CHOOSING WISELY
(Physicians)

Choosing Wisely (Physicians)

Choosing Wisely (Physicians)

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.

About the Lists

Canadian national societies, representing a broad spectrum of clinicians, participating in the campaign have or are in the process of developing lists of “Things Clinicians and Patients Should Question.” These lists contain tests and treatments commonly used in their specialty, but are not supported by evidence, and/or could expose patients to unnecessary harm.

National medical professional societies are free to determine the process for creating their lists, as long as they are done in accordance with the following principles:

  • The development process is thoroughly documented and publicly available
  • Each recommendation is within the specialty’s scope of practice
  • Tests and treatments included are those that are frequently used and may expose patients to harm or stress
  • Each recommendation is supported by evidence
  • Choosing Wisely Canada recommendations are not intended to be used to establish payment and coverage decisions. Rather, the lists are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, clinicians and patients should use the Choosing Wisely Canada materials to determine an appropriate treatment plan together.

    What Makes CWC a Great Resource

    Unnecessary tests, treatments and procedures do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. And of course unnecessary tests, treatments and procedures put increased strain on the resources of our health care system.

    Canadian national specialty societies participating in the campaign, representing a broad spectrum of physicians, have been asked to develop lists of “Five Things Physicians and Patients Should Question.” These lists identify tests, treatments or procedures commonly used in each specialty, but are not supported by evidence, and/or could expose patients to unnecessary harm.

    Choosing Wisely Canada is modelled after the Choosing Wisely® campaign in the United States, which was launched by the ABIM Foundation in April 2012.
    Choosing Wisely Canada is organized by Dr. Wendy Levinson in partnership with the Canadian Medical Association.

    Choosing Wisely Canada got underway initially in Ontario and has quickly been adopted by all provincial and territorial medical associations which have established or are in the process of establishing mechanisms to support the adoption of the Choosing Wisely Canada lists. It is now a truly national campaign in Canada and, in fact has spread to Australia, Germany, Italy, Japan, Netherlands, Switzerland and elsewhere. Choosing Wisely Canada leads the international effort.

    Choosing Wisely Canada recognizes the importance of educating and engaging patients so that they could make informed choices about their care. This campaign has created patient-friendly materials to help patients learn about the tests, treatments or procedures in question, when they are necessary and when they are not, and what patients can do to improve their health. Choosing Wisely Canada is working with various stakeholder groups to disseminate the patient materials widely.

    Choosing Wisely Canada is also working with medical schools to introduce new content into the undergraduate, postgraduate and continuing medical education curricula.

    Opportunities are currently being identified, through partnerships with various health care organizations and associations, to support implementation of the physician recommendations in practice settings. Choosing Wisely Canada has recently introduced an “Early Adopter Collaborative” to bring such groups together.

    The lists of “Five Things Physicians and Patients Should Question” are not intended to be used to establish payment and coverage decisions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, physicians and patients should use the Choosing Wisely Canada materials to determine an appropriate treatment plan together.

    Rheumatology : Five Things Physicians and Patients Should Question

    1. Don’t order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus (SLE) or another connective tissue disease (CTD).

    ANA testing should not be used to screen subjects without specific symptoms (e.g., photosensitivity, malar rash, symmetrical polyarthritis, etc.) or without a clinical evaluation that may lead to a presumptive diagnosis of SLE or other CTD, since ANA reactivity is present in many non-rheumatic conditions and even in “healthy” control subjects (up to 20%). In a patient with low pre-test probability for ANA-associated rheumatic disease, positive ANA results can be misleading and may precipitate further unnecessary testing, erroneous diagnosis or even inappropriate therapy.

    2. Don’t order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms.

    HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without further spondyloarthropathy (SpA) signs or symptoms (e.g., inflammatory back pain _≥_3 months duration with age of onset

    3. Don’t repeat dual energy X-ray absorptiometry (DEXA) scans more often than every 2 years.

    The use of repeat DEXA scans at intervals of every 2 years is appropriate in most clinical settings, and is supported by several current osteoporosis guidelines. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD. If bone mineral densities are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered. Shorter or longer intervals between repeat DEXA scans may be appropriate based on expected rate of change in bone mineral density and fracture risk.

    4. Don’t prescribe bisphosphonates for patients at low risk of fracture.

    There is no convincing evidence that anti-osteoporotic therapy in patients with osteopenia alone reduces fracture risk. The 2008 Cochrane Reviews for three bisphosphonates (Alendronate, Etidronate, Risedronate) found no statistically significant reductions for primary prevention of fracture in postmenopausal women. Fracture risk is determined using either the Canadian Association of Radiologists and Osteoporosis Canada risk assessment tool (CAROC) or FRAX®, a World Health Organization fracture risk assessment tool. Both are available as online calculators of fracture risk. Given the lack of proven efficacy, widespread use of bisphosphonates in patients at low risk of fracture is not currently recommended.

    5. Don’t perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adults.

    The diagnosis of peripheral and axial inflammatory arthritis can usually be made on the basis of an appropriate history, physical exam and basic investigations. Whole body bone scans, such as the Tc-99m MDP scintigraphy, lack specificity to diagnose inflammatory polyarthritis or spondyloarthritis and have limited clinical utility. The equivalent of radiation exposure of a total whole body bone scan is reported as over 40 routine chest X-rays, thus posing risk.

    How the list was created

    The Canadian Rheumatology Association (CRA) established its Choosing Wisely Canada Top 5 recommendations using a multistage process combining consensus methodology and literature reviews. A steering committee solicited a group of practicing rheumatologists from across the country from diverse clinical settings and an allied health professional to form the CRA Choosing Wisely Canada committee. This group generated candidate recommendations using the Delphi method. Recommendations with high content agreement and perceived prevalence advanced to a survey of CRA members. CRA members ranked these top items based on content agreement, impact and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential impact on patients and the member survey results. The Top 5 candidate items were selected to advance for literature review. The list was approved by the CRA Board of Directors and has been reviewed by a group of patient collaborators with rheumatic diseases. Patient collaborators also worked with the CRA to ensure the CRA Choosing Wisely Canada statements were translated into lay-language and made accessible to patients and the public.

    Sources

    1. BC Guidelines. Antinuclear antibody (ANA) testing protocol [Internet]. 2013 Jun [cited 2014 Feb 22]. Available from: http://www.bcguidelines.ca/pdf/ana.pdf.

    Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med. 2000 Jan;124(1):71-81.

    Solomon DH, Kavanaugh AJ, Schur PH, American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum. 2002 Aug;47(4):434-44.

    Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, et al. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol. 2002 Feb;117(2):316-24.

    2. Rostom S, Dougados M, Gossec L. New tools for diagnosing spondyloarthropathy. Joint Bone Spine. 2010 Mar;77(2):108-14.

    Rudwaleit M, van der Heijde D, Khan MA, Braun J, Sieper J. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004 May;63(5):535-43.

    Rudwaleit M, van der Heijde D, Landewe R, Listing J, Akkoc N, Brandt J, et al. The development of assessment of SpondyloArthritis international society classification criteria for axial spondyloarthritis (part II): Validation and final selection. Ann Rheum Dis. 2009 Jun;68(6):777-83.

    Sidiropoulos PI, Hatemi G, Song IH, Avouac J, Collantes E, Hamuryudan V, et al. Evidence-based recommendations for the management of ankylosing spondylitis: Systematic literature search of the 3E initiative in rheumatology involving a broad panel of experts and practising rheumatologists. Rheumatology (Oxford). 2008 Mar;47(3):355-61.

    3. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. CMAJ. 2010 Nov 23;182(17):1864-73.

    Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive summary of the 2013 international society for clinical densitometry position development conference on bone densitometry. J Clin Densitom. 2013 Oct-Dec;16(4):455-66.

    U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011 Mar 1;154(5):356-64.

    4. FRAX®. WHO fracture risk assessment tool [Internet]. 2011 Jun [cited 2014 Feb 22]. Available from: http://www.shef.ac.uk/FRAX/tool.aspx.

    Osteoporosis Canada. Assessment of 10-year fracture risk – women and men [Internet]. 2010 [cited 2014 Feb 22]. Available from : http://www.osteoporosis.ca/multimedia/pdf/CAROC.pdf

    Roux C. Osteopenia: Is it a problem?. Int J Clin Rheumtol. 2009 Dec;4(6):651-5.

    Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001155.

    Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, et al. Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003376.

    Wells G, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004523.

    5.Fisher BA, Frank JW, Taylor PC. Do tc-99m-diphosphonate bone scans have any place in the investigation of polyarthralgia? Rheumatology (Oxford). 2007 Jun;46(6):1036-7.

    Picano E, Matucci-Cerinic M. Unnecessary radiation exposure from medical imaging in the rheumatology patient. Rheumatology (Oxford). 2011 Sep;50(9):1537-9

    Song IH, Carrasco-Fernandez J, Rudwaleit M, Sieper J. The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: A systematic literature research. Ann Rheum Dis. 2008 Nov;67(11):1535-40

    Whallett A, Evans N, Bradley S, Jobanputra P. Isotope bone scans: An assessment of their diagnostic use in polyarticular pain of uncertain origin. Ann Rheum Dis. 2003 Aug;62(8):784-5

    Orthopaedics : Five Things Physicians and Patients Should Question

    1. Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.

    Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.

    2. Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.

    The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.

    3. Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

    Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.

    4. Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.

    In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.

    5. Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.

    Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental effects including adhesion formation, stiffness and prevention of nerve and tendon movement.

    How the list was created

    The Canadian Orthopaedic Association (COA) established its Choosing Wisely Canada Top 5 recommendations by asking its National Standards Committee to review the evidence base associated with the five treatments and procedures chosen by the American Academy of Orthopaedic Surgeons for the Choosing Wisely® campaign in the United States. Satisfied that the list was relevant to the Canadian clinical context, the Committee recommended its adoption to the COA’s Executive Committee, and the motion was then unanimously approved by the Board of Directors. Therefore, all five items were adopted with permission from the Five Things Physicians and Patients Should Question. © 2013 American Academy of Orthopaedic Surgeons