Choosing Wisely Canada is a national campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective care choices.
Don’t use ultrasound routinely to evaluate clinically evident inguinal hernias.
The diagnosis of most inguinal hernias can be made with a focused patient history and physical examination. Routine ultrasounds add little value to the diagnosis and management of clinically evident inguinal hernias and can result in treatment delay. These investigations should therefore not be performed where there is a clearly palpable abdominal wall defect and should instead be limited to use in the evaluation of occult inguinal hernias.
Consider a watchful waiting approach in patients with asymptomatic or minimally symptomatic inguinal hernias.
For minimally symptomatic hernias, surgical repair can prevent potential complications of hernia incarceration and strangulation, but the risk of post-operative complications from infection, hernia recurrence, and chronic inguinal pain approaches the overall risks of incarceration. Watchful waiting for asymptomatic or minimally symptomatic inguinal hernias is a safe option for carefully selected patients and does not preclude patients from undergoing elective repair should discomfort worsen.
Don’t use computed tomography (CT) for the evaluation of suspected appendicitis in pediatric patients until an ultrasound has been considered as an option.
Ultrasound is an accurate and cost-effective imaging modality for initial evaluation of suspected appendicitis in the pediatric population. Evidence shows that the sensitivity and specificity of ultrasound is high with reports of up to 95%, though this may vary based on center experience and capabilities. Where findings on ultrasound exam are equivocal, CT can be considered as part of a step-up investigative approach after discussion with the patient and caregivers about risks of childhood radiation exposure.
Routine preoperative chest x-rays and baseline laboratory studies, such as complete blood count, metabolic panel, or coagulation studies, should not be obtained in patients undergoing low-risk surgery with no significant systemic disease (ASA I or II) and the absence of symptoms.
Obtaining routine preoperative radiological and laboratory testing offers little value to the perioperative care of asymptomatic patients undergoing low-risk surgery. Evidence suggests that abnormal results within this setting rarely affect management or change clinical outcomes. Instead, a focused history and physical examination should be performed to identify which preoperative investigations are required. Where preoperative testing may add value is in the setting of symptomatic patients or higher risk surgery where significant blood loss and fluid shifts may be expected. A discussion with the patient, anesthesiologists, and surgical team would help guide decision-making in these circumstances.
Avoid colorectal cancer screening tests in asymptomatic patients with a life expectancy of less than 10 years and with no personal or family history of colorectal neoplasia.
The aim of screening investigations for colorectal cancer, such as fecal immunochemical test (FIT) and colonoscopy, is to reduce deaths through early detection and removal of polyps (a precursor to colon cancer) and early stage colorectal cancers. While colonoscopy is a safe screening modality, increased risks have been associated with advanced age and comorbidities. Life expectancy, presence of symptoms, personal and family history, previous investigations, and patient preference must all be considered in order to determine the safety and appropriateness of screening investigations and surveillance colonoscopy. If colonoscopy is determined to be unsafe or inappropriate, FIT should not be offered as an alternative.
Contralateral prophylactic mastectomy (CPM) is not recommended for average risk women with early stage unilateral breast cancer.
CPM for early stage breast cancer lacks evidence for survival benefit in average risk women with unilateral breast cancer. CPM can be associated with chronic pain, poor cosmetic outcome, and doubles the risk of post-operative infection and bleeding. Recommended surgical options for treatment for a unilateral early breast cancer in average risk women include lumpectomy and nodal staging or unilateral mastectomy and nodal staging. CPM is recommended for women with unilateral breast cancer and previous Mantle field radiation or a BRCA 1/2 gene mutation. CPM can also be considered by the surgeon on an individual basis for women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 genes, and in women who may have difficulty achieving symmetry after unilateral mastectomy. In all cases, the rationale, risks, and benefits of CPM should be discussed with patients and carefully considered based on each individual patient’s particular situation.
Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended.
Opioid use poses considerable health risks to patients including opioid use disorder, overdose, and side-effects such as psychomotor impairment. While opioid analgesia may be appropriate in select circumstances, prolonged use of opioids beyond the immediate postoperative period and for chronic non-cancer pain is not recommended. Instead, clinicians and patients should consider alternative therapies, such as non-opioid pharmacologic therapy or non-pharmacologic therapies. If opioid analgesia is required, the lowest effective dose, potency, and number of doses required to address the acute pain episode should be prescribed.
About Choosing Wisely
Choosing Wisely Canada launched on April 2, 2014, and is organized by a small team from the University of Toronto, Canadian Medical Association and St. Michael’s Hospital.
It is part of a global movement that began in the United States in 2012, which now spans 20 countries across 5 continents.
Choosing Wisely Canada inspires and engages health care professionals to take leadership on reducing unnecessary care, and enables them with simple tools and resources that make it easier to choose wisely.
We do this by partnering with professional societies representing different clinical specialties to come up with lists of “Things Clinicians and Patients Should Question.” These lists of recommendations identify tests and treatments commonly used in each specialty that are not supported by evidence, and could expose patients to harm.
We also partner with a wide range of medical associations, health system as well as patient organizations to help put these recommendations into practice.
Facts About Unnecessary Care
Unnecessary tests and treatments are not only clinically useless, they potentially expose patients to harm, lead to more testing to investigate false positives, contribute to unwarranted stress for patients and their families, and consume precious time and resources for everyone involved.
So why do they occur? Well, there are many possible drivers of unnecessary care, including:
- Practice habits are traditionally difficult to change, even in the face of new evidence
- Patients might demand tests and treatments they are misinformed about
- Lack of time for shared decision-making between clinicians and patients
- Outdated decision-support systems encourage over-ordering
- Defensive medicine and fear of malpractice lawsuits drive over-investigations
- Payment systems reward doing more