“Choosing Wisely” – time to import an American initiative into Canadian health care?

Here’s a startling but true story.

In 2008, the Ontario Ministry of Health and Long-Term Care paid about 10 million dollars for 13 million blood sugar test strips. They were used by 49,000 Ontarians aged 65 or older who had diabetes.

What’s so startling about that? The people who used the strips were not receiving any medications to lower their blood sugar levels, which meant that they had little to no chance of benefiting from frequent testing.

Why were the tests prescribed? A relatively small number of patients probably aggressively demanded frequent testing because they were convinced that more testing had to be a good thing, and nothing their doctor could say would persuade them otherwise. In another small number, there was probably something about the patient that made their doctor think that it was really important to test frequently. However, in the vast majority of those 49,000 people, I suspect the doctors gave little or no consideration to the cost of testing, and prescribed the test strips because it seemed like a reasonable thing to do.

Part of the current battle between the Ontario government and the Ontario Medical Association is focused on how to deal with the apparent wasteful use of tests. I suspect that a number of task forces will soon be established in the hope of changing how doctors order tests.

However, given the magnitude, complexity and rate of change of our health care system, establishing numerous task forces focused on individual technologies just doesn’t seem like a sustainable way of achieving change.

More importantly, I think we need a large cultural shift in how both doctors and patients think about testing in medicine. This won’t happen overnight, and will require lots of work. Physicians need to accept that although their primary responsibility is to their patients, it is also part of their job to think about the financial sustainability of the health care system. Patients need to recognize that tests are not “free” and that sometimes not having a test is just as good or better as having one.

Earlier this year, the American Board of Internal Medicine Foundation and nine major American physician organizations (including the American College of Physicians, the American College of Cardiology, and the American College of Radiology) launched an initiative called “Choosing Wisely”, focused on “….encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.” Interestingly, this is a joint initiative with Consumer Reports, which now features guidance about avoiding “unnecessary tests and treatments” on its web site.

It is early days, and we don’t know if Choosing Wisely will have any impact. Their task is particularly difficult because virtually all tests are useful – the challenge is to use the tests only in people who are likely to benefit from the results, and not use them in people who are unlikely to benefit or in whom they may do harm. That’s easier said than done.

However, at least these organizations are trying, and they have engaged the public in their efforts, through Consumer Reports. I think it is also commendable that they are doing this without government or insurance company involvement.

I sure would love to see Canada’s physician organizations do something similar.

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  1. Scott Wooder

    I agree with the Editor’s guarded optimism. This type of initiative could produce some much needed savings in Ontario. The Board of Directors of the Ontario Medical Association has commenced similar work with it’s clinical Sections. It is hoped that if the MOHLTC and the OMA ever get back to a constructive relationship, then this work could inform negotiations.

  2. Elizabeth Doyle

    I take your general point, Andreas, but the example you raised seems like it could offer another explanation (one which may take away from your overall conclusion). Isn’t it possible that these test strips were prescribed to monitor sugar levels that were borderline (i.e. should the levels spike consistently, medication should be initiated, and should they remain the same, continue testing (so as to monitor))?

    • Andreas

      Hi Elizabeth. Thanks for your comment.

      I think it is highly unlikely that monitoring of borderline blood sugar values explains the 13 million test strips used in 49,000 people, none of whom were on any drugs to control the blood sugar level. That works out to an average of 265 strips per person per year.

      I think it is MUCH more likely that these strips were ordered because we (patients and doctors) like to monitor things, and we pay little attention to the cost of so doing.


      • Andrew Holt

        Sounds like a good research area that moves this from speculation into evidence – maybe there should be some systems research funding allocated towards systematically sorting out the costs, benefits, and overall clinical value of these types of observations. In the bigger scheme of things it would be a low cost to generate such knowledge to inform policy and funding decisions.

  3. Ed Weiss

    What was most surprising to me about Choosing Wisely was how many of the recommendations appeared, to my Canadian-trained mind, to be either common sense, or aligned with the most basic points of resource utilization hammered home during medical school here in Canada.

    With regard to the issue of the test strips specifically, I think you’ve touched on a major point in suggesting that they were prescribed because it was “a reasonable thing to do.” Lord knows there are many things we prescribe that have no quality evidence for long-term efficacy (the majority of oral drugs for diabetes come to mind), but yet, I’d bet that many physicians wouldn’t feel comfortable ignoring a high LDL or HbA1C value, and tend to prescribe something less evidence-based simply because it’s a reasonable thing to do, or because of the cognitive difficulty of changing one’s established practice when faced with new evidence. The same could probably be said for a lot of tests. I think the challenge for the near future will be the process of sorting out what’s still reasonable to do in the face of uncertainty, and what can be safely left by the wayside based on quality evidence.

    (Anecdotally, I was further reminded of some of the excesses of American medicine when I spoke with my brother recently, who informed me that he had been prescribed “this great antibiotic” for a sinus infection. It really worked wonders, he said. Was it amoxicillin, I asked? Perhaps amox-clav? Some macrolide or another? It turned out to be a potentially expensive fluoroquinolone, which I have to imagine would be quite far from the first choice of any Canadian doctors I know. To be fair, I don’t know all the details of my brother’s health history and allergy status, but one wonders what sort of evidence (other than a glossy drug ad) the prescribing doctor would’ve been able to muster had he/she been challenged to support that clinical decision.)

  4. Bernard A.Yablin(MD)

    Are health insurance companies being charged for lab tests not actually performed(Rochester,NY Urology Group-urinalyses not done) and possibly Strong Memorial Hospital labs(also in Rochester,NY- blood work)

  5. Syed

    Hi Dr Andreas
    great to hear from you, I agree there is huge wastage in the health care system that can be put to better use. but I am not sure if there is anything better in American HC system to import in our system.

    Syed K
    Citizens Council

  6. Kenneth Lam

    Do either patients or doctors ever see a bill? It’s difficult to optimize cost if the decision-makers don’t know the cost: like ordering at a restaurant without menu prices.

  7. Kathy Kilburn

    I was diagnosed with diabetes (2) over ten years ago, and have been on medication ever since. It’s taken until the last six month to find a medication combination that has brought my blood levels down to an acceptable range. I stopped testing regularly shortly after being diagnosed, once I had a sense of how my body was reacting, or not, to the illness, and to the medication. There were no fluctuations that I didn’t already know the cause of: exercise and forget to eat, blood sugar drops; have a chocolate bar, blood sugar rises.

    I’ve asked health care providers and other diabetics often and often what then would be the purpose of me testing regularly. I’ve never received a clear answer–everyone’s just been bumscuzzled by the question.

    I’d gladly change my mind if someone would only give me a valid reason, but in the meantime, I consider it to be a waste of health care funds, to no end.

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