Updated: Feb 27
Authors: Ahmed Taher and Davy Tawadrous
Welcome to another HiQuiPs post! This is the first in a series of posts highlighting Choosing Wisely, an international movement that addresses unnecessary tests and treatments, which has spurred many local, national, and international QI initiatives.
In our last post, we discussed the variation in the efficiency of medical processes and how this can be attributed to random or non-random (special cause) variation. Variation can be seen throughout different processes in the ED. For example:
Patient transfer from the ED to the imaging department
Environmental Services’ turn-around time for patient rooms
Nursing staff’s utilization of equipment for blood draws
In this context, we can examine variation in the provision of care, including how the ordering of diagnostic tests and therapeutic interventions varies between individual physicians. Imagine an audit was conducted in an ED and it was discovered that Dr. X orders CT scans on 10% of minor head injury patients, while Dr. Y orders CT scans on 90% of minor head injury patients. Assuming each sees a similar population of patients, one might question whether Dr. X is missing important diagnoses, or whether Dr. Y is exposing patients to unnecessary radiation, wasting precious resources, and disrupting ED flow.
Why might practice variation be important to address? Minimizing process variation has long been applied to manufacturing, and similar concepts have been utilized in medicine in recent years including lean thinking and six sigma. Using these approaches, manufacturers aim to consistently and reliably produce their products or service at the highest quality and lowest cost possible. Similarly, in medicine, providers aim to consistently and reliably provide patients with the highest quality care at the lowest cost possible. This is not to say that all patients are the same or that an assembly line approach should be applied to patient care. Rather, the aim is to reduce variation in testing and treatment so as to consistently provide effective care and the best possible outcomes to every patient.
Why Does Variation Exist?
There are three main reasons why there might be variations in the use of diagnostic testing and therapeutic procedures. These include differences in types of healthcare systems, physician practice patterns, and patient characteristics or preferences.(1) These three reasons need to be examined in light of evidence-based medicine and practice guidelines. One landmark project is the Dartmouth Atlas, which provides an atlas of healthcare highlighting regional variation in the United States.(2) In the Canadian context, variation has been studied across a spectrum of patient presentations and locations as well. (3)
Reducing Unnecessary Tests and Treatments
Unnecessary variation can be seen in the form of too few or too many diagnostic tests, therapeutic tests and treatments. Practice guidelines and other evidence-based medicine approaches attempt to reduce this unnecessary variation. However, it may take up to 17 years to widely disseminate practice guidelines.(4)
Recently, there has been a focus on resource stewardship and reducing variation by reducing unnecessary testing. This movement has paved the way for Choosing Wisely Canada (CWC), which is part of the international Choosing Wisely movement. CWC promotes conversations between clinicians and patients and encourages them to choose care that is supported by evidence, necessary, not duplicative, and free from harm.(5) To do so, CWC publishes specialty-specific lists of recommendations identifying common unnecessary tests and treatments that are not in keeping with the classic elements of quality of medical care.(6) As we discussed in a previous HiQuiPs post, quality medical care should be safe, effective, patient-centred, timely, efficient, and equitable.
Since 2012, CWC has gained much traction in Canada with high levels of awareness about the lists of recommendations amongst providers. Furthermore, CWC has spurred many regional and local implementation efforts, including 12 provincial and territorial campaign hubs and over 350 QI projects related to CWC across the country. (7)
Ultimately, CWC recommendations highlight opportunities to utilize QI methodology to reduce variation. For example, a recent QI project in one ED found that 50% of their laboratory ordering was through medical directives. Additionally, they found significant variation in the utilization and application of medical directives. Using a QI approach, this group was able to update and standardize this process, thereby decreasing laboratory orders by 23% over two years.(8) To encourage the prudent use of resources elsewhere, CWC offers a toolkit that addresses many of the key steps of QI methodology that we have covered in previous posts. These include creating a core change team with appropriate aims, engaging a wide variety of stakeholders and implementing several sequential targeted interventions. It is also important to measure the outcome, process, and balancing measures along the way.
Consider your own ED. Are there specific tests or procedures where there is a large variation in practice? Are there unnecessary tests or treatments that are ordered? Using the QI methodology that we have discussed in previous HiQuiPs posts and the CWC toolkit, healthcare providers are well-equipped to begin tackling these issues! Join us for part two of this special HiQuiPs post where we will examine a specific QI project inspired by CWC recommendations, using the QI methodology that we have previously discussed!
Senior Editor: Shawn Mondoux
Copyedited by: Ed Mason
Detsky AS. Regional Variation in Medical Care. N Engl J Med. August 1995:589-590. doi:10.1056/nejm199508313330911
Dartmouth Atlas. Dartmouth Atlas of Health Care. https://www.dartmouthatlas.org . Accessed October 19, 2019.
Chen E, Naylor CD. Variation in Hospital Length of Stay for Acute Myocardial Infarction in Ontario, Canada. Medical Care. May 1994:420-435. doi:10.1097/00005650-199405000-00002
Morris Z, Wooding S, Grand J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510-520. doi:10.1258/jrsm.2011.110180
5Our Mission. Choosing Wisely. https://www.choosingwisely.org/our-mission/. Published 2019. Accessed October 19, 2019.
Cheng AHY, Campbell S, Chartier LB, et al. Choosing Wisely Canada’s emergency medicine recommendations: Time for a revision. CJEM. September 2019:1-4. doi:10.1017/cem.2019.405
Implementing Choosing Wisely Canada Recommendations. Choosing Wisely Canada. https://choosingwiselycanada.org/implementation/. Accessed October 19, 2019.
Give the Test a Rest: A Toolkit for Decreasing Unnecessary Emergency Department Laboratory Testing. Choosing Wisely Canada; 2017:1-13. https://choosingwiselycanada.org/wp-content/uploads/2017/09/CWC-Toolkit-GiveTheTestARest-V1.pdf. Accessed October 19, 2019.