Choosing Wisely Canada recommendations

Internal medicine recommendation 4

In the inpatient setting, do not order repeated complete blood counts and chemistry testing in the face of clinical and laboratory result stability.

Family medicine recommendation 5

Do not do annual screening blood tests unless they are directly indicated by the risk profile of the patient.

How have you implemented these recommendations in your practice?

As I am involved with the College of Family Physicians of Canada, I had the chance to look at the Choosing Wisely recommendations and hear about the implementation work going on in family medicine across the country. This made me reflect on my own practice. I noticed that many of my patients, and patients I accepted from other practices, had been recurrently tested for a large part of their lives—sometimes unnecessarily. For example, one patient had had cholesterol testing every 3 months for 14 years without treatment.

In response, I requested that all recurrent testing requests for my patients at the hospital laboratory be sent to me for review. Many patients had been booked for repeat testing every 2 to 3 months for cholesterol, fasting glucose, hemoglobin A_1c (HbA_1c), or thyroid levels.

Following the Choosing Wisely Canada theme, I have made some substantial changes. I have stopped “routine” prostate-specific antigen blood testing and paced HbA_1c testing at 6-month intervals (unless the patient’s level is unstable). The diabetes nurse navigator does the same. We have spaced thyroid testing at 6- to 12-month intervals. We have stopped ordering fasting glucose tests altogether in favour of HbA_1c tests. We will be re-spacing cholesterol monitoring as well.

This by itself has cut the rate of unnecessary blood testing at the hospital laboratory from my practice by 48% to 50%. My effect might be modest but if multiplied by many physicians, it could make a big difference.

How have you brought the Choosing Wisely principles to your relationship with patients?

Our review of laboratory testing has created personalized “best courses of treatment” for patients. And we have reduced wait times for patients who need laboratory testing.

What does Choosing Wisely mean to you as a family physician?

By examining my practice and all the little bits and pieces of what we do every day, we can increase patient safety and improve stewardship of the resources we have in Canada. The savings accumulated could be applied to purchasing better technology, studying culture change, and providing preventive care or maintaining care for the elderly population. We are looking forward to progressing our Choosing Wisely efforts during the next few months.