The Choosing Wisely Canada (CWC) campaign was launched in 2014 with the aim of reducing unnecessary tests and treatments in health care. This all-encompassing initiative encourages health care professionals and patients to engage in discussions about unnecessary tests and treatments, to make smart and effective care choices.
North York General Hospital (NYGH) was an early adopter of CWC undertaking its own campaign in 2014.
The Pharmacy department has been key to supporting many of the initiatives implemented at the hospital and has spearheaded and sustained several medication-related Choosing Wisely recommendations into practice.
“When it comes to reducing unnecessary medication use, pharmacists are the experts who can lead this work,” says Edith Rolko, Director of Pharmacy. “There are implications to taking medication that don’t improve the condition or symptoms they are prescribed for including decreasing adverse side-effects, interactions with other medication, and reducing pill burden.”
Highlighting the pharmacy team’s experience and successful adoption of the Choosing Wisely campaign, as they embrace the philosophy that in medicine, more is not always better:
- CWC Recommendation: Benzodiazepines and Older Adults
In Canada, benzodiazepines are often prescribed for the treatment of anxiety disorders and insomnia. Research indicates that long-term use of benzodiazepines in elderly patients can lead to increased risk of falls, hip fractures, motor vehicle accidents and cognitive impairment. CWC recommends exploring safer alternatives to treat insomnia, agitation, or delirium.
North York General’s Pharmacy team successfully applied and sustained this recommendation towards the use of benzodiazepines. Efforts were made to introduce melatonin as a treatment alternative and include non-pharmacological interventions like the use of ear-plugs to treat insomnia in hospitalized older adults. Further, clinicians were reminded not to rely on benzodiazepines in the management of delirium.
- CWC Recommendation: Proton pump inhibitor (PPI) therapy for gastrointestinal symptoms
PPIs are one of the most prescribed drugs in Canada for the treatment of gastro-esophageal reflux disease. While PPIs are safe and well-tolerated for short-term use, it can cause a number of adverse effects which may increase with a patient’s age, long-term use, or when inappropriately prescribed. Some of the risks associated with over-use of PPIs include pneumonia, fractures, and vitamin B12 deficiency. For this reason, CWC recommends against long-term use without attempting to reduce or stop therapy at least once a year, except for high-risk patients.
After evaluating the use of the drug among specific units of the hospital, the Pharmacy team successfully deprescribed the use of PPIs among select patients deemed stable and cleared of any acute medical issues. North York General continues to explore strategies for deprescribing PPIs and ensuring duration of treatment is appropriately outlined, where possible, for new starts when patients are discharged from hospital.
- CWC Recommendation: Stool softeners and opioid induced constipation
Stool softeners are widely prescribed to prevent opioid-induced constipation. Studies suggest this drug is no more effective than a placebo in the prevention of constipation in any patient, not only those on opioids.
The Pharmacy team at North York General applied the CWC recommendation more widely, given the number of studies that supported evidence that stool softeners have no benefit to patients, regardless of their condition or other medications being prescribed. The team significantly reduced the number of stool softeners administered to patients, by providing physicians with more effective alternatives and eventually discontinued use of the drug altogether.
This initiative is outside of the CWC’s framework of recommendations, but it aligns with CWC’s mandate, so it was proposed and implemented by the Pharmacy leadership team and approved by North York General’s Medical Advisory Committee.
“The Choosing Wisely framework serves as a great starting point, but there’s definitely room to expand the scope of this campaign and look beyond the list of recommendations,” says Jenny Chiu, NYGH Pharmacist. “By evaluating the hospital’s drug formulary, our team was able to identify additional initiatives to put forward and improve patient care.”