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Nickel for Your Thoughts
(Choosing Wisely Canada)

By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

Article printed on page 33 in the April 16, 2014 issue of
The Mississauga News under the feature: Health & Beauty, Medicine Matters.
Portrait of Dr. Peter W. Kujtan, supplied 2005
Dr. Peter W. Kujtan

The cost of medical testing has escalated in Canada. As a primary care physician, I spend about a third of my time trying to encourage patients to have appropriate screening tests performed. I probably spend even more time explaining to some that the test which they feel they may need may be premature, create false reassurance and have no practical use in guiding any treatment. These requests often originate with a well meaning friend or Dr. Google. Free advice about health, hockey, money and used car buying is not worth the air it is uttered with. In many front line clinics, it is far easier to simply order the test than to spend time discussing the merits and needs, since both choices pay the same. The doctor may receive $40, but ends up ordering several thousand dollars of services.

We doctors are trained with a “price doesn’t matter” attitude. I have spent an entire career in medicine and to this day, I still have no idea of what various blood tests cost, or what an MRI costs, or other tests that we routinely order. The costs are fractionated and you cannot even find the information, so how to contain and better manage it is impossible. For example, a hospital may get public money to buy an MRI. The funds for staffing, technical analysis, etc, all come from different pools, making it hard to determine the cost of one test. ut our American friends know the answers well.

Imagine if there was a supermarket where all the shelves were lined with products and no prices. You are free to fill your cart full and go out the door, because there are no checkouts either. That is how medicine is practiced today. One person may buy only what he or she needs, while the next walks out with huge excess that is left to rot uneaten.

We try to teach students to use scientific basis and evidence as a way to guide their test selection, and are ignorant of costs. All the rhetoric in medical circles is to focus on “service costs” which is the amount of money spent on doctor services. Few notice that “testing costs” are a magnitude higher. I have no idea what the cost to the system is of the tests I order. How could I possibly improve this without any knowledge of this vital information?

One of my patients brought me an itemized bill from a three-day stay in a Florida Hospital. It was educational for both of us, and I was amazed at how genuinely interested we were and the kinds of questions that ensued afterwards.

I often wonder how useful it may be to provide patients an itemized account of what their health care costs are in Ontario. Giving doctors a valid report on how they spend public money on testing may be an eye-opening start.

Two doctors with similar practices can have vastly differing costs and achieve the same results. I think it is time to involve patients in the process. I believe that if patients had the facts about the costs, wiser choices would be made. And I bet those hard working hospital volunteers could teach us a lot about how to spend wisely, if only we knew the cost.


Related resources:

Choosing Wisely® is an initiative of the American Board of Internal Medicine (ABIM) Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices. Site includes: Scheduled Choosing Wisely list release dates: , Choosing Wisely partners that have released lists, Consumer-oriented organizations that have joined Choosing Wisely to help disseminate information and educate patients on making wise decisions.

About the Choosing Wisely Campaign in the United States.

Choosing Wisely from Albert Medical Association. "The original American initiative, Choosing Wisely®, encourages physicians, patients and other health care stakeholders to talk about medical tests and procedures that may be unnecessary and which in some instances could be harmful. According to its website, Choosing Wisely® aims “to promote conversations between physicians and patients by helping patients choose care that is:
● Supported by evidence.
● Not duplicative of other tests or procedures already received.
● Free from harm.
● Truly necessary.”

Choosing Wisely - Five Things Physicians and Patients Should Question. Five More Things Physicians and Patients Should Question. List from American Academy of Allergy, Asthma & Immunology.

Choosing Wisely Canada is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures. Site includes: PHYSICIANS: Five things you should question. PATIENTS: Tests and treatments you may not need. Recent News: Choosing Wisely Canada – After the Launch. "On Wednesday, April 2, 2014, at 10:00 am in Ottawa, Ontario, the Wave 1 launch of Choosing Wisely Canada took place in the form of a press conference. Dr. Wendy Levinson sat alongside a group of primary partners of Choosing Wisely Canada to introduce a campaign focused on helping physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and helping physicians and patients make smart and effective choices to ensure high-quality care."

Canadian doctors to tackle unnecessary medical tests by Jessica McDiarmid, News Reporter, Toronto Star, Published on Thu Aug 22 2013. "The Canadian Medical Association throws its support behind a move to stop unnecessary tests and treatment of patients.

... Dr. Wendy Levinson, a professor of medicine at the University of Toronto who worked on the Choosing Wisely campaign in the U.S. ... who chairs Choosing Wisely Canada, said society has built an underlying belief that 'more is better.' 'But when you talk about not ordering a test . . . Canadians can think this is about rationing,' said Levinson. 'This is not about cost-cutting. It’s about changing the culture and starting to talk about overuse and waste and harm. I don’t think patients really appreciate that when they ask for a CT scan or imaging, that’s unnecessary X-ray radiation. Or drugs that can cause side effects.'"

Canadian doctors urged to limit testing to contain costs by Kelly Grant, Health Reporter, The Globe and Mail, Published Tuesday, Feb. 18 2014. "Canadian doctors are under increasing pressure to think twice before reflexively ordering some tests and procedures as evidence mounts of the costs of unnecessary testing to the health-care system and to the well-being of patient.

... Dubbed Choosing Wisely Canada, the campaign piggybacks on a U.S. effort that identified dozens of tests and procedures as of little or no value, including imaging for uncomplicated headaches and lower back pain, pap smears for women who have had hysterectomies or are under the age of 21; routine check-ups for healthy adults; ...

... First ministers agreed last summer to adopt guidelines for the appropriate use of medical imaging for lower back pain, headaches and minor head injuries, a move they estimated could help save $220-million of the more $2.2-billion spent annually on diagnostic imaging across the country."

Why medical diagnostic tests are due for a cost checkup by Renata D'Aliesio, The Globe and Mail, Published Monday, Sep. 03 2012. "... the astronomical growth of diagnostic testing – some of it unnecessary or questionable – remains a significant challenge for Canada’s financially strained health system.

... Ontario Health Minister Deb Matthews contends that studies show physicians who have a financial interest in testing equipment are much more likely to order exams, some unnecessarily.

... The Canadian Association of Radiologists estimated in 2009 that as many as 30 per cent of CT scans and other imaging procedures were inappropriate or contributed no useful information. At the same time, the growth of diagnostic tests has been substantial, in part because technology and medicine have improved, more machines are available, and patients are asking for tests they’ve read about on the Internet. Last year, Canadians had 1.6 million MRI exams and 4.3 million CT tests, nearly double the number performed in 2003, according to the Canadian Institute for Health Information."

Improving the appropriateness of diagnostic tests by Jeremy Petch, Emily Latourell, and Andreas Laupacis. HealthyDebate.ca, 8 Nov. 2012. "One test that has seen dramatic increases is echocardiography, which is an ultrasound test of the heart. According to data Healthydebate has acquired from the Institute for Clinical Evaluative Sciences, 652,714 echocardiograms were done by cardiologists in Ontario in 2010/11, which is about one echocardiogram for every 20 Ontarians in one year. That compares with only 361,440 echocardiograms 5 years earlier – an 81 percent increase.

The Ministry of Health and Long-Term Care spent $68 million on physicians’ fees alone for echocardiograms in 2010/11. (The Ministry pays "technical fees" as well, which are not included in this figure).

... No studies have calculated the costs of all diagnostic tests in Ontario, or the magnitude of the rise in costs, but the costs are large enough that the cash strapped Ministry of Health and Long-Term Care has taken notice. Earlier this year, the Ministry appointed an Expert Panel to provide "advice regarding the appropriate utilization of diagnostic and imaging studies.

Decreasing “unnecessary” testing is not easy ... Can the public become more informed consumers of diagnostic tests?"

Many common medical tests and treatments are unnecessary. Learn when to say ‘Whoa!’ to your doctor from Consumer Reports magazine: June 2012. "... the Congressional Budget Office says that up to 30 percent of the health care in the U.S. is unnecessary. All that unneeded care can be hazardous to your health—and your wallet. For example, X-rays and CT scans expose you to potentially cancer-causing radiation, and can lead to follow-up tests and treatment with additional risks. And the costs can be substantial. A 2011 study found that the price tag for 12 commonly overused tests, such as annual electrocardiograms (EKGs) for heart disease and imaging tests for lower-back pain, was about $6.8 billion."

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