'Choosing Wisely': a growing international campaign.

Much attention has been paid to the inappropriate underuse of tests and treatments but until recently little attention has focused on the overuse that does not add value for patients and may even cause harm. Choosing Wisely is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments and procedures. The campaign began in the United States in 2012, in Canada in 2014 and now many countries around the world are adapting the campaign and implementing it. This article describes the present status of Choosing Wisely programs in 12 countries. It articulates key elements, a set of five principles, and describes the challenges countries face in the early phases of Choosing Wisely. These countries plan to continue collaboration including developing metrics to measure overuse.

The incidence of adverse events among home care patients.

OBJECTIVE: Incidence of adverse events (AEs) among home care patients and preventability ratings were estimated. Risk factors, AE types and factors associated with AEs were identified. DESIGN: This study used a stratified, randomized sample of home care patients discharged in the fiscal year 2004/05. Trained nurse reviewers completed retrospective chart abstractions; charts for cases that were positive for screening criteria suggesting the presence of AEs were reviewed by trained physicians to determine the presence of and preventability of AEs. SETTING: Three publicly funded home care programs in Ontario, Canada. MAIN OUTCOME MEASURES: Prevalence and types of AEs; ratings of preventability. RESULTS: At least one screening criterion was positively identified in 286 (66.5%) of 430 cases. Physician reviewers identified 61 AEs in 55 (19.2%) of the 286 (12.8% of the 430) cases. The AE rate was 13.2 per 100 home care cases [95% confidence interval (CI): 10.4-16.6%, standard error 1.6%]. 32.7% (20 of 61 AEs) of the AEs were rated as having >50% probability of preventability; 6 deaths (10.9% of patients with an AE; 1.4% of all patients) occurred in AE-positive patients. The most common AEs were falls and adverse drug events. CONCLUSIONS: Providing health care through home care programs creates unintended harm to patients. The incidence rate of AEs of 13.2% suggests a significant number of home care patients experience AEs, one-third of which were considered preventable. Improvements in patient and informal caregiver education, skill development and clinical planning may be useful interventions to reduce AEs.

Disentangling the effects of disability and age on health service utilisation.

PURPOSE: This article examines two competing hypotheses for the impact of disability and age on health service utilisation in Canada: the double jeopardy and age-as-leveller hypotheses. METHOD: The study uses a retrospective cohort design to examine the effect of age and disability on four aspects of health service utilisation: family doctor, medical specialist, hospital and homecare. The cohort was assembled from the longitudinal component of the National Population Health Survey. The effective sample size for this analysis was 1629. RESULTS: This study showed that disability is a stronger predictor of doctor and hospital utilisation than age. No significant relationship was found between age and specialist use, and there were only small to moderate increases in the use of family doctors and hospitals with each 5-year increment of age over 65. There is a strong association between the use of home care and both age and disability. Results support the age-as-leveller hypothesis, in that negative interaction effects were found between age and disability for use of both family physicians and medical specialists. In other words, age and disability together have an effect that is less than would be expected, given the main effects of each. CONCLUSION: The results of this study support the importance of disability as an indicator of health service utilisation. Rehabilitation practitioners are encouraged to continue to sensitise other members of the health care team to the importance of disability as a way of understanding health and health service use.

Adverse events in community care: developing a research agenda.

Little is known about the extent to which adverse events compromise the quality of community care. This article describes the results of a consensus workshop in which 31 healthcare professionals were asked to identify and rank common adverse events and important research questions relating to community care. Workshop participants were decision-makers and healthcare providers with areas of expertise that included community and home care; acute and primary care; patient safety; medical errors; and health services policy, administration and research. Results include prioritized lists of adverse events, research questions and contributing factors associated with adverse events. Further study should be aimed at defining and implementing research priorities and developing standardized definitions of common adverse events associated with community care.

Another way to look at high service utilization: the contribution of disability.

OBJECTIVES: High users of health services are usually identified in terms of their health complications stemming from the coincidence of a number of chronic conditions. Instead, this analysis attempts to characterize high users in terms of disability, based on the belief that disability provides a more detailed and accurate representation of functional needs and health consequences. The study compares the characteristics of high users of health services among Canadian adults (aged 20-65) with those of low to moderate users and non-users. METHODS: Secondary analysis of data collected for the National Population Health Survey, a cross-sectional public-use population-based national survey, conducted in 1998-99. RESULTS: No matter how disability is conceptualized and measured, it has the strongest association of all the variables considered with health service utilization. Whether looking at the simple presence of a disability or at specific impairments or activity restrictions, there is at least a two-fold increase in the risk of high use over the non-disabled. CONCLUSIONS: The present study challenges the clinical wisdom that high users should be the target for efforts to reduce the overall consumption of health services. Many high users consume on the basis, not of choice, but of need rooted in disability. Moreover, when compared with low or moderate service users, their clinical condition is exacerbated by social factors, including lower income, less education and less immediate family support. Equity cannot be achieved by focusing on reducing consumption by this clinically and socially vulnerable group.

What matters most in end-of-life care: perceptions of seriously ill patients and their family members.

BACKGROUND: Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care. METHODS: After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members. RESULTS: Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as "extremely important" most frequently by the patients were "To have trust and confidence in the doctors looking after you" (55.8% of respondents), "Not to be kept alive on life support when there is little hope for a meaningful recovery" (55.7%), "That information about your disease be communicated to you by your doctor in an honest manner" (44.1%) and "To complete things and prepare for life's end - life review, resolving conflicts, saying goodbye" (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care. INTERPRETATION: Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.

End-of-life care in acute care hospitals in Canada: a quality finish?

Understanding patients' and family members' perspectives on the relative importance of elements of end-of-life (EOL) care and their satisfaction with those elements will help prioritize quality improvement initiatives. We administered a face-to-face questionnaire containing a selection of 28 elements of care to eligible inpatients with advanced lung, heart, or liver disease, or metastatic cancer, and available family caregivers (FCGs) in five tertiary care hospitals across Canada. 440 of 569 (78%) eligible patients and 160 of 176 (91%) FCGs participated. No respondent reported complete satisfaction with all elements of care. The average satisfaction score was 4.6 on a 26 point scale. Medical patients reported lower levels of satisfaction than cancer patients. Elements rated as "extremely important" and anything other than "completely satisfied" most frequently by respondents related to discharge planning, availability of home health services, symptom relief, not being a burden, physician trust, and communication. In conclusion, most patients and their family members in our survey were not completely satisfied with EOL care. Improvement initiatives to target key elements identified by patients and FCGs have the potential to improve satisfaction with EOL care across care settings.