Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care. It focuses on tests and treatments for which there is concrete evidence of no benefit to patients.
The number of available tests and treatments in modern medicine is large and growing. But just because something is available, it doesn’t mean that we should use it. However, this is easier said than done. It often takes less time to order a test than to explain why doing nothing is the best option. Clinicians might sometimes respond to patient requests, and some patients might feel that if they didn’t get a script or test, the doctor didn’t take care of them.
Unnecessary tests and treatments do not add value to care. In fact, they can potentially be hazardous to the health of patients. For example, X-rays and CT scans expose patients to potentially cancer-causing radiation, and can lead to follow-up tests and treatment with additional risks.
Choosing Wisely Canada aims to dispel the false notion that “more care is better care”. Its goals are to promote provider-patient communication and care that is truly patient-centered and free from harm.
In partnership with the Canadian Medical Association, Choosing Wisely Canada is led by Canadian clinicians through their medical specialty societies. Participating specialty societies have developed “Top 5 Lists” of tests and treatments they say are done more often than necessary. Below are the five examples culled from those lists.
1. ECGs (electrocardiograms)
The problem: An ECG records the electrical activity of your heart at rest. It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous heart attack (myocardial infarction).
The risks: The ECG will not harm you. However, it can sometimes show mild nonspecific abnormalities that are not due to underlying heart disease, but cause worry and lead to follow-up tests and treatments that you do not need.
When to consider the tests: You may need an ECG test if you have risk factors for heart disease such as high blood pressure, or symptoms such as palpitations or chest pain. Or you may need it if you already have heart disease.
2. Imaging tests for lower-back pain
The problem: Getting an X-ray, CT scan or MRI may seem like a good idea. But back pain usually subsides in about a month, with or without testing. For example, one study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didn’t recover faster.
The risks: X-rays and CT scans expose you to radiation, which can increase cancer risk. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain, but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes even including surgery.
When to consider the tests: X-ray and CT scans often make sense if you have nerve damage, or signs of a serious underlying condition such as cancer or a spinal infection. “Red flags” that can alert your doctor that imaging may be worthwhile include a history of cancer, unexplained weight loss, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.
3. CT scans and MRIs for headaches
The problem: Many people who have headaches want a CT scan or MRI to find out if their headaches are caused by a brain tumour or other serious illness and doctors often comply to provide reassurance. But all that’s usually needed is a careful medical history and neurological exam. Adding a CT scan or MRI rarely helps.
The risks: A CT scan of the head uses a low radiation dose. This may slightly increase the risk of harmful effects such as cancer. Risks from radiation exposure may add up, so it is best to avoid unnecessary radiation. The results of your CT scan or an MRI may also be unclear. This can lead to more tests and even treatment that you do not need.
When to consider the tests: They are often warranted if you have an abnormal result on a neurological exam, or if your doctor can’t diagnose the problem based on your symptoms and medical exam. See a doctor if you have head pain that is sudden or explosive; different from headaches you’ve had in the past; brought on by exertion; or accompanied by fever, a seizure, vomiting, loss of coordination, or a change in vision, speech or alertness.
4. Bone-density tests (DEXA scans)
The problem: Many people are routinely screened for weak bones with an imaging test called a DEXA scan. If it detects osteoporosis, the results can help patients and their doctor decide how to treat the problem. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.
The risks: A bone-density test gives out a small amount of radiation, but radiation exposure can add up. A diagnosis of osteopenia often leads to treatment with such drugs as alendronate (Fosamax) and risedronate (Actonel), which pose numerous risks. But there is little evidence that people with osteopenia benefit from these drugs.
When to consider the test: Women should have a DEXA scan at age 65 and men at age 70. Younger women and men ages 50 to 69 should consider the test if they have risk factors such as a fracture from minor trauma, rheumatoid arthritis, low body weight, a very low vitamin D level, a parent who had a hip fracture, or if they have used corticosteroid drugs for a long time, or they drink excessively or smoke. Whether follow-up tests are needed depends on the results of the initial scan.
5. Antibiotics for sinusitis
The problem: People with sinusitis (congestion combined with nasal discharge and facial pain) are often prescribed antibiotics. In fact, 15 to 21 percent of all antibiotic prescriptions for adults are to treat sinusitis. But most people don’t need the drugs. That’s because the problem almost always stems from a viral infection, not a bacterial one—and antibiotics don’t work against viruses.
The risks: About one in four people who take antibiotics report side effects, such as a rash, dizziness and stomach problems. In rare cases, the drugs can cause severe allergic reactions. Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.
When to consider antibiotics: Antibiotics should usually only be considered when symptoms last longer than a week, start to improve but then worsen again, or are very severe. Worrisome symptoms that can warrant immediate antibiotic treatment include a fever over 38.6°C, extreme pain and tenderness over your sinuses, or signs of a skin infection, such as a hot, red rash that spreads quickly.