For so many years the patient voice has been missing in health care, contributing to varying outcomes for patients. By incorporating the voice of the patient throughout many areas of this work, Appropriateness of Care will ensure the goals of the initiative will be met. The Appropriateness of Care vision, ‘Right care provided by the right provider, to the right patient, in the right place, at the right time, resulting in optimal quality care,’ is so promising for our patients and families, but also will make sure our patients will be getting the safest quality of care.

Heather Thiessen, patient and family advisor

Several factors contribute to inappropriate care, including availability of services, access to care, variation in physician practices, and lack of definitive evidence upon which physicians can base decisions about testing and treatment. This can lead to uncertainty and variation in how physicians make decisions.

Saskatchewan’s health system is addressing these factors through the provincial Appropriateness of Care Program.  The program is led by two physicians and an administrative co-lead, with support from the Ministry of Health and the Health Quality Council (HQC).

The work of the provincial program is based on the framework pictured below. This framework is designed to support physicians, health care providers, patients, and families in improving appropriateness of care throughout the health system.

Appropriateness of Care Framework

Choosing Wisely Saskatchewan

Choosing Wisely Saskatchewan is part of a larger national campaign, Choosing Wisely Canada , which is aimed at helping clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective choices to ensure high-quality care.

HQC is coordinating Choosing Wisely Saskatchewan efforts in collaboration with provincial organizations including the Saskatchewan Medical Association, the University of Saskatchewan’s College of Medicine, and the provincial Appropriateness of Care Program. Together we are implementing the following strategy, through the engagement of clinicians, patients, and medical students:

Partners

  • Health Quality Council
  • Saskatchewan Medical Association
  • Regional Health Authorities
  • Ministry of Health (Provincial Appropriateness of Care Program)
  • College of Medicine, University of Saskatchewan
  • eHealth Saskatchewan
  • Saskatchewan Cancer Agency
  • Provincial Patient and Family Advisors

Want to stay connected about Choosing Wisely Saskatchewan?

Join us on Twitter:  @ChooseWiselySK

For more information about Choosing Wisely Saskatchewan, please contact

Provincial Appropriateness Projects

The Appropriateness of Care Program coordinates a number of provincial projects aimed at improving care where evidence suggests there may be inappropriate care or unjustified variation (which can be a sign of overuse, underuse, or misuse) in care delivery. For each project, a group of clinicians with special expertise in the topic area, called a clinical development team, identifies reasons for variation or inappropriate care, and develops strategies for improvement. As part of this work, teams engage with patients to incorporate their input and perspectives.

Surgical Care: Peripheral Artery Disease

What’s the opportunity

There is variation in how different Saskatchewan physicians treat patients with moderate peripheral vascular disease of the lower limbs (i.e. patients with poor blood flow in their legs). Unwarranted variation can be a sign of inappropriate care (i.e., overuse, underuse and/or misuse).

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The clinical development team is examining reasons for variation and developing a standard of care for patient management.

The clinical development team is working with eHealth Saskatchewan to develop an electronic tool that will make it easier for clinicians to collect and analyse data on how they treat this condition. This electronic tool will replace the current standard practice for documentation (oral dictation) and will allow for patient information to be collected only once, at the point of care.

Who is involved?

The clinical development team consists of vascular surgeons and interventional radiologists from Saskatoon and Regina Qu’Appelle Health Regions, and staff from the Ministry of Health, Health Quality Council, and eHealth Saskatchewan.

For more information, please contact:

Deb Gundmundson Deb Gundmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Surgical Care: Breast Cancer

What's the opportunity?

A 2012 report from Canadian Institute of Health Information (CIHI) found substantial variation in the use of surgical breast cancer treatments across Canada. The results showed Saskatchewan rates of radical mastectomies are the second highest in Canada, compared to an equivalent and less invasive treatment, such as breast conserving surgery plus radiation.

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

A team of clinicians, along with eHealth Saskatchewan and the provincial Appropriateness of Care program are trying to determine why mastectomy rates in Saskatchewan are some of the highest in the country. Together, they are working to develop and test a template for capturing electronically standardized information after each breast cancer surgery. Right now, physicians dictate this information following surgery.

Once the new template is implemented, the resulting report will help identify reasons why patients are opting for mastectomy versus breast conserving surgery plus radiation.

Who is involved?

The clinical development team consists of general surgeons from Saskatoon and Prince Albert Parkland Health Regions, with support from the Ministry of Health, the Health Quality Council, and eHealth Saskatchewan.

For more information, please contact:

Deb Gudmundson Deb Gudmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Imaging of Low Back: CT Imaging of Lumbar Spine

What's the opportunity?

Data suggests that some Saskatchewan patients with low back pain may be receiving both a lumbar spine CT and a lumbar spine MRI. After reviewing the medical literature, a team of clinicians has concluded that, where imaging is warranted, an MRI is the most appropriate test. There are few instances where a lumbar spine CT should be used for diagnosis and treatment.

Choosing Wisely Canada

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The clinical development team has developed a checklist to help physicians determine when it is appropriate to order a lumbar spine CT.  It is currently being piloted in four health regions (Regina Qu’Appelle, Saskatoon, Five Hills, and Prairie North) and will subsequently be rolled out provincially.

This project builds on earlier work done as part of the MRI Lumbar Spine Project.

Who is Involved?

The clinical development team comprises orthopedic surgeons, a neurosurgeon, radiologists, family physicians, a chiropractor, and patients from Regina Qu’Appelle, Saskatoon, Five Hills, and Kelsey Trail, along with staff from the Ministry of Health and the Health Quality Council.

For more information, please contact:

Deb Gudmundson Deb Gudmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Imaging of Low Back: MRI Imaging of Lumbar Spine

What's the opportunity?

Recent evidence suggests diagnostic imaging of the lower spine may have minimal impact on patient treatment options or outcomes. Inappropriate MRI testing contributes to increased wait times for those patients who truly require an MRI, and may put patients at risk for further testing and invasive procedures.

Choosing Wisely Canada

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The clinical development team has developed a lumbar spine MRI checklist based on best practice guidelines, including the Choosing Wisely Canada recommendations. The checklist provides a list of different clinical indications for ordering lumbar spine MRIs for patients with low back pain and is designed to be a decision support tool for physicians.

The MRI checklist was successfully piloted in the Saskatoon and Regina Qu’Appelle health regions in the fall of 2015. By the end of the pilot, physician compliance rate for use of the MRI checklist was above 90%, indicating that the checklist has been adopted by many physicians, particularly orthopedic surgeons and neurosurgeons who frequently order lumbar spine MRIs.

The lumbar spine checklist was rolled out provincially in May 2016, including the Five Hills Health Region, where MRI services started in January 2016.  It was also implemented at private pay MRI services in Regina, to ensure that all MRIs ordered are appropriate and medically necessary. 

Who is Involved?

The project was led by a provincial clinical development team comprised of orthopedic surgeons, neurosurgeons, radiologists, a family physician, a chiropractor, and patients. 

Pre-operative Testing and Evaluation for Elective Surgery

What’s the Opportunity?

Pre-operative tests for low-risk surgical procedures are performed frequently in Saskatchewan. Recent Canadian Institute for Health Information (CIHI) data (2013) found that 10,000 pre-operative tests were conducted for every 35,000 low-risk procedures. Evidence shows that routine testing in patients undergoing low-risk procedures does not improve outcomes or change clinical management. However, it may lead to further unnecessary testing and the cancellation of surgery, as well as increases in patient anxiety and cost.

Choosing Wisely Canada

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The goal of this project is to standardize and reduce unnecessary pre-operative testing and evaluation of patients scheduled for elective surgery, through the development and implementation of standardized provincial pre-operative testing guidelines. 

Choosing Wisely Canada has produced evidence-based recommendations regarding tests for low-risk surgical procedures. For example, the program recommends that physicians do not order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery. These recommendations have been combined by Choosing Wisely Canada into a decision-support grid for all surgical cases.

This project’s clinical development team has begun developing provincial standard guidelines based on the Choosing Wisely Canada recommendations for pre-operative testing and evaluation. The guidelines will be pilot tested in four health regions (Regina Qu’Appelle, Saskatoon, Prince Albert Parkland and Prairie North) in 2017-2018, and subsequently implemented province wide.

Who is involved?

The clinical development team consists of clinical experts in anesthesia, surgery, and internal medicine, family physicians, pre-operative nurses and patients, with support from the Ministry of Health and the Health Quality Council.

For more information, please contact:

Deb Gudmundson Deb Gudmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Saskatchewan Disease Control Laboratory Testing: Vitamin D

What's the opportunity?

To determine whether Vitamin D testing in this province is consistent with Choosing Wisely Canada recommendations, the Saskatchewan Disease Control Laboratory examined ordering practices of Saskatchewan physicians. They found that, while the vast majority of doctors are using Vitamin D testing appropriately, a handful order a disproportionally large volume of tests relative to their peers.

Choosing Wisely Canada

What action is being taken?

In partnership with medical health officers and other clinical specialists, the SDCCL developed and distributed to physicians across the province a clinical guideline for ordering vitamin D testing, along with information for patients about testing and dietary and other sources of the vitamin. Click here for the clinical guideline and here for patient information.
 

For more information, please contact:

Patrick O’Byrne, Consultant, Ministry of Health
patrick.obyrne@health.gov.sk.ca | 306-787-3129

Antimicrobial Stewardship Programs

What's the opportunity?

In 2013, Accreditation Canada made antimicrobial stewardship programs a required organizational practice, to ensure patients are receiving the right drug, dose, duration, and route when treating antimicrobial-related illnesses in acute care facilities.

Choosing Wisely Canada

What action is being taken?

The provincial Ministry of Health is supporting implementation of this program across Saskatchewan’s health system. The Saskatchewan Disease Control Laboratory has developed an antibiotic susceptibility guideline to help clinicians selecting the best antibiotic for each patient’s care.

Contact:

Contact your health region to learn more about local antimicrobial stewardship programs. 

Examples:

Acute Stroke Pathway

HQC is contributing to the work of the Saskatchewan Acute Stroke Pathway. HQC researchers provide measurement support to the pathway development team and to health regions that are testing and implementing the pathway. This work is led by the Ministry of Health. Click here for more information.

Education and training

Education and training in clinical quality improvement is a key foundational piece to support appropriateness work. Increasing the quality improvement capacity and capability in the Saskatchewan health care system is an important component for driving and sustaining these improvement efforts.

HQC is implementing an 11-month pilot of the Clinical Quality Improvement Program (CQIP) in partnership with the Saskatchewan Medical Association and the Ministry of Health. Sixteen Saskatchewan physicians are participating in this initial program pilot. To learn more about this program, please see Clinical Quality Improvement Program under HQC’s Education and Learning webpage.

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For more information about Ensuring Patients Get Appropriate Care, please contact: