Whenever it meets with physicians in their environment, the QMA has observed that many of its members are committed to improving care and services on a daily basis. Great initiatives are taking shape everywhere. Some of them should even be implemented or adapted elsewhere, but for this to happen, we need to know that they exist!
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When a CPDP decides to do something about overdiagnosis
Overdiagnosis, overmedication, overmedicalization… we all now know about the harmful effects of unnecessary tests, treatments and procedures. But it is not easy to change one’s daily practice. Nevertheless, some environments are acquiring the means to improve the appropriateness of care. One example is the CISSS de Laval, with its lab test optimization and appropriateness committee, and its ongoing medical training committee that Dr. Mark-Andrew Stefan, a public health and preventive medicine specialist, tells us about today.
A little over a year ago, the CISSSS de Laval’s Council of Physicians, Dentists and Pharmacists (CPDP) decided to make tackling overdiagnosis its priority. To do so, it started by expanding the mandate of the lab test optimization and appropriateness committee.
“The four lab departments that were part of it realized that they could not really change the practices of prescribers by themselves,” explains Dr. Stefan. Besides representatives from the pathology, microbiology, hematology and biochemistry services, the committee now also has representatives from all the clinical departments, from emergency to surgery, including pediatrics, family medicine and obstetrics.
Tackling the lists of tests for check-ups
This much “broader and more representative” committee can take the concerns and ideas of the prescribers themselves into account. It has also increased in stature. It has become a permanent fixture thanks to the power it has been given by the CPDP, and is an interesting approach for improving appropriateness because it is involved with the actual decision-making process.
We must systematically refer to the committee to get approval for a new check-up, a new collective prescription or a modification to any existing ones. This enables us to “at least avoid worsening overdiagnosis,” even if it seems we are “opportunistic”, points out Dr. Stefan, because we are being “reactive”.
During these meetings, held every six weeks, the committee examines the appropriateness of the tests requested on the forms. “We have often had to remove tests that we felt were not appropriate or reduce their frequency. So just by doing that, we can have an impact on overdiagnosis,” Dr. Stefan explains.
Targeting priority projects
However, the committee wanted to go further and be pro-active. It therefore decided to target five projects every year deemed to be a priority that could impact lab tests or medical imaging. For instance, Dr. Stefan is in charge of a pap test sub-committee. “With pathology, family medicine, obstetrics-gynecology, we want to look at how we can reduce the frequency of pap tests in order to follow the schedule recommended by the learned societies, since we know that some women needlessly continue to have pap tests every year.”
The first five priority projects have all been identified with inspiration from Choosing Wisely. The committee will conduct monitoring to determine the “starting point, but also to see if the strategies implemented have changed anything”.
It is not that simple to change practices. While ongoing training is needed, it is not sufficient and must be accompanied by other strategies. It does not work if a workshop is organized or a speaker is invited without doing anything else. It may also be necessary to change usage rules, redo formulas when they are the reason behind overdiagnosis, and sometimes even compare the practices of physicians in order to harmonize them. “It’s not about naming physicians who have irregular practices compared with others. But we know that physicians hate to be the worst ones because they are very competitive. So if we can show them that their colleagues are doing things better than they are, they will look at their own practices and quickly modify them!” says Dr. Stefan.
For its part, the ongoing medical training committee, which is also overseen by the CPDP, has been given the mandate to always “focus on appropriateness”. As a result, in the last two years, not only has it organized several training sessions centred wholly on the appropriateness of care, but every workshop on other topics – there is about one session every month – must cover the aspect of overdiagnosis, for instance by highlighting the Choosing Wisely recommendations related to the topic, even if this is not the main message.