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

SLIDE 1

CHOOSING WISELY CANADA BRINGING PM&R TO THE TABLE

Larry Robinson MD

SLIDE 2

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.

SLIDE 3

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

SLIDE 4

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

SLIDE 5

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

SLIDE 6

Who’s Participated So Far?

http://www.choosingwiselycanada.org/



Cardiology



Emergency



Endocrinology and Metabolism



Family Practice



Gastroenterology



General Surgury



Geriatrics



Hematology



Hospital Medicine



Internal Medicine



Nephrology



Nuclear Medicine



Occupational Medicine



Medical Oncologists



Radiation Oncology



Surgical Oncology



Orthopaedics



Paediatric Surgery



Palliative Care



Pathology



Child and Adolescent Psychiatry



Geriatric Psychiatry



Radiology



Rheumatology



Spine



Transfusion Medicine



Urology



Vascular Surgery

SLIDE 7

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

SLIDE 8

• 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.

SLIDE 9

• 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.

SLIDE 10

• 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.

SLIDE 11

• 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

• f 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

• f 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

SLIDE 12

• 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

• f resources for special populations and collaboration with our allied health

colleagues.



SLIDE 13

• 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 3rd, 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)

SLIDE 14

• 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.

SLIDE 15

• 4. Do not order prescription drugs for pain

without considering functional improvement



Chou R and Huffman LH. (2007) Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine. 147(7): 505-14.



Harned M and Sloan P. (2016) Safety concerns with long-term opioid use. Expert Opinion on Drug Safety. 26: 1-8.



Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt MJ, and Lee MJ. (2011) Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 36(21 Suppl):S54-68.



Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, and Gallagher EJ. (2015) Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. Journal of the American Medical Association.. 314(15): 1572-80.



Houry D and Baldwin G. (2016) Announcing the CDC guideline for prescribing

• pioids for chronic pain. Journal of Safety Research. 57:83-4.

SLIDE 16

• 5. Do not order CT scans for low back

pain unless red flags are present

• Dr. Pamela Joseph, PGY 3, University of Toronto

Low back pain is one of the leading causes of disability, with a lifetime prevalence of 40%. Routine imaging for low back pain in the absence of red flag symptoms does not change clinical

• utcomes including pain, function, quality of life and mental
• health. In comparing early versus late imaging for non-specific

low back pain, there is no difference between groups in terms

• f overall treatment plan. Imaging can result in “labeling” of

patients, exposure to radiation, unnecessary invasive procedures, and increased health care costs. In the US, it is estimated that eliminating unnecessary MR and CT imaging for low back pain could save $120-200 million.

SLIDE 17

• 5. Do not order CT scans for low back

pain unless red flags are present



Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirsch JA. (2012). Epidemiology of low back pain in adults. Neuromodulation, 17: 3-10



Murray CJ, Lopez AD. (2013). Measuring the global burden of disease. New England Journal of Medicine, 369(5):448-457.



Srinivas SV, Deyo RA, Berger ZD. (2012). Application of “Less is more” to low back

• pain. Archives of Internal Medicine , 172(13): 1016-1020.



Chou R, Fu R, Carrino JA, Deyo RA. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet, 373: 463-72



Jarvik JG, Gold, LS, Cornstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW, Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM, Deyo RA. (2015). Association of early imaging for back pain with clinical outcomes in older adults. Journal of the American Medical Association, 31(11):1143-1153



Gilbert FJ, Grant MG, et a; Scottish Back Trial Group. (2004). Low back pain: influence of early MR imaging or CT on treatment and outcome – multicenter randomized trial. Radiology, 231(2):343-351.

SLIDE 18

• 6. Do not use benzodiazepines for the treatment of

agitation in the acute phase of traumatic brain injury.

• E. Ali Bateman, PGY 1, Western University

In animal models of acute TBI, benzodiazepines have been associated with slowed or halted recovery. Moreover, benzodiazepines have adverse effects on cognition, and can cause respiratory depression, paradoxical agitation, and anterograde amnesia. Beta blockers, such as propranolol, are first line pharmacotherapeutic agents, and anticonvulsants can also be used to decrease agitated behaviours. Due to its negative side effects, and the availability of effective alternatives, the use of benzodiazepines in the acute phase of traumatic brain injury should be limited to specific medical indications, such as alcohol withdrawal.

SLIDE 19

• 6. Do not use benzodiazepines for the treatment of

agitation in the acute phase of traumatic brain injury.



Goldstein, L. B. (1995). Prescribing of potentially harmful drugs to patients admitted to hospital after head injury. J Neurol Neurosurg Psychiatry, 58(6), 753-755.



Lombard, L. A., & Zafonte, R. D. (2005). Agitation after traumatic brain injury: considerations and treatment options. Am J Phys Med Rehabil, 84(10), 797-812.



Nott, M. T., Chapparo, C., & Baguley, I. J. (2006). Agitation following traumatic brain injury: an Australian sample. Brain Inj, 20(11), 1175-1182.



Rao, V., Rosenberg, P., Bertrand, M., Salehinia, S., Spiro, J., Vaishnavi, S., et al. (2009). Aggression after traumatic brain injury: prevalence and correlates. J Neuropsychiatry Clin Neurosci, 21(4), 420-429.



Schallert, T., Hernandez, T. D., & Barth, T. M. (1986). Recovery of function after brain damage: severe and chronic disruption by diazepam. Brain Res, 379(1), 104-111.



Singh, R., Venkateshwara, G., Nair, K. P., Khan, M., & Saad, R. (2014). Agitation after traumatic brain injury and predictors of outcome. Brain Inj, 28(3), 336-340.



Zafonte, R. D. (1997). Treatment of Agitation in the Acute Care Setting. J Head Trauma Rehab, 12(2), 78-81.

SLIDE 20

7. Do not recommend carpal tunnel release without electrodiagnostic studies to confirm the diagnosis and severity of nerve entrapment.

• Dr. Colin Mascaro, PGY 2, Queen’s University

Carpal tunnel release is a highly effective treatment for Carpal Tunnel Syndrome. Clinicians considering referral for surgical management should be aware that good surgical outcome is best correlated with a combination of positive clinical and positive electrodiagnostic studies (EDX). Clinical tests together with EDX alone have a better association with surgical outcome than either alone. Pre-op nerve conduction study severity can also better predict time to resolution and degree of resolution of symptoms.

SLIDE 21

7. Do not recommend carpal tunnel release without electrodiagnostic studies to confirm the diagnosis and severity of nerve entrapment.



Keith M.W., Masear V., Chung K., Maupin K., Andary M., Amadio P.C., Barth R.W., Watters W.C. 3rd, Goldberg M.J., Haralson R.H. 3rd, Turkelson C.M., & Wies J.L. (2010) Diagnosis of carpal tunnel syndrome. Journal of American Academy of Orthopedic Surgeons, 17(6), 389-396.



Basiri, K., & Katirji, B. (2015). Practical approach to electrodiagnosis of the carpal tunnel syndrome: A review. Advanced Biomedical Research, 4, 50.



Bland, J. D. P. (2001). Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle & Nerve, 24(7), 935-940.



Fowler, J. R., Munsch, M., Huang, Y., Hagberg, W. C., & Imbriglia, J. E. (2016). Pre-

• perative electrodiagnostic testing predicts time to resolution of symptoms after

carpal tunnel release. Journal of Hand Surgery (European Volume), 41(2), 137-142.



Kronlage, S. C., & Menendez, M. E. (2015). The benefit of carpal tunnel release in patients with electrophysiologically moderate and severe disease. Journal of Hand Surgery, 40(3), 438-444.



Ono, S., Clapham, P. J., & Chung, K. C. (2010). Optimal management of carpal tunnel syndrome. International Journal of General Medicine, 3, 255–261.

SLIDE 22

Thanks to Many who Participated

 Executive Committee  CAPM&R Office  SIGs  Residents  CAPM&R Membership

SLIDE 23

Next Steps

 Please provide any final feedback to the CAPM&R

• ffice before June 30.

 info@capmr.ca

SLIDE 24

Thank you for your attention!