Patient-centred approach is the way

I thank Hudzik and colleagues for drawing attention to the Choosing Wisely Canada campaign.¹ Hudzik et al make the point that while general guidelines are helpful, decisions on investigations must take into account the individual circumstances of each case and recognize that “the choice of diagnostic and therapeutic modalities might not be the same for any 2 patients, even those with the same condition.”¹ This is salutary but leaves open the question of how unnecessary test ordering can be reduced in daily practice.

Instituting a patient-centred clinical method² has been shown to reduce overall test-ordering behaviour. In the United States, Epstein and colleagues³ found that those physicians who scored low on measures of patient-centredness when compared with those who scored higher had greater diagnostic testing expenditures. Even after controlling for the shorter-visit-length characteristic of low-scoring physicians, this difference remained. Total expenditures, including testing and ambulatory and hospital care, were also higher in those who scored low on this measure.

In an analysis of the Patient-Centred Outcomes Study, Stewart and colleagues⁴ found that mean diagnostic costs in the 2 months following an index visit were significantly higher (P < .004) for physicians who scored in the lowest quartile in measures of patient-centredness compared with physicians scoring in the highest quartile ($29.48 vs $11.46). When these figures were extrapolated, the extra costs per month amounted to $14 million provincially and $38 million nationally. Clearly patient-centred care provides substantial cost savings, as well as better care and greater patient and physician satisfaction.

Identifying unnecessary test ordering is an important first step but needs to be translated into action at the practice level. Taking a patient-centred approach has been demonstrated to show the way.

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