Updated: Feb 27
Patient Engagement in Practice: Case of Minor Traumatic Brain Injury (mTBI) A 40-year-male presents to the ED after sustaining a closed head injury during a soccer game. There is a question of a brief loss of consciousness and he is now complaining of a mild headache. At the ED triage, it is suspected that he has suffered a concussion. The patient appears anxious and is concerned that without imaging, his health may be at imminent risk. Consequently, he demands a head CT scan.
Welcome to the third post of the series highlighting Choosing Wisely – the national voice for resource stewardship in healthcare. In our first post, we discussed the concept of variation in care provided in the Emergency Department (ED), and its role as a surrogate of unnecessary tests and/or procedures. In our second post, we examined how the St. Michael’s Hospital ED utilized QI methodology to successfully and safely reduce unnecessary coagulation profile testing. Today, we will delve into the topics of patient engagement, shared decision-making, and patient-centred care as strategies to reduce low-value care.
Patient engagement: Meaningful involvement of patients and their loved ones in healthcare provision or decision-making process to help healthcare providers better understand patients’ experiences and preferences. (1)
Shared decision-making: An approach where clinicians engage patients with the best available evidence to make informed decisions regarding their healthcare needs and their values. (2)
Patient-centered care: Care in which an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. (3)
Low-value care: Medical services include tests and procedures that provide little or no value to the patient and are associated with the potential for harm, unnecessary costs, or wasting healthcare resources. (4–6)
Strategies to Combat Low-Value Care in the ED
Shared decision-making leads to increased patient empowerment, education, engagement and a higher likelihood of seeking treatment options that align with the patient’s goals and values. (2) Engaging with patients and their caregivers while making healthcare decisions, has also been shown to have positive outcomes such as the reduction in ED visits, minimization of incidental findings, increased safety and patient satisfaction. (1) This positively affects the healthcare system’s sustainability by increasing its efficacy, decreasing costs, and redirecting resources to where they are most needed. As such, shared decision-making and the delivery of patient-centred care should be used as strategies to reduce the provision of low-value care.
Impact of Low-value Care on Patients and Healthcare System
Here are some ways in which low-value care could potentially impact patients and the healthcare system.
Patient Engagement in Practice: Case of Minor Traumatic Brain Injury (mTBI) Continued
Resource Stewardship and Medical Considerations
As per CWC recommendations, CT head scans should not be routinely ordered for adults and children who have suffered minor head injuries unless positive for a validated head injury clinical decision rule such as the Canadian CT head rule.(10–12) However, a study by Lin et al. identified that head CT scans for mTBI were the most commonly ordered low-value test, and that perceived patient or family expectations were the most frequently cited reason for ordering the CT.(13) This is where effective communication during patient engagement and shared decision-making comes into play.
Due to the high patient volumes and the chaotic nature of the ED, patient education is often delivered by a physician as an intermediate or the last step of the patient encounter – paired with an overview of investigation findings, treatment options and follow-up instructions. However, evidence suggests that patients only retain about 20% of instructions given verbally by clinicians.(14) Thus, it may be reasonable to introduce health information for common ED presentations before the patient-clinician encounter. This would empower patients to actively participate in their healthcare decision-making process.(15,16) For example, one study assessed the influence of a patient-focussed infographic regarding mTBI and the utility of CT scans. It explored patients’ beliefs about the risks and benefits of CT scans and patients’ willingness to have a discussion with their healthcare provider on its necessity. This study demonstrated that targeted patient education materials could help support CWC recommendations and reduce low-value care.(17) Similarly, a quality improvement study by Masood et al., in which one of the components of the project was the implementation of a patient mTBI handout, resulted in a significant reduction in CT for mTBI.(14)
Back to our patient…
While waiting to be seen by a physician, our patient was provided with the following infographic and given the opportunity to ask questions to nursing staff, who were able to alleviate some of his fears and concerns.
Additionally, the ED physician used the following script, integrating the shared decision-making principles (18):
“Hi Mr. X, I am Dr. ____ and I am one of the ED resident/staff physicians. Thank you for patiently waiting to be seen. I saw the triage note and have some idea of what happened, but I would like to hear it from you…”
“I also heard from the nursing staff that you are afraid that without a head CT your health will be at risk. Would you mind sharing what are some of your fears and concerns right now?”
After actively listening to the patient, the ED physician proceeded:
“Based on your history, physical exam, and the CT Head Rule, you do not require a head CT. In cases like yours, a head CT will not give us any new information that would alter our treatment plan. If anything, it may expose you to unnecessary radiation and increase your stay in the ED.”
The ED physician proceeded to go through the CT Head Rule with the patient, explaining what information a CT head scan provides, when it is a helpful investigation, and what low risk and high risk means in the context of the patient.
“How do you feel about what I am telling you? Do you have any more questions before we move on to discuss our plan?”
Finally, the ED physician said:
“Okay, let’s summarize the plan to ensure we are both on the same page.”
The patient was asked to repeat the plan in their own words. The plan included the creation of a safety net and a discussion regarding follow-up with the family doctor. The ER physician also outlined reasons for return to the ED and the red flag symptoms that would warrant additional investigations.
As a result of this early intervention in the ED, the patient was actively engaged in his care, and with support from the ED physician, he was able to have an informed discussion regarding the next steps. His health concerns were alleviated as he screened negative according to the Canadian CT Head Rule. Additionally, he appreciated the harmful effects of unnecessary CT-associated radiation on his health. Consequently, a mutual agreement was reached, and the patient was amenable to being discharged home with follow-up instructions, including counselling on concussion management, and return to activity guidelines.
Reducing low-value care improves patient outcomes and healthcare system sustainability. It creates a virtuous cycle of healthcare whereby focusing on the patient via prevention and reduction of unnecessary procedures, positive patient outcomes increase while healthcare spending decreases, allowing improved resource utilization. However, for this model to work effectively, health care providers, patients, and families need to work together. Collaborative efforts also need to be promoted between hospital executives and hospital policymakers, so that changes can occur at a system and departmental level
Additional Resources for Patients and Practitioners
Communication Toolkit – Communicating with Patients and Families About Resource Stewardship http://www.royalcollege.ca/rcsite/canmeds/resource-stewardship-e#toolkit-3
Four questions to ask your healthcare provider:https://choosingwiselycanada.org/wp-content/uploads/2017/05/Four-questions-EN.pdf
Copyedited by: Mark Hewitt
Health Quality Ontario. Ontario’s Patient Engagement Framework: Creating a strong culture of patient engagement to support high-quality health care. hqontario.ca. https://www.hqontario.ca/Portals/0/documents/pe/ontario-patient-engagement-framework-en.pdf
Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6
What Is Patient-Centered Care? Explore the definition, benefits, and examples of patient-centered care. How does patient-centered care translate to new delivery models? New England Journal of Medicine. Published 2017. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559
Limiting Low-Value Care by “Choosing Wisely.” AMA Journal of Ethics. Published online February 1, 2014:131-134. doi:10.1001/virtualmentor.2014.16.2.pfor2-1402
Chassin M, Galvin R. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11):1000-1005. doi:10.1001/jama.280.11.1000
Choosing Wisely: The Harms of Overuse in Health Care | Commonwealth Fund. commonwealthfund.org. Published May 13, 2019. https://www.commonwealthfund.org/publications/infographic/2019/may/choosing-wisely-harms-overuse-health-care
Stemming the Superbug Tide. OECD; 2018. doi:10.1787/9789264307599-en
Technical Report Unnecessary Care in Canada. Canadian Institute of Health Information. Published April 1, 2017. https://www.cihi.ca/sites/default/files/document/choosing-wisely-technical-report-en-web.pdf
The Surprising Dangers of CT Scans and X-rays. Consumer Reports . Published 2015. https://www.consumerreports.org/cro/magazine/2015/01/the-surprising-dangers-of-ct-sans-and-x-rays/index.htm
Ten Things Physicians and Patients Should Question. CAEP. Published July 1, 2017. https://caep.ca/wp-content/uploads/2017/07/emergency_medicine_top_10_eng.pdf
Stiell I, Clement C, Rowe B, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511-1518. doi:10.1001/jama.294.12.1511
Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical Decision Rules for Adults With Minor Head Injury: A Systematic Review. The Journal of Trauma: Injury, Infection, and Critical Care. Published online July 2011:245-251. doi:10.1097/ta.0b013e31820d090f
Lin MP, Nguyen T, Probst MA, Richardson LD, Schuur JD. Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP’s Choosing Wisely Recommendations: A Survey Study. Pines JM, ed. Acad Emerg Med. Published online May 18, 2017:668-675. doi:10.1111/acem.13167
Masood S, Woolner V, Yoon JH, Chartier LB. Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department. BMJ Open Qual. Published online February 2020:e000811. doi:10.1136/bmjoq-2019-000811
Cook D, Thompson J, Dearani J, Prinsen S. How Mayo Clinic Is Using iPads to Empower Patients. Harvard Business Review . Published online February 14, 2014:online.
Jotterand F, Amodio A, Elger BS. Patient education as empowerment and self-rebiasing. Med Health Care and Philos. Published online May 14, 2016:553-561. doi:10.1007/s11019-016-9702-9
Dowling S, Hair H, Boudreau D, et al. A Patient-focused Information Design Intervention to Support the Minor Traumatic Brain Injuries (mTBI) Choosing Wisely Canada Recommendation. Cureus. Published online October 9, 2019. doi:10.7759/cureus.5877
The Royal College of Physicians and Surgeons of Canada: Resource stewardship. Royal College of Physicians and Surgeons of Canada. Published January 1, 2015. http://www.royalcollege.ca/rcsite/canmeds/resource-stewardship-e