is complete.

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Process

Communication with CCS Membership via:

• 1. Affiliate societies
• 2. Webinars
• 3. Regional Meetings
• 4. Web based –CCS.ca
• 5. Twitter
• 6. Email questions to choosewisely@ccs.ca

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Consultation process – reaching out to the CCS community

Canadian Adult Congenital Heart Network

• yes and supportive

Canadian Association of Interventional Cardiology

• yes and supportive

Canadian Heart Failure Society

• yes and supportive

Canadian Heart Rhythm Society

• yes and supportive

Canadian Nuclear Cardiology Society

• yes and supportive

Canadian Pediatric Cardiology Association

• yes and supportive

Canadian Society of Cardiac Surgeons

• yes and supportive

Canadian Society of Cardiovascular Magnetic Resonance

• yes and supportive

Canadian Society of Echocardiography

• yes and supportive

The Ontario Association of Cardiologists are also supportive. It is worth noting that the two of the five ACC Choosing Wisely “don’ts” are included in the most recent OMA service agreement with the Ontario Ministry of Health.

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What’s being used now – Ontario and Alberta

Ontario

The 2012 physician services agreement between the Ontario Medical Association and the Ontario Ministry of Health and Long Term Care identified two of the five Choosing Wisely Don’ts in the agreement set out in Appendix F – Evidence and Appropriateness Phase I (see below).

Schedule of Benefits Alignment with Recommendations Screening & Routine Tests ( Effective January 1, 2013)

Annual stress tests (CCS proposed don’t #2) Pre-Operative Cardiac Testing (CCS proposed don’t #5)

Alberta

The 2013 Alberta Health and AMA agreement included an agreement to achieve “system-wide efficiencies”. AMA has endorsed the CMA Choosing Wisely Canada Initiative and is also working with Strategic Clinical Networks to bring stewardship savings to the table in 2015.

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Future Plans - CMA

Phase 2. (Jan – Mar 2014) Knowledge Translation and Communications Work with the CMA and the University of Toronto on a communications strategy to:

• A. Patients
• B. CCS and Physician community
• C. Policy makers

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CCS Choosing Wisely Future – Looking past the initial 5

• Iterative process
• Develop ongoing don’ts

– Engagement of CCS membership and affiliate societies

• Dissemination – Media
• Knowledge translation strategies
• Evaluation strategies

– Potentially via Data Definitions and Quality Indicators

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Conclusions – Choosing Wisely Canada

• Physicians need to be prudent stewards of our

health care resources

• All of us have a role to play in ensuring

appropriateness and the highest value for resources spent in our health care system

• If we are not part of the solution, we will

become the solution to this problem

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