CHOOSING WISELY CANADA BRINGING PM&R TO THE TABLE Larry - PowerPoint PPT Presentation

CHOOSING WISELY CANADA BRINGING PM&R TO THE TABLE Larry Robinson MD

Choosing Wisely Canada  Choosing Wisely Canada (CWC) is a campaign to  help physicians and patients engage in conversations about unnecessary tests, treatments and procedures  help physicians and patients make smart and effective choices to ensure high-quality care.  Choosing Wisely started in the US (ABIM) as a way to both reduce unnecessary procedures and improve quality.

Choosing Wisely Canada Canadian national specialty societies have been asked to develop lists of “ Five Things Physicians and Patients Should Question”  Tests, treatments or procedures  Commonly used in each specialty  Not supported by evidence  Could expose patients to unnecessary harm  Aid in physician conversations with patients

CWC Items – What they are  Information for us to use in discussions with patients  Not for someone else to use  Engagement of the field is critical  Ways to avoid unnecessary tests/procedures  That might cause harm or cost  Supported by the specialty and literature

CWC Items What they are not  Suggestions for other specialists or generalists  Ways to do more (don ’ t forget to ….)  Comprehensive guidelines or the ultimate in evidence based medicine  High level of engagement is critical

Who’s Participated So Far ? http://www.choosingwiselycanada.org/ Cardiology Radiation Oncology   Emergency Surgical Oncology   Endocrinology and Metabolism Orthopaedics   Family Practice Paediatric Surgery   Gastroenterology Palliative Care   General Surgury Pathology   Geriatrics Child and Adolescent Psychiatry   Hematology Geriatric Psychiatry   Hospital Medicine Radiology   Internal Medicine Rheumatology   Nephrology Spine   Nuclear Medicine Transfusion Medicine   Occupational Medicine Urology   Medical Oncologists Vascular Surgery  

CWC - Where are we?  Discussion at CAPM&R Exec in May 2015  SIGs – proposed items during the summer  Weaned down to 23 items this fall  Survey of 23 items to CAPM&R members  Weaned down to 7 top vote getters  Literature background – residents  Presentation to CAPM&R in May 2016  CAPM&R Exec submits to CWC and communicates

1. Do not treat asymptomatic urinary tract infections in catheterized patients - Dr. Sarah Courtice, PGY 2 University of British Columbia Urinary tract infections (UTIs) in catheterized patients are considered “complicated UTIs”. However, this term can be misleading and prompt clinicians to over treat infections in this population. It is generally recommended that persons with SCI be treated for bacteriuria only if they have symptoms . Specifically, the 2006 Consortium for Spinal Cord Medicine Guidelines for Healthcare Providers require that 3 criteria be met before an individual with SCI is diagnosed with a UTI: 1) significant bacteriuria, 2) pyuria, and 3) signs and symptoms of a UTI.

1. Do not treat asymptomatic urinary tract infections in catheterized patients  Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014) Bladder Management Following Spinal Cord Injury Version 5.0. Spinal Cord Injury Rehabilitation Evidence.  Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury: a clinical practice guideline for health- care providers. Consortium for Spinal Cord Medicine; 2006.  Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. (2005) Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases, 40(5), 643-654.

2. Do not regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result. - Dr. Colin Mascaro , PGY 2, Queen’s University Bed rest is often used to treat a variety of medical conditions. Prolonged bed rest causes major cardiovascular, respiratory, musculoskeletal and neuropsychological changes. Negative effects include thromboembolism, pneumonia, muscle wasting and physical deconditioning. Many of the negative effects begin within days of confinement, but consequences can last much longer. Specifically, in acute DVT/PE, bed rest has no impact on the risk of developing new PE. Furthermore, in acute low back pain, advice to stay active compared to rest in bed showed benefits in pain relief and functional improvement. Therefore, it is important to limit bed rest as much as possible.

2. Do not regularly prescribe bed rest and inactivity following injury and/or illness unless there is scientific evidence that harm will result. Allen C, Glasziou P , Del Mar C. (1999) Bed rest: a potentially harmful treatment  needing more careful evaluation. Lancet 354(9186), 1229-1233. Harper CM, Lyles YM. (1988) Physiology and complications of bed rest. Journal of  American Geriatrics Society, 36(11), 1047-1054 Adler J, Malone D. (2012) Early Mobilization in the Intensive Care Unit: A  Systematic Review. (2012) Cardiopulmonary Physical Therapy Journal , 23(1), 5-13 Castelino T, Fiore JF JR, Niculiseanu P , Landry T, Augustin B, Feldman LS. The effect  of early mobilization protols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. (2016) Surgery, 159(4), 991-1003. Aissaoui N, Martins E, Mouly S, Weber S, Meune C. (2009). A meta-analysis of bed  rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. (2009) International Journal of Cardiology , 137(1), 37-41. Stuempfle K, Drury D. (2007) The Physiological Consequences of Bed Rest. Journal  of Exercise Physiology, 10(3), 32-41 Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. (2010) Advice to rest in bed versus  advice to stay active for low-back pain and sciatica. Cochrane Database of Systematic Reviews, 6

3. Do not forget exercise as a medication - Dr. Jordan Silverman, PGY 2 University of Toronto Physical inactivity is the most significant population risk factor for cardiovascular disease, above smoking, hypertension and high BMI. The Canadian Physical Activity guidelines recommend 150 minutes of moderate to vigorous aerobic activity and two to three resistance training sessions per week for those 18-64 years old. Only 5% of Canadians meet recommended exercise targets. In addition to improving function, strength, mental health and cognition, adherence to these guidelines reduces heart disease, stroke, obesity and HbA1c more so than medications. Physicians should provide written exercise prescription specifying frequency, intensity, time and type. PM&R practitioners can address barriers to exercise including pain, disability, accessibility, and motivation through knowledge of resources for special populations and collaboration with our allied health colleagues. 

3. Do not forget exercise as a medication Brown WJ, Pavey, T, Bauman AE. (2015) Comparing population attributable risks for heart disease across  the adult lifespan in women. British Journal of Sports Medicine, 0,1 – 8. Canadian Society for Exercise Physiology 2011. The Gold Standard in Exercise Science and Personal  Training. Statistics Canada 2011  Sattelmair J, Pertman J, Ding EL, Kohl HW 3 rd , Haskell W, Lee IM. (2011) Dose response between physical  activity and risk of coronary heart disease; a meta-analysis. Circulation, 124(7), 789-795 Buckley JP , Mellor DD, Morris M, Joseph F. (2014) Standing-based office work shows encouraging signs of  attenuating post-prandial glycemic excursion. Occupational Environmental Medicine, 71, 109-11 Blair et al., Exercise is medicine handbook  Diabetes Prevention Program Research Group (2002) Reduction in the Incidence of Type 2 Diabetes with  Lifestyle Intervention or Metformin. New England Journal of Medicine , 346, 393-403. Marzolini S, Oh PI, Brooks D. (2012) Effect of Combined Aerobic and resistance training versus aerobic  training alone in individuals with coronary artery disease: a meta-analysis. European Journal of Preventive Cardiology , 19(1), 81-94 Susan Marzolini, Paul Oh, William McIlroy, Dina Brooks. (2013) The effects of an aerobic and resistance  exercise training program on cognition following stroke. Neurorehabilitation Neural Repair , 27, 392-402 Exercise medicine Canada – resources (exercise prescription) 

4. Do not order prescription drugs for pain without considering functional improvement Dr. Becky Iwanicki, PGY 2, University of Calgary Prescription pain medications have been shown to be effective for pain relief. However, a number of adverse events have been established. While pain reduction is an important outcome measure for patients, they also highly value improved function and quality of life. The addition of prescription pain medications does not always improve functional outcomes, or even pain. It is imperative that providers work with patients to establish treatment goals, regularly reassess pain and function, and taper or discontinue medications as able or if patients experience harm.