“In 2022, about 1 in 5 (19%) Canadians reported that a test or treatment they did not feel was necessary for their health had been recommended to them. This has declined compared with 25% in 2019 and 30% in 2017.

“Among this group, more than half (55%) asked their doctor why they thought the test was necessary.”

“High rates of inappropriate use of screening tests have been documented, often in the context of concurrent underuse in appropriate populations. In the USA, where there is widespread public support for cancer screening,¹⁰⁶ overuse of screening for cervical cancer^107,108 in women at very low-risk, and overuse of mammography in women with short life expectancy, who are unlikely to benefit from diagnosis and treatment,¹⁰⁹ has been documented. Furthermore, inappropriate use of colonoscopy screening has been found in both the USA and Canada.^110–12

“Few studies have evaluated rates of inappropriate cancer screening outside of North America.”

“This analysis examined how many patients got diagnostic imaging within 6 months of their initial visit to a family physician for lower-back pain, even when there were no red flags denoting that imaging might be necessary. The trends for imaging rates in patients with uncomplicated lower-back pain varied by province. Between 2015–2016 and 2019–2020, the diagnostic imaging rate dropped more than 13% in Alberta and 11% in Nova Scotia, while remaining stable in the 3 other provinces. Overall, the number of diagnostic imaging tests (X-rays, CTs and MRIs) was reduced by approximately 22,000 for 2019–2020 compared with 2015–2016. In 2019–2020 alone, up to 1 in 3 patients with uncomplicated lower-back pain across reporting provinces — about 181,000 patients — received imaging. Some of the variation may be due to how provinces report and fund diagnostic imaging.”

“With policy adjustments, healthcare systems are better supported to reduce low-value care by addressing these factors.^17,26-28 For example, moving from pay for performance toward other payment structures, such as capitation or paying for quality instead of quantity can remove the pressure on clinicians to generate volumes.²⁹ Most physicians in the United States and Canada receive a fee for service, while in the Netherlands, half of the specialists is salaried and general practitioners receive a capitation fee per registered patient. The United States is trying to shift towards value-based payment.³⁰ The predominantly capitated National Health System in England,³¹ and no longer reimbursing care in Canada¹³ have shown to reduce low-value care use. In addition, local strategies such as global budgets for hospitals,³² a fixed budget contract between hospital and insurer and fixed income for specialists,³³ and a cost accounting and shared savings program34 have potential to reduce low-value care.”

“Patients are also exposed to direct or indirect marketing. Whereas direct marketing of drugs is prohibited in Canada and the Netherlands, marketing the disease is legal. Companies raise awareness on for example prostate cancer and recommend the public to go to their doctor, increasing the necessary but also unnecessary use of their product. According to the experts, patient organizations sometimes receive financial support from the industry, which can help these organizations to support the patient population. It, however, also places them at risk of providing biased information to patients or the interests for which they advocate. For example, one expert described when a diabetes association argued for tighter hemoglobin a1c control, which would lead to more medicine being used.”

“In many countries, evidence exists for the overuse of aggressive care for dying patients and simultaneous underuse of appropriate palliative care. Despite evidence that the majority of people around the world would prefer to die at home,^141–46 about half die in hospital worldwide, with considerable variation among countries.¹⁴⁷ Inappropriately aggressive cancer care near the end of life has been identified as a common problem in Canada,¹⁴⁸ the USA,¹⁴⁹ and the UK,¹⁵⁰ with regional variations observed.¹⁵¹ Overuse of aggressive end-of-life care in the UK, for example, includes futile insertion of percutaneous endoscopic gastrostomy tubes¹⁵¹ and administration of chemotherapy that hastens death.¹⁵² Furthermore, ineffective intensive care unit treatment at the end of life has been reported in Canada,¹⁵³ the USA,¹⁵⁴ and Brazil.¹⁵⁵ A study from Korea found that the majority of terminal cancer patients received futile intravenous nutrition during the last week of life, with discussions of palliation in only 7% of cases.¹⁵⁶“

“Choosing Wisely Canada Recommendations

“Developed by professional societies representing different clinical specialties in Canada, these recommendations identify tests and treatments commonly used in specialties that are not supported by evidence and could expose patients to harm.

“These recommendations are not intended to be used to establish payment and coverage decisions. Rather, they are meant to spur conversation about what is appropriate and necessary treatment. As each patient situation is unique, clinicians and patients could use the Choosing Wisely Canada materials to determine an appropriate treatment plan together.”

Source: Choosing Wisely Canada: Recommendations. From the Choosing Wisely Canada website, last accessed Jan. 4, 2023.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated Jan. 5, 2023 by Doug McVay, Editor.