Baseline Inappropriate Antibiotic Use in Primary Care Patients with Viral Respiratory Tract Infections with 2019 and 2020.

Context: Respiratory tract infection (RTI) is the leading cause of avoidable antimicrobial use in primary care. How the COVID-19 pandemic has impacted antibiotic prescribing practices across Canada is unknown. The purpose of this study was to examine rates of antibiotic prescribing for RTI in primary care during the first year of the pandemic (2020), compared to baseline in 2019. Study Design and Analysis: Cross sectional study. Dataset: Canadian Primary Care Sentinel Surveillance Network electronic medical record data from sites in British Columbia, Alberta, Manitoba, Ontario, Quebec, Nova Scotia and Newfoundland. Population Studied: Patients that met the case definition criteria for an RTI or a Urinary Tract Infection (UTI) in 2019, and in 2020. Outcome measures: We examined oral antibiotic prescribing for patients who were identified as having a primary care visit for RTI. The same analysis was repeated for urinary tract infection (UTI) as a tracer condition. The antibiotic use considered avoidable for RTI was defined by Choosing Wisely Canada. Results: A total of 1,692,876 patients with a valid birth year and sex and at least one visit to primary care in 2019 and 2020 were included. Patient visits for RTI decreased from 2.3% in 2019 to 1.6% in 2020 (p<.0001), as did patient visits for UTI (1.1% vs 0.7%, p<.0001). In 2019, 28.0% of patients visits for RTI were prescribed an antibiotic, and this proportion decreased significantly to 20.6% in 2020 (<.0001). The drop in antibiotic prescriptions for RTI was driven by a decrease in prescribing for common cold (13.6% vs. 11.3%, <.0001) and for acute bronchitis/asthma (15.2% vs. 7.3%, p<.0001). In comparison, antibiotic prescribing for visits related to UTI increased marginally between 2019 and 2020 (71.6% vs. 72.3%, p=0.007). Conclusions: A significant decrease in antibiotic prescribing for RTI across primary care was observed during the first year of the COVID-19 pandemic, likely related to the changes in epidemiology and care delivery models in primary care. CPCSSN can provide pan-Canadian surveillance of antibiotic prescribing practices in primary care that can be used for provider feedback and quality improvement.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

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.

Medical Practice and the Climate Crisis.

This JAMA Insights discusses the significant role that health care plays in the climate crisis and provides strategies to assist clinicians with improving patient care while also protecting the environment.

'Choosing Wisely' culture among Brazilian cardiologists.

OBJECTIVE: (i) To describe how aligned the 'Choosing Wisely' concept is with the medical culture among Brazilian cardiologists and (ii) to identify predictors for physicians' preference for avoiding wasteful care. DESIGN: Cross-sectional study. SETTING: Brazilian Society of Cardiology. PARTICIPANTS: Cardiologists who agree to fill a web questionary. INTERVENTION: A task force of 12 Brazilian cardiologists prepared a list of 13 'do not do' recommendations, which were made available on the Brazilian Society of Cardiology website for affiliates to assign a supported score of 1 to 10 to each recommendation. MAIN OUTCOME MEASUREMENT: Score average for supporting recommendations. RESULTS: Of 14 579 Brazilian cardiologists, 621 (4.3%) answered the questionnaire. The top recommendation was 'do not perform routine percutaneous coronary intervention in asymptomatic individuals' (mean score = 8.0 ± 2.9) while the one with the lowest support was 'do not use an intra-aortic balloon pump in infarction with cardiogenic shock' (5.8 ± 3.2). None of the 13 recommendations presented a mean grade >9 (strong support); 7 recommendations averaged 7-8 (moderate support) followed by 6 recommendations with an average of 5-7 (modest support). Multivariate analysis independently identified predictors of the score attributed to the top recommendation; being an interventionist and time since graduation were both negatively associated with support. CONCLUSIONS: (i) The support of Brazilian cardiologists for the 'Choosing Wisely' concept is modest to moderate, and (ii) older generations and enthusiasm towards the procedure one performs may be factors against the 'Choosing Wisely' philosophy.

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures.

BACKGROUND: Increasing attention has been focused on low-value healthcare services. Through Choosing Wisely campaigns, routine laboratory testing before low-risk surgery has been discouraged in the absence of clinical indications. The authors investigated rates, determinants, and institutional variation in laboratory testing before low-risk procedures. METHODS: Patients who underwent ophthalmologic surgeries or predefined low-risk surgeries in Ontario, Canada, between April 1, 2008, and March 31, 2013, were identified from population-based administrative databases. Preoperative blood work was defined as a complete blood count, prothrombin time, partial thromboplastin, or basic metabolic panel within 60 days before an index procedure. Adjusted associations between patient and institutional factors and preoperative testing were assessed with hierarchical multivariable logistic regression. Institutional variation was characterized using the median odds ratio. RESULTS: The cohort included 906,902 patients who underwent 1,330,466 procedures (57.1% ophthalmologic and 42.9% low-risk surgery) at 119 institutions. Preoperative blood work preceded 400,058 (30.1%) procedures. The unadjusted institutional rate of preoperative blood work varied widely (0.0 to 98.1%). In regression modeling, significant predictors of preoperative testing included atrial fibrillation (adjusted odds ratio [AOR], 2.58; 95% CI, 2.51 to 2.66), preoperative medical consultation (AOR, 1.68; 95% CI, 1.65 to 1.71), previous mitral valve replacement (AOR, 2.33; 95% CI, 2.10 to 2.58), and liver disease (AOR, 1.69; 95% CI, 1.55 to 1.84). The median odds ratio for interinstitutional variation was 2.43. CONCLUSIONS: Results of this study suggest that testing is associated with a range of clinical covariates. However, an association was similarly identified with preoperative consultation, and significant variation between institutions exists across the jurisdiction.

A commitment to high-value care education from the internal medicine community.

The Alliance for Academic Internal Medicine, American Board of Internal Medicine (ABIM), ABIM Foundation, and American College of Physicians are collaborating to enhance the education of physicians in high-value care (HVC) and make its practice an essential competency in undergraduate and postgraduate education by 2017. This article serves as the organizations' formal commitment to providing a foundation of HVC education on which others may build. The 5 key targets for HVC education are experiential learning and curriculum, environment and culture, clinical support, regulatory requirements, and sustainability. The goal is to train future health care professionals for whom HVC is part of normal practice, thus providing patients with improved clinical outcomes at a lower cost.

Building Bridges to Integrate Care (BRIDGES): Incubating Health Service Innovation across the Continuum of Care for Patients with Multiple Chronic Conditions.

Integrating care for people with complex needs is challenging. Indeed, evidence of solutions is mixed, and therefore, well-designed, shared evaluation approaches are needed to create cumulative learning. The Toronto-based Building Bridges to Integrate Care (BRIDGES) collaborative provided resources to refine and test nine new models linking primary, hospital and community care. It used mixed methods, a cross-project meta-evaluation and shared outcome measures. Given the range of skills required to develop effective interventions, a novel incubator was used to test and spread opportunities for system integration that included operational expertise and support for evaluation and process improvement.

Preoperative testing before low-risk surgical procedures.

BACKGROUND: There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures. METHODS: For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure. RESULTS: Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%-31.1%) and 10.8% (95% CI 10.8%-10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%-2.9%) and 2.1% (95% CI 2.1%-2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66-75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6-19.0; for radiography, adjusted OR 2.9, 95% CI 2.8-3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5-8.8; for radiography, adjusted OR 2.2, 95% CI 2.1-2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7-6.9; for radiography, adjusted OR 3.6, 95% CI 3.5-3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively. INTERPRETATION: Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors.

Impact of a formal mentoring program on academic promotion of Department of Medicine faculty: a comparative study.

PURPOSE: To evaluate the impact of a formal mentoring program on time to academic promotion and differences in gender-based outcomes. METHODS: Comparisons of time to promotion (i) before and after implementation of a formal mentoring program and (ii) between mentored and non-mentored faculty matched for covariates. Using paired-samples t-testing and mixed repeated measures ANCOVA, we explored the effect of mentor assignment and influence of gender on time to promotion. RESULTS: Promotional data from 1988 to 2010 for 382 faculty members appointed before 2003 were compared with 229 faculty members appointed in 2003 or later. Faculty appointed in 2003 or later were promoted 1.2 years (mean) sooner versus those appointed before 2003 (3.7 [SD = 1.7] vs. 2.5 [SD = 2], p < 0.0001). Regardless of year of appointment, mentor assignment appears to be significantly associated with a reduction in time to promotion versus non-mentored (3.4 [SD = 2.4] vs. 4.4 [SD = 2.6], p = 0.011). Gender effects were statistically insignificant. Post hoc analyses of time to promotion suggested that observed differences are not attributable to temporal effects, but rather assignment to a mentor. CONCLUSIONS: Mentoring was a powerful predictor of promotion, regardless of the year of appointment and likely benefited both genders equally. University resource allocation in support of mentoring appears to accelerate faculty advancement.

Factors associated with poor mental health status among homeless women with and without dependent children.

The purpose of this study was to estimate the prevalence of mental health problems among a representative sample of homeless women with and without dependent children and determine if the effects of risk factors for mental health are modified by the presence of dependent children. Homeless women (n = 522) were recruited in 2004-2005 from shelters and meal programs in Toronto, Canada. Linear and logistic regression was performed to identify factors associated with mental health status. Poor mental health was associated with low perceived access to social support, physical/sexual assault in the past 12 months, presence of a chronic health condition, and presence of a drug use problem in the past month. Efforts to improve mental health in this population will need to address the associated problems of victimization, substance abuse, and lack of social supports.

Using Blood Wisely: lessons learnt in establishing a national implementation programme to reduce inappropriate red blood cell transfusion.

BACKGROUND: Up to 50% of blood is transfused inappropriately despite best evidence. In 2020, Choosing Wisely Canada launched a major national programme, 'Using Blood Wisely', the aim was to engage hospitals to audit their red blood cell transfusion use against national benchmarks and participate in a programme to decrease inappropriate use. STUDY DESIGN: Using Blood Wisely is a quality improvement programme including national benchmarks, an audit tool, recommended evidence-based effective interventions and a designation to reward success. Hospital engagement was measured using the number of hospitals signing up, performing a baseline audit, submitting the planning survey, entering two or more audits and achieving hospital designation. Barriers to implementation were collected. RESULTS: From 1 September 2020 to 31 December 2022, 229 individual hospitals signed up over time to participate. Their results are reported as 159 hospitals and hospital groups. Collectively, this accounts for 72% of the blood used in Canada. Overall, 147 (92%) performed a baseline audit, 10 (6%) submitted a planning survey and 130 (82%) entered two or more audits. At baseline (time of enrolment), 75 (51%) met both benchmarks. The designation was awarded to 62 (39%) hospital groups (a total of 105 individual hospitals) that met and sustained benchmarks. Barriers to implementation included human resource shortages, lack of local expertise to advise the team, need for more education of transfusion prescribers and competing priorities. CONCLUSION: In its initial phase, Using Blood Wisely engaged a substantial number of hospitals in transfusion quality improvement work and maintained that engagement. This large-scale engagement across a big country was more successful than anticipated. Additional efforts are needed to rigorously evaluate the programme's impact on utilisation.

High utilizers of emergency health services in a population-based cohort of homeless adults.

OBJECTIVES: We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. METHODS: We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005-2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). RESULTS: Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. CONCLUSIONS: Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors.