These are very interesting questions about appropriateness, because, of course, appropriateness is very difficult to define.
You're well aware, I'm sure, of the Choosing Wisely initiative, whereby medical practitioners are trying to say upfront that we recognize that appropriateness is something that can be enhanced. It's one of those things you kind of know when you see them, but it's kind of difficult to define. Ultimately, I suppose the way forward is to have some sort of reduction in the practice variation we see, have some sort of unanimity around what constitutes good practice, and then have the outcomes be the measure.
So it really speaks to how this part of the problem has to be wrapped up in the bigger envelope of managing pain in Canada, because at the end of the day we want people to be in as little pain as possible, and we want to have as few people addicted as possible, and we want to have as much of the inappropriate prescribing disappear as possible. Those are the outcomes we're trying to reach, and if we reach those, we will have increased appropriateness by definition. The most powerful tools are those that measure these important outcomes and give us ways to access best practices and to assure ourselves and others that we are following best practices.
The idea of monitoring prescriptions, I think, has met with modest success in the past, but really I suppose it's a red flag. If you find that Dr. X prescribes 10 times as much as Dr. Y, does that mean that Dr. X is prescribing inappropriately, or does it mean that he has a different practice profile? It may be sort of a signal that we need to go in and look a little bit deeper. It may be the first pass, but it may not be the sole tool required.