Sunnybrook Magazine - Spring 2019

Choosing wisely: the positive impact of reducing unnecessary tests

Dr. Jeannie Callum, blood transfusion specialist at Sunnybrook.

Dr. Jeannie Callum, blood transfusion specialist at Sunnybrook. (Photograph by Kevin Van Paassen)

Blood tests are crucial tools in diagnosing and treating illness. But when not medically necessary, too many blood tests can be too much of a good thing. These, and other medical tests, are being scrutinized at Sunnybrook in order to improve patient care and free up resources.

No one likes being pricked with a needle for a blood test – especially when it’s happening every day.

In September 2018, Stafan Williams was undergoing surgery at Sunnybrook to remove tumours caused by colon cancer. The 70-year-old Toronto resident spent four days in the hospital, and each day she had blood drawn.

“It didn’t seem necessary,” says Stafan of the daily tests. “Especially for a patient like me, who has low iron.”

Daily blood tests are a familiar routine for anyone who has spent a significant amount of time in any hospital for surgery or another medical procedure.

But Dr. Jeannie Callum, a blood transfusion specialist at Sunnybrook, says that in many cases, daily blood tests have become a habit for doctors everywhere. “We get our coffee, then we check everybody’s blood work results from that morning and then we go and see the patients,” says Dr. Callum, who is also an associate scientist at the Sunnybrook Research Institute.

It would make more sense, she says, to check on the patient first, then perform only blood tests that are required for the patient’s care.

Daily blood work is just one of the practices that are being scrutinized at Sunnybrook through an initiative called Choosing Wisely, a program that aims to improve patient care and free up resources. The premise is simple: Doctors should consider which tests and procedures are necessary to properly diagnose and care for a patient – and then make smarter choices about what’s done.

With a more judicious review of the benefits of a test or procedure, doctors can reduce tests that offer little or no value to specific patients.

Choosing Wisely was started in the United States by the American Board of Internal Medicine Foundation in 2012, and the movement made its way to Canada in 2014. Dr. Adina Weinerman, a general internist at Sunnybrook, is leading the charge to implement significant changes around the hospital.

“We grew up with a North American culture in medicine that ‘more was more,’ and, as technology advanced, we started using it,” says Dr. Weinerman, who also chairs the Choosing Wisely committee of the Canadian Society of Internal Medicine. “But now the pendulum has swung, where we’re sometimes using things because they’re available and not because they’re necessary.”

There can be a downside to unnecessary procedures for both patients and the hospital, Dr. Weinerman says.

Because phlebotomists (the clinicians who draw blood) have so many patients to attend to, in some cases they have to wake patients in the middle of the night or early in the morning to have their blood drawn. It’s a time- consuming process that can be uncomfortable for patients. Also, a surplus of routine blood tests can create a backlog in the lab where the blood is analyzed, delaying more urgent tests.

In some cases, too many blood tests can lead to patients developing anemia or requiring a blood transfusion. Transfusions can be risky procedures for any patient, and they can be problematic for patients like Stafan, a Jehovah’s Witness whose religion prohibits blood transfusions.

Beyond blood tests, the initiative at Sunnybrook is reviewing the routine administration of other procedures such as computerized tomography (CT) scans.

Like blood tests, CT scans are invaluable tools that aid in the diagnosis of illness and injury. They provide images that are much more detailed than ultrasounds or X-rays. But they shouldn’t be overused, Dr. Weinerman says. If a CT scan is administered unnecessarily, doctors may see something on the scan that appears abnormal, but never would have caused problems for that person.

“[Once] we see [those abnormalities], it leads to a snowball effect where we feel compelled to do more tests, like a biopsy,” she says.

Patients may need to take time off work for unnecessary tests that might have been avoided if an ultrasound had been done instead of a CT scan.

Reducing unnecessary CT scans also cuts down on wait times for those who really need them, Dr. Weinerman notes.

“There’s a finite number of resources and a finite number of hours in the day, and if we can reduce the number of medically unnecessary tests, that frees up those resources,” she says.

Vials of blood

(Photograph by Kevin Van Paassen)

The initiative at Sunnybrook has already shown the positive impact of reducing unnecessary tests. In 2017, Dr. Callum decided to tackle two high-volume blood tests: one a measure of kidney function, the other a liver test. Both are not needed except in very specific cases, she says, but doctors routinely order them.

Dr. Callum first held widely publicized “grand rounds” with hospital staff, where she and her team outlined the tests they wanted to reduce and why. Then, she ensured that these tests were not automatically included in the
order sets for patients getting other kidney and liver tests done. After that, it was a matter of sending monthly emails to doctors who were still ordering these tests, unless their patients needed them.

Dr. Callum’s efforts paid off. “Between 2017 and 2018, we reduced the volume of [these two] tests by 75,000, which was a 75 per cent reduction,” she says.

In addition to reducing the total number of tests, Dr. Callum says they have decreased the amount of blood drawn for all blood tests.

“We switched the entire hospital to low-vacuum tubes for drawing blood,” she says.

With low-vacuum tubes, about half the amount of blood gets drawn per tube. There is also less pressure on the blood that’s drawn, leading to less of the sample becoming haemolyzed (when red blood cells become ruptured). Haemolyzed blood is unfit for testing, which subsequently leads to more blood having to be drawn.

“We’ve dramatically cut down on the amount of blood that we’re taking out of a patient, which helps keep them healthy and fit,” Dr. Callum says.

Efforts to improve the use of resources and patient care are ongoing, says Dr. Weinerman. So far, she has looked mostly at tests and procedures already identified by Choosing Wisely as most likely to be overused. But now she is turning to examples more specific to Sunnybrook, to see what changes can be made.

For her part, Dr. Callum has two new targets in mind: one is a routine heart muscle blood test that has been replaced by a newer and better test; the second is a blood test which assesses vitamin D levels.

In Canada, about half of all blood vitamin D measurements in healthy people are low, says Dr. Callum.

“In a healthy person without any serious diseases who eats a complete diet, there is no evidence that these low levels need any treatment – so why are we doing the measurement in the first place?”

Read more: Sunnybrook awarded Level 3 designation by Choosing Wisely Canada »