Inappropriateness of health care in Canada: a systematic review protocol

As health systems in Canada and around the world struggle with sustainability [1], there is increasing recognition that a substantial proportion of the health care delivered is clearly inappropriate as evidenced by (1) harmful and/or ineffective clinical practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused [2‐10]. Several studies have highlighted the negative effects that inappropriate health care may have on patients. In a study by Baker and colleagues [11], 20 hospitals were randomly chosen across 5 provinces in Canada (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) to identify adverse events and their preventability: an adverse event being defined as an unintended injury or complication, resulting in disability, death, or a prolonged hospital stay [11]. The methods of this study were based on several global studies from Australia [12], the UK [13], New Zealand [14‐16], Denmark [17], and the USA [18‐20]. A screening process was completed in 4164 hospital admissions, and physician reviewers identified a total of 1133 injuries or complications in 858 charts. In 401 of those charts (46.7%), the adverse events resulted in death, disability at the time of discharge, or prolonged hospital stay [11]. Overall, 7.5% of patients experienced one or more adverse event and 36.9% of those patients experienced highly preventable adverse events [11]. In response, there is widespread professional and policy interest in reducing such inappropriate health care in Canada. For example, in 2014 Choosing Wisely Canada (CWC), a campaign designed to help clinicians and patients engage in conversations about unnecessary tests/treatments, and make optimal choices to ensure high-quality appropriate health care, was established [21]. CWC, modeled after the US Choosing Wisely® campaign, is physician-led in partnership with the Canadian Medical Association and is now endorsed by all provincial/territorial medical associations in Canada [21].

Inappropriate health care leads to negative patient experiences [22], poor health outcomes [23, 24], and inefficient use of scarce health care resources [25]. Summaries of inappropriate health care, each revealing astonishingly high levels, exist for the USA [2, 9], the UK [4], and Australia [5]; no summary exists for Canada. In the USA, performance in preventive, acute, and chronic care was evaluated; care was found to be inappropriate (i.e., overused or underused) in all three care areas, with 30% of patients receiving inappropriate acute care services, 40% receiving inappropriate chronic care services, and 50% receiving inappropriate preventive care services [2]. A second more recent review in the USA focused only on overuse, one dimension of inappropriate care; overuse rates were substantial, ranging from a high of 89% for antibiotic use in upper respiratory tract infections to a low of 1.4% for coronary artery bypass graft [9]. In the UK, performance in primary care was evaluated and care was found to be inappropriate more often than not, ranging from a high of 97% inappropriate care for diabetic foot examination to a low of 51% for diabetic fundal examinations [4]. In Australia, performance in primary care was also evaluated; patients received inappropriate care in 43% of encounters, ranging from a high of 87% inappropriate care for alcohol dependence to a low of 10% for coronary artery disease [5]. These reviews have provided much needed additions to the field of health care quality by confirming that inappropriate health care is a serious and widespread problem, and one to which no health sector is immune. These reviews also laid the foundation for several highly successful quality improvement initiatives, e.g., the 100,000 Lives and Protecting 5 Million Lives from Harm campaigns in the USA and Safer Healthcare Now! in Canada, which led to substantial reductions in inappropriate health care resulting in large numbers of saved lives [26, 27].

While no comparable comprehensive synthesis of inappropriate health care exists in Canada, it is reasonable to assume that similar high levels of inappropriate care exist in Canada. However, we do not know which types of care are inappropriately delivered; whether they are overused, underused, or misused; or how this inappropriate use may vary by province/territory, and the jurisdictional unit in Canada where most practice optimization efforts take place [2]. As a result, it is currently difficult to make informed judgments about which clinical practices to prioritize and where to focus quality improvement efforts in Canada. This task is further complicated by the fact that Canada does not presently have a mandatory comprehensive national quality tracking system. While the Canadian Institute for Health Information (CIHI), an independent organization that provides information on Canada’s health system and the health of Canadians, houses multiple pan-Canadian databases spanning different health sectors, it does not collect information on all clinical practices and contributions to their databases vary greatly by jurisdiction and health sector. Thus, in the absence of a mandatory and more comprehensive national quality tracking system, a systematic summary of published and grey literature is the best way to provide an overview of inappropriate health care in Canada [7].

Inappropriate health care is a core component of health care quality, which is a multidimensional concept comprised of (1) structure (organizational factors that define the health system, includes physical and staff characteristics); (2) care processes (interactions between users, includes clinical care and interpersonal care); and (3) outcomes (consequences of care) [28, 29]. In our review, we will focus on inappropriate health care (which are care processes), because this is the dimension of health care quality that is associated with the most waste in health care [2].

A scoping review [30] of health care appropriateness revealed two dimensions to the concept: (1) appropriate health care and (2) inappropriate health care. Both dimensions were consistently defined across studies: appropriate health care in terms of positive effects for patients and inappropriate health care in terms of negative effects for patients [30‐34]. This notion of positive and negative effects was explicitly defined by researchers at the RAND Corporation (23) with the introduction of risks and benefits. According to RAND, a clinical practice was considered to be inappropriate when the “risks exceeded the expected benefit” [34] (p. 669). This definition applies to an “average patient” presenting to an “average physician” [30, 35]. Building on the RAND definition of inappropriate health care, several conceptual frameworks emerged that shed further light on what constitutes inappropriate health care. In 1996, Lavis [6] published a framework proposing that health care could be inappropriate along two dimensions: (1) the clinical practice (e.g., administration of a drug) and (2) the setting where the service is delivered (e.g., hospital). In this framework, an inappropriate clinical practice is one that is “not expected to benefit the patient or, in the more extreme case, may harm the patient” [6] (p. 326). In a second framework, Sharpe and Faden [32] furthered our understanding of inappropriate care by asserting that it includes both under- and overuse of clinical practices [32]. A third framework, from the US National Roundtable on Health Care Quality [36], used a tripartite classification to describe inappropriate health care: (1) underuse, (2) overuse, and (3) misuse. Underuse refers to a failure to provide a clinical practice when patient benefits clearly outweigh the risks (e.g., missing a childhood immunization for measles) [36]. Overuse occurs when a clinical practice is provided under circumstances in which its potential for harm exceeds the possible benefit (e.g., prescribing an antibiotic for a viral infection for which antibiotics are ineffective) [36]. Misuse occurs when an appropriate practice is selected but a preventable complication occurs resulting in the patient not receiving the full potential benefit of the practice (e.g., a patient suffers a rash after receiving penicillin for a strep throat (which is appropriate) despite having a known allergy to that antibiotic) [36]. Drawing on each of these conceptualizations, we define “inappropriate health care” for this review as inappropriate clinical practices that may harm the patient, or when health care risks exceed the benefits. We will use the Institute of Medicine’s [36] tripartite classification above of inappropriate clinical practices: (1) underuse, (2) overuse, and (3) misuse.

The purpose of the study described in this protocol is to conduct a systematic review of inappropriate health care in Canada to inform urgently needed quality improvement programs. This review will serve as a foundation of evidence-based knowledge for future progress in quality improvement provincially and nationally. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada and (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions.

This project will be the first-ever systematic assessment of inappropriate health care in Canada and its jurisdictions. We will be able to provide an urgently needed snapshot of inappropriate health care in Canada and to develop the first-ever evidence-based Canadian compendium of inappropriate health care. We will develop provincial and territorial jurisdictional reports summarizing both the nature and magnitude of inappropriate health care in each jurisdiction. These reports will serve to advance much needed quality improvement programs at the provincial, territorial, and national government’s levels, as well as support agencies dedicated to quality and patient safety. It will enable the prioritization of programs and benchmark progress for quality improvement activities focused on improving health care quality and patient outcomes in Canadian jurisdictions.