Improving Appropriateness of Care – October 2017 Update

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Improving Appropriateness of Care – October 2017 Update


2017-18 Strategies to Advance AC in the Health System

The provincial Appropriateness of Care (AC) program team continues to work collaboratively with health system partners, including Regional Health Authorities (RHAs), the Saskatchewan Cancer Agency (SCA), the Health Quality Council (HQC) and the Saskatchewan Medical Association (SMA) to build the health system’s capacity for clinical quality improvement work, which is directly linked to improving AC. To date, efforts include:

  • Implementing several provincial AC Projects, applying the AC framework and lessons learned (see Appendix A for detailed information on provincial projects).
  • Supporting AC Network meetings (members include senior leaders from all health regions, SCA, eHealth, SMA, and the College of Medicine) and attempting to expand their roles in decision making related to provincial AC strategic directions and spreading AC at the local organizational level.
  • In partnership with the SMA and HQC, supporting opportunities for physicians to learn and engage in clinical QI work through development of two programs:
    • Clinical Quality Improvement Program (CQIP) is a formal training program adapted from the Intermountain Health located in Utah. It was launched in September 2016 with the first cohort of 16 physicians who will complete the program on November 17th with a capstone event in Saskatoon. Recruitment is underway for participants for the second cohort which will start in January 2018 and finish in September 2018. HQC is currently accepting applicants for the second cohort. Details on the application process is posted on the HQC website:
    • SMA’s AC Initiative (SACI) will provide a centralized, coordinated approach to providing support/information for physicians who may have a “QI” idea they want to further develop. The support will include coaching by a physician with QI expertise, project development advice and data/measurement support. The concept of SACI will be piloted in the Saskatoon Health Region (SHR) in the fall of 2017. More information will be provided regarding this initiative in November.
      • Funding has been provided by the Ministry of Health to three health regions: Regina Qu’Appelle Health Region (RQHR), SHR and Prairie North Health Region (PNHR) to enhance their capacity for data analytics and measurement related to AC projects underway within their region and surrounding health regions.
      • Working with HQC and the SMA to align AC work with Choosing Wisely Canada (CWC) recommendations to decrease unnecessary testing, treatment and procedures in various clinical areas:
      • CWC launched regional campaign hubs in eight provinces, including SK. A CWC SK Coordinator position was hired in March 2017, based out of HQC and is part of the AC Program team.
      • The regional CWC coordinators are currently working on strategies to increase physician, patient and public awareness of CWC and the implications of unnecessary testing, treatment and procedures.
      • The national CWC meeting will be held on April 23, 2018 in Toronto. An inquiry to the SMA has been made regarding sponsorship for SK physicians to attend the meeting.

In June 2017, the AC Program Team made a request to the AC Network members to provide information regarding AC/clinical QI projects underway at the regional level. This information has been used to develop a provincial AC inventory, which will help:

  • Coordinate and align AC efforts across the system;
  • Facilitate replication of successful projects;
  • Identify where gaps exist; and,
  • Provide health regions and SCA with better support to build capacity for improving clinical appropriateness. 

Currently there are 77 known clinical quality improvement projects underway at the regional level with more than half taking place in RQHR (41 projects). Most regional clinical QI projects are led by physicians or other clinicians. Many of them are aligned with CWC and various provincial/regional priorities:

  • 24 projects are aligned with recommendations made by CWC.
  • 30 projects are aligned with the Connected Care Strategy that includes connected community care (Primary Health Services, Long-Term Care, Home Care), connected hospital care (Accountable Care Unit) and high-quality care transitions (Discharge Planning, Medication Reconciliation on Discharge).
  • 12 projects are aligned with provincial outcomes (e.g., patient safety, primary health care, seniors’ care, wait 1 and mental health & addictions).

The AC Inventory will be posted on HQC’s website under the AC Webpage.

With these efforts to build the health system’s capacity, there is the expectation that health regions will start to use the provincial AC framework to improve clinical appropriateness of care.

For further information about the AC program work please contact Deb Gudmundson (AC provincial co-lead): 

Appendix A: Provincial Appropriateness of Care Projects

Magnetic Resonance Imaging (MRI) Lumbar Spine Project

  • In 2015, MRI of the lumbar spine was selected as a prototype project to test the Appropriateness of Care (AC) framework. The goal of this project was to improve appropriate ordering of MRI lumbar spine.
  • The project was led by a provincial Clinical Development Team comprised of orthopedic surgeons, neurosurgeons, radiologists, a family physician, chiropractor and patients. They developed a lumbar spine MRI Checklist based on best practice guidelines. The checklist provides a list of different clinical indications for ordering MRI lumbar spine for patients with low back pain and was designed to be used as a decision support tool for physicians.
  • The MRI Checklist was successfully piloted in SHR and RQHR in the fall of 2015. By the end of the pilot, physician adherence rate for use of the MRI Checklist was above 90% indicating that the checklist has become part of daily work for many physicians, particularly specialists who frequently order lumbar spine MRIs.
  • The lumbar spine checklist was implemented provincially in May 2016, including the Five Hills Health Region (FHHR), where MRI services started January 2016. It was also implemented at the private pay MRI services in Regina to ensure that MRIs ordered are appropriate and medically necessary.
  • To assess the impact of the checklist, the AC Program Team looked at volumes of MRI Lumbar Spine requisitions before and after the implementation of the checklist in RQHR and SHR. The Radiology Information System (RIS) data shows there was a total of 20% reduction in the number of requisitions one year after the implementation of the checklist. 

CT Lumbar Spine Project

  • In April 2016, the Clinical Development Team that led the MRI Lumbar Spine project decided to investigate appropriateness of lumbar spine CTs performed for low back pain. Data indicates that there is an issue with duplicate testing between these two imaging modalities. In 2016-17, a total of 4,234 L-spine MRI requisitions were submitted, and 7.5% (318) of lumbar spine MRI requisitions received a lumbar spine CT within one year prior to submitting a lumbar spine MRI requisition.
  • According to the literature reviewed, and agreement of the Clinical Development Team, there are only a few clinical indications (i.e., tumor of vertebra/bone, trauma/suspected lumber fracture, prior low back surgery, MRI is contraindicated) appropriate for lumbar spine CT. MRI is the optimal choice for most patients with low back pain who need an advanced diagnostic imaging test to diagnose and treat their conditions.
  • A retrospective review of 50 requisitions was conducted in six health regions (Regina Qu’Appelle, Saskatoon, Sunrise, Prince Albert Parkland, Prairie North, and Five Hills) over the summer of 2016. The results show that 58% of lumbar spine CT requisitions may not be for the most appropriate clinical indications for ordering the CT scan.
  • After reviewing this data, the Clinical Development Team developed a checklist to guide appropriate ordering of lumbar spine CTs. This checklist is currently being trialed until November 30th in four health regions (Regina Qu’Appelle, Saskatoon, Prairie North and Five Hills). The data collected during the trial period will be shared with the Clinical Development Team in early December. The checklist will be reviewed and finalized based on the data and the feedback received from referring physicians. The finalized checklist will be implemented provincially by March 31, 2018.

Standardizing Pre-Operative Testing and Evaluation for Elective Surgery

  • The goal of this project is to standardize and reduce unnecessary pre-op testing for adult patients scheduled for elective surgery through development and implementation of standardized provincial pre-op testing and consultation guidelines.
  • Evidence indicates that routine testing in patients undergoing low-risk surgery does not improve outcomes or change clinical management and may lead to further unnecessary downstream testing, cancellation of surgery, and increase patient anxiety and cost.
  • Choosing Wisely Canada (CWC) and other health organizations have produced evidence-based recommendations regarding tests for low-risk surgical procedures, and the North York Hospital in Toronto has developed a grid for all surgical cases based on CWC recommendations.
  • Four health regions (Regina Qu’Appelle, Saskatoon, Prince Albert Parkland and Prairie North) are currently participating in this project.
  • Baseline data has been collected in each of the four participating regions.
  • A draft provincial Pre-Op Testing and Consultation Grid for all elective surgical procedures has been developed by a small subgroup of physicians from the participating regions. The grid is being tweaked, and a meeting with regional internist representation is scheduled for November to reach consensus regarding indications for consultations.
  • Next steps include finalize the testing/consultation grid, identify the testing sites and start discussions regarding how to improve the Pre-Op History and Physical process.
  • Once the testing is completed, the provincial grid will be implemented provincially. 

Improving Quality of Care for Patients Requiring Colonoscopy

  • This initiative is being led by the SCA with support from the provincial AC Program Team in applying the AC framework.
  • The quality of colonoscopies in SK as measured by adenoma detection rate (ADR) is excellent, exceeding the national standard of 50% as set by Canadian Partnership Against Cancer (CPAC). However, there are a number of physicians who do not meet this standard.
  • A key strategy to improve quality is through a Direct Observation of Procedural Skills (DOPS) program, developed initially in the U.K. Bowel Screen Program and later adopted by the Royal College of Physicians in the United Kingdom for training and credentialing of endoscopists. This program has been adopted in various provincial programs in Canada, including the British Columbia Colon Screening Program. Not only does this program assess procedural skills it also reviews the whole process, from procedure indication to communication, diagnostic and therapeutic ability and safety.
  • The DOPS Assessors are practicing endoscopists interested in colonoscopy quality improvement. Eight DOPS Program assessors, from both urban and rural health regions, are being trained at Saskatoon City Hospital on November 23, 2017.
  • The DOPS process involves two assessors simultaneously and independently observing an endoscopist perform two consecutive colonoscopies resulting in four separate assessments for each endoscopist. The assessments typically are conducted in the endoscopists’ hospital during their regular endoscopy slate. The assessors will provide feedback during the colonoscopy and then following the two procedures.
  • DOPS results will only be shared with the endoscopist and the Screening Program for Colorectal Cancer. The endoscopist may choose to share their results with their Health Region SMO or endoscopy committee.