Canadian Medical Association

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The inappropriate use of medical interventions is a widespread problem in Canada.1 Reducing unnecessary diagnostic tests and treatments can help improve patient care outcomes as well as health care sustainability, especially at a time when Canada’s health care system is already stretched to the limit. 

Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in Canada. POEMs (Patient Oriented Evidence that Matters) are synopses of new, practice-changing evidence published in medical journals. They are sent to members of the Canadian Medical Association (CMA) daily by email. 

Starting in December of 2021, in partnership with Choosing Wisely Canada and the POEMs editorial team, the CMA Joule’s Ask a Librarian team added to selected POEMs a new “Overuse Alert” feature to highlight POEMs that align with Choosing Wisely Canada recommendations. 

As of December 2022, a total of 19 POEMs have included an overuse alert linking to the Choosing Wisely Canada recommendations. Among them, 14 POEMs address the issue of overtreatment (mostly overprescribing). The other five POEMs are related to unnecessary tests. 

POEMs on unnecessary and even harmful prescribing of proton pump inhibitors, antibiotics as well as screening colonoscopies were among the most read by CMA members. 

Here are the 19 POEMs linked to Choosing Wisely Canada recommendations to date.


POEMs on overtreatment

Proton pump inhibitor use associated with an increased risk of gastric cancer

This POEM aligns with the Choosing Wisely Canada recommendation that advises not to maintain long-term PPI therapy for gastrointestinal symptoms without stopping at least once per year in most patients. Choosing Wisely Canada’s toolkit provides tools for deprescribing PPIs.

American College of Gastroenterology guideline for diagnosing and managing GERD

This POEM aligns with the Choosing Wisely Canada recommendation that advises not to maintain long-term PPI therapy for gastrointestinal symptoms without stopping at least once per year in most patients. Choosing Wisely Canada’s toolkit provides tools for deprescribing PPIs.

NICE guidance: Type 2 diabetes (2022) 

This POEM aligns with the following Choosing Wisely Canada recommendations: 1. The Canadian Geriatrics Society’s recommendation: Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c < 7.5% in many adults aged 65 and older; moderate control is generally better. 2. The Canadian Society of Endocrinology and Metabolism’s recommendation: Don’t recommend routine or multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.

Tight control associated with more frequent and persistent hypoglycemia in elderly persons with diabetes mellitus

This POEM aligns with Choosing Wisely Canada recommendations: Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c <7.5% in many adults age 65 and older; moderate control is generally better.

Hypnotic agents are effective for insomnia but at the expense of adverse effects

This POEM aligns with the Canadian Geriatric Society’s Choosing Wisely Canada recommendation: Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Choosing Wisely Canada’s primary care toolkit and hospital toolkit provide tools to reduce unnecessary benzodiazepines use in older adults.

Comparable outcomes with 5 days and 10 days of antibiotics in children with community-acquired pneumonia (SCOUT-CAP)

This POEM aligns with Choosing Wisely Canada recommendations. The Choosing Wisely Canada Cold Standard toolkit provides tools for reducing unnecessary antibiotics.

Only some musculoskeletal conditions benefit from surgery

This POEM aligns with the following Choosing Wisely Canada recommendations: 1. The Canadian Orthopaedic Association’s recommendation: Don’t use arthroscopic debridement as a primary treatment in the management of osteoarthritis of the knee. 2. The Canadian Spine Society’s recommendation: Don’t perform fusion surgery to treat patients with mechanical axial low back pain from multilevel spine degeneration in the absence of: (a) leg pain with or without neurologic symptoms and/or signs of concordant neurologic compression, and (b) structural pathology such as spondylolisthesis or deformity.

Postoperative opioids are no better for pain relief and cause more adverse effects than nonopioids

This POEM aligns with the Canadian Association of General Surgeons’ Choosing Wisely Canada recommendation: Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended. The Opioid Wisely campaign provides recommendations and tools for reducing unnecessary opioid prescribing.   

Comparable post-op pain relief for opioid- and nonopioid-based regimens following ACL reconstruction

This POEM aligns with Choosing Wisely Canada recommendations. Choosing Wisely Canada's Opioid Wisely campaign aims to reduce harm associated with opioid prescribing.

Antibiotics for asymptomatic bacteriuria in residents of aged care facilities: bacteriological, but not clinical, cure; more adverse events

This POEM aligns with the Choosing Wisely Canada campaign called Using Antibiotics Wisely in Long-Term Care, which provides practice change recommendations on reducing unnecessary antibiotic use for asymptomatic bacteriuria.

Amoxicillin for children with CAP: low-dose for 3 days is noninferior to high-dose for 7 days (CAP-IT)

This POEM aligns with Choosing Wisely Canada recommendations. The Choosing Wisely Canada Cold Standard toolkit provides tools for reducing unnecessary antibiotics.

Point-of-care testing for respiratory pathogens does not reduce antibiotic use or improve outcomes

This POEM aligns with Choosing Wisely Canada’s Using Antibiotics Wisely campaign. The Choosing Wisely Canada Cold Standard toolkit provides tools for reducing unnecessary antibiotics.

Amoxicillin does not improve outcomes for nonpneumonia lower respiratory tract infection in children

This POEM aligns with Choosing Wisely Canada recommendations. The Choosing Wisely Canada Cold Standard toolkit provides tools for reducing unnecessary antibiotics.

NICE guidelines on treatment of depression

This POEM aligns with the Canadian Psychiatric Association’s Choosing Wisely Canada recommendation: Don’t routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults.


POEMs on unnecessary diagnostics

Screening colonoscopies are overused

This POEM aligns with the Canadian Association of General Surgery’s Choosing Wisely Canada recommendation: Avoid colorectal cancer screening tests in asymptomatic patients with a life expectancy of less than 10 years and with no personal or family history of colorectal neoplasia.

White cells do not equate to bacterial cells in the urine of hospitalized patients

This POEM aligns with the Canadian Nurses Association’s Choosing Wisely Canada recommendation: Don’t do a urine dip or send urine specimens for culture unless urinary tract symptoms are present.

Neither vitamin D nor omega-3 fatty acid supplementation reduce the risk of frailty (VITAL)

This POEM aligns with the College of Family Physicians of Canada’s Choosing Wisely Canada recommendation: Don’t routinely measure vitamin D in low-risk adults.

Urine collection devices do not reduce contamination in women with suspected urinary tract infections

This POEM aligns with the Association of Medical Microbiology and Infectious Disease Canada’s Choosing Wisely Canada recommendation: Don’t use a bag for collection of urine cultures to diagnose urinary tract infections.

A high-sensitivity troponin T less than 6 ng/L is very good at ruling out myocardial infarction or death in next 30 days

This POEM aligns with the Canadian Cardiovascular Society’s Choosing Wisely Canada recommendation: Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction. Instead, use troponin I or T.


References:

1. Squires JE, Cho-Young D, Aloisio LD, Bell R, Bornstein S, Brien SE, Decary S, Varin MD, Dobrow M, Estabrooks CA, Graham ID, Greenough M, Grinspun D, Hillmer M, Horsley T, Hu J, Katz A, Krause C, Lavis J, Levinson W, Levy A, Mancuso M, Morgan S, Nadalin-Penno L, Neuner A, Rader T, Santos WJ, Teare G, Tepper J, Vandyk A, Wilson M, Grimshaw JM. Inappropriate use of clinical practices in Canada: a systematic review. CMAJ. 2022 Feb 28;194(8):E279-E296. doi: 10.1503/cmaj.211416. Available: https://www.cmaj.ca/content/194/8/E279

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