Apr 172014


CMA call to curb tests, scans wise
By Mark Lemstra, Health Issues

What is going on with the Canadian Medical Association? It used to be an advocacy group that simply demanded spending more money on health care, but now the CMA is promoting evidencebased practices.

On April 3, the association began a campaign, called Choosing Wisely Canada, to reduce unnecessary medical tests and procedures. It is based on a similar campaign launched in the United States in 2011. The Canadian program is funded by the CMA, the University of Toronto and the Ontario government.

Nine national medical organizations were consulted to help determine the diagnostics and interventions being overused. To date, there are 40 tests and procedures listed on the organization’s website, with more to come.

Let’s take one step back at this point and remember what the CMA did in July 2013, when it released a report titled What Makes Us Sick. It was based on comprehensive national consultations and a review of the literature. The CMA report concluded that social factors predict at least 50 per cent of all health outcomes.

The association recommended an action plan to eliminate poverty: that Canada consider a guaranteed annual income to alleviate poverty, and that governments invest more in affordable housing, food security and early childhood development. The CMA concluded that without addressing the social determinants of health, the demands on the reactive health care system will be unsustainable. Although none of this is new, it was refreshing to hear the powerful CMA advocate for evidence-based practices.

The problem is finding a source of money for new proactive social investments. With health care consuming nearly 50 cents of every tax dollar raised in every province, the solution must come from savings in the reactive health-care system.

This is where the latest report from the CMA is so meaningful and helpful. If doctors themselves begin to identify unnecessary tests and procedures, this will save money and free up money for social interventions.

Choosing Wisely Canada’s website advocates for doing fewer imaging tests for low back pain, fewer bone density tests, fewer colonoscopies, reducing the number of electrocardiograms, fewer imaging tests for headaches, less antibiotic use to treat sinusitis, and so on. A common sense descriptor is required in each case, but the overall conclusion is that it is fairly easy to identify and reduce unnecessary tests and procedures.

For example, the group explains that although low back pain can be bothersome, an X-ray, CT scan or MRI isn’t usually necessary because most cases resolve themselves without treatment. As well, more investigation results in more treatment and delayed recovery. It cites evidence that back pain sufferers who receive imaging tests are eight times more likely to get surgery, with no improvement in recovery.

The tests also come with risks that include high exposure to radiation for instance, of the testicles and ovaries, and concern that tests will uncover non-harmful spinal abnormalities that will lead to even more unnecessary tests and procedures.

To be fair, the CMA did not come up with the idea of reducing medical intervention on its own.

In February 2012, facing a $16 billion budget deficit due mostly to the $45 billion spent on health care, the Ontario government released a report by its Commission on the Reform of Ontario’s Public Services. It recommended paying doctors for health outcomes achieved, not for the number of patients seen or tests or procedures performed.

As well, the commission recommended freezing the salaries of doctors and moving 70 per cent of them to salaries instead of fee for service reimbursement. In plain language, doctors had to evolve or have drastic measures imposed on them. Former Ontario premier Dalton McGuinty likely said it best when he concluded in the Canadian Medical Association Journal: “There will be a time when the Ministry of Health is the only ministry we can afford to have – and we still won’t be able to afford the Ministry of Health.”

Regardless of the motivation, the CMA is being incredibly helpful by leading a process in which doctors and patients begin to receive less medical intervention. In a world of long waiting lists, it makes sense to prioritize necessary intervention by removing unnecessary services from the list. Equally important, this will allow governments to invest in social programs that promote health.

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