Overuse of Tests and Treatments: Has Canada Made Progress?

Overuse of healthcare services is a complex issue. Also known as low-value care, these are tests, treatments and procedures that are commonly ordered despite clear evidence that they do not help with patient care and may even cause harm. National clinician societies have developed over 450 Choosing Wisely Canada (CWC) recommendations to spur conversation about what is appropriate and necessary treatment. The latest report from the Canadian Institute for Health Information and CWC measured the trends and variation in the use over time of tests and treatments related to 12 CWC recommendations (CIHI 2022). Reductions in overuse were observed in eight of the 12 tests and treatments examined; findings for two of these measures - chronic benzodiazepine use and red blood cell transfusions - are highlighted. Despite some progress on reducing overuse, there remains considerable room for improvement in the appropriate and judicious use of tests and treatments in Canada.

How Children and Youth with Medical Complexity Use Hospital and Emergency Department Care across Canada.

Children and youth with medical complexity are a diverse group with uncommon diagnoses, a spectrum of needs and varying access to supports. Although this population represents a small proportion of all children, their unique needs lead to substantial use of healthcare services. With its first pan-Canadian report on children and youth with medical complexity, the Canadian Institute for Health Information examined how this population uses healthcare services. Key findings include the wide variation in the rate of medical complexity among children and youth across Canada. Children and youth with medical complexity were found to require a high proportion of hospital and emergency department care; however, their readmission rates were found to be lower than that of the general pediatric population.

Measuring the frequency and variation of unnecessary care across Canada.

BACKGROUND: Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS: Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS: Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS: The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.

Access to Palliative Care in Canada.

Palliative care enables a better end of life, but not all Canadians have access to it. Access to community-based palliative care has become a priority for federal, provincial and territorial governments, with an emphasis on services that can help people remain in the community even at the end of life. The Canadian Institute for Health Information (CIHI) investigated the current state of access to publicly funded palliative care across the country. The purpose of the research is to help health system planners to identify service gaps and develop strategies for improving care. Using linked administrative data, the analysis found that while many people could benefit from palliative care at the end of life, only a few (15%) received palliative home care in Alberta and Ontario in 2016-2017. The analysis also found that early palliative care in the community was associated with better end-of-life outcomes and that access to palliative care varied by age and whether a patient had cancer or not.

Rehabilitation service models for people with physical and/or mental disability living in low- and middle-income countries: A systematic review.

OBJECTIVE: To compare models of rehabilitation services for people with mental and/or physical disability in order to determine optimal models for therapy and interventions in low- to middle-income countries. DATA SOURCES: CINAHL, EMBASE, MEDLINE, CENTRAL, PsycINFO, Business Source Premier, HINARI, CEBHA and PubMed. STUDY SELECTION: Systematic reviews, randomized control trials and observational studies comparing >2 models of rehabilitation care in any language. Date extraction: Standardized forms were used. Methodological quality was assessed using AMSTAR and quality of evidence was assessed using GRADE. DATA SYNTHESIS: Twenty-four systematic reviews which included 578 studies and 202,307 participants were selected. In addition, four primary studies were included to complement the gaps in the systematic reviews. The studies were all done at various countries. Moderate- to high-quality evidence supports the following models of rehabilitation services: psychological intervention in primary care settings for people with major depression, admission into an inpatient, multidisciplinary, specialized rehabilitation unit for those with recent onset of a severe disabling condition; outpatient rehabilitation with multidisciplinary care in the community, hospital or home is recommended for less severe conditions; However, a model of rehabilitation service that includes early discharge is not recommended for elderly patients with severe stroke, chronic obstructive pulmonary disease, hip fracture and total joints. CONCLUSION: Models of rehabilitation care in inpatient, multidisciplinary and specialized rehabilitation units are recommended for the treatment of severe conditions with recent onset, as they reduce mortality and the need for institutionalized care, especially among elderly patients, stroke patients, or those with chronic back pain. Results are expected to be generalizable for brain/spinal cord injury and complex fractures.