Thank you for the privilege of addressing your committee. I am here in my role as the chair of Choosing Wisely Canada.
We are a national clinician-led campaign that helps clinicians and patients have conversations about unnecessary tests, treatments, and procedures in order to help patients make informed choices. We also organize an international collaboration of Choosing Wisely campaigns that are presently in 20 to 25 countries around the world.
There is evidence from the Canadian Institute for Health Information that up to 30% of all the tests and treatments we do are unnecessary, meaning that they don't add value for the patient, and in some cases they are potentially harmful. Certainly, unnecessary antibiotic use is one such problem, where it doesn't necessarily benefit the patient, can potentially have harm, and has harm potentially to the broader society as a driver of antimicrobial resistance.
As you well know, antimicrobial resistance is a global problem, with causes far beyond human health care, and there needs to be multifactorial solutions, but in health care, antibiotics are overused unnecessarily in hospitals, primary care and outpatient clinics, and long-term care facilities.
I will provide you a bit of the understanding of the drivers of the overuse and some insights into some strategies that might be used to tackle it. It's important to say that overuse of many tests and treatments, such as antibiotics, is complicated. Overuse is baked into our system. It's in our medical culture. There are clinician, patient, and systems factors that relate to this overuse.
Clinicians might prescribe antibiotics unnecessarily for a variety of reasons. They have a perception that patients want a prescription, and they want to please their patients. If you're with a parent and the child has been up all night with an earache and a fever, you want to provide relief. It can actually take longer to explain to a mother why her child has a viral infection, not a bacterial one, and that antibiotics won't help, so we know that it is often easier to just prescribe them.
We also know from research that patients are typically comforted if they feel that a physician has listened and paid attention to their symptoms. They don't necessarily need the prescription. To be frank, in a busy and full clinic, when doctors are rushed, it can be easier to write a prescription than have a conversation that physicians might experience as challenging.
On the broader public side, there are many misconceptions, as you know, about the effectiveness of antibiotics for common colds and viral infections. We live in a society where people might expect medicine to offer quick fixes and a magic pill for every ailment. That's our culture. Patients often come to the doctor's office with an expectation that they'll leave with a prescription in hand. They're also not aware of the potential harms in general of unnecessary tests and treatments, and certainly of antibiotics in particular.
Finally, there are just health system factors that drive unnecessary antibiotic use. For example, we lack in Canada good information systems to give feedback to doctors and other clinicians about their prescribing practices. We work in hospitals and clinics with a real heterogeneity in the types of computer systems that we have that could be harnessed to help prescribers pick the right antibiotic for the situation. We also in hospitals have existing order sets, which are basically pre-written orders for certain situations, and they might encourage overuse.
What does Choosing Wisely Canada have to do with this? In our view, change happens from the inside out. It's our view that health care professionals themselves need to lead the conversation about the problem of overuse in general, and specifically about antibiotics. This is done through national specialty societies. There are about 60 participating organizations right now, including family medicine, physician specialists, nurses, pharmacists, and dentists. These societies work internally to develop a list of Choosing Wisely recommendations that are inside their specialty. They pick, as a minimum, five tests and treatments that are clinically unnecessary or could potentially be harmful to patients. Having that physician, nurse, or clinician buy-in generating the lists ensures that the campaign is grassroots. We think that's the most effective way, rather than top-down.
At present, there are about 270 Choosing Wisely recommendations, and about 20 specifically addressing antibiotics. I'll give you a couple of examples. In family medicine, there's a recommendation that reads, “Don't use antibiotics for upper respiratory tract infections that are likely viral in origin.” For the emergency room, they have a recommendation, “Don't use antibiotics in adults or children with uncomplicated sore throats.”
Another way of engaging the clinicians in this is through the next generation. We are working to teach in medical schools. Two years ago we launched a very interesting program called Choosing Wisely STARS. It was actually started by the students. STARS stands for students and trainees advocating for resource stewardship. It's a grassroots, student-led campaign designed to change the culture in medical education by addressing the behaviours that drive overuse.
At the patient level, we also need to work to change patient and public expectations, but this is clearly a major challenge. We've been working on it through a number of strategies to promote the message that more is not always better. Maybe some of you have seen our hot dog with too much mustard on it, and of course, then, specifically, for antibiotics, it's the same.
The campaign has been aimed broadly at the public through the media. We've worked with news media, and radio and TV outlets, and have written op-eds, but more specifically, we've launched targeted campaigns to educate patients when they are in the physician's office where these issues are top of mind. For example, we've distributed posters to all the family doctors in Ontario where the message is that more antibiotics will not get rid of your cold. We have these posters and additional materials for patients because we're trying to promote patients asking three questions: do I really need antibiotics; what are the risks; and are there simpler or safer options for my condition?
Finally, there's a need to tackle the health system drivers. Physicians practise in a way that is strongly influenced by their local clinical environment. In order to tackle the system factors that drive overuse, we've tried to bring together stakeholders who influence that practice environment and make it easier for physicians to do the right thing, which is to avoid unnecessary prescriptions.
There's growing evidence in Canada through demonstration projects that we can change that practice environment. For example, in Newfoundland and Labrador, the Choosing Wisely group is giving primary care doctors data about their prescribing practices compared to their colleagues, and additionally, they have a big public education campaign about avoiding unnecessary antibiotics.
At Choosing Wisely, we help foster this burgeoning community of early adopters. In fact, just earlier today there were almost 100 sites on a webinar about antibiotics and how to avoid using them. We've seen clinicians really from coast to coast, in a variety of settings, such as hospitals and clinics, try to start using quality improvement measures to promote the recommendation that more is not always better.
Finally, of course, antimicrobial resistance is a global concern. As I mentioned, we have an international collaboration of between 20 and 25 Choosing Wisely countries. We've been working with the OECD, for example, which has measured the rates of antibiotic use in different countries. As you might know, our antibiotic use is quite a bit higher than that of some countries. In fact, it's double that of the Netherlands, so we're trying to learn from our Dutch colleagues why they did better than us on this, especially in their outpatient setting.
In summary, we have a long way to go to tackle the problem, but we're optimistic. We think unnecessary antibiotics, similar to other overused tests and treatments, are just part of the medical culture, but if we can engage physicians and health care professionals to provide leadership in making change, change is very possible.
Physicians are not the only drivers. We have to work in a complex system with a variety of clinicians, patients, and health care system factors. Between clinician leadership and patient education, we can stimulate those conversations one on one between doctors and patients or nurses and patients about whether the patient really needs these antibiotics or not. We're using evidence-based, informed strategies to change and work with the broad network of people in the system—clinicians, patients, the public, and the health care provider organizations—to try to deliver the message that more is not always better in health care, particularly with antibiotics.
I'm very eager to participate in your discussion.