Choosing Wisely? Let’s Start with Working Wisely

Abstract

There is an increasing emphasis on quality and, relatedly, cost-effectiveness as it relates to the delivery of health care. Choosing Wisely is an initiative adopted by numerous specialties with the goal of starting a dialogue about efficient use of health care resources. People need to be able to access care to have an opportunity to choose wisely. There is a considerable amount of evidence that access to care is poor for specialty mental health care, particularly access to psychiatrists. Consequently, we suggest that psychiatrists and the broader mental health system need to consider working wisely, and in our paper outline key issues (for example, implementation of wait times and objective measures of need in a centralized referral management system; incorporation of performance indicators with longitudinal monitoring for continuous quality improvement) that need to be addressed to develop a mental health system that would allow people to access care to choose wisely.

There is an increasing emphasis on quality and, relatedly, cost-effectiveness as it relates to the delivery of health care. ¹ This is conceptualized by Berwick et al ² from the Institute for Healthcare Improvement as the triple aim: improving the experience of care; improving the health of populations; and reducing the per capita cost of health care. The focus on quality and cost-effectiveness intensifies at a time when health care costs are increasing and are forecast to increase further still. ^3,4 Consequently, in 2012 the American Board of Internal Medicine initiated Choosing Wisely, a campaign intended to change practice by promoting conversation between health care providers and patients. ⁵ Choosing Wisely is intended to help patients and their care providers choose effective care that is supported by evidence, waste-free (that is, not duplicative of other tests or procedures already received), free from harm, and truly necessary. ⁶ The idea behind Choosing Wisely is that, in the absence of conversation and reflection, patients could be subjected to medical tests and procedures that are not supported by evidence, and thus contribute to unnecessary costs and potential harm. Choosing Wisely also emphasizes the importance of investigation and treatment decisions that are not only evidence-informed, but also in keeping with a patient’s personal goals of care determined through a collaborative process.

Since its initiation, Choosing Wisely has enlisted a large number of medical and surgical organizations. ⁶ These organizations provided lists of treatments or investigations that had the potential to be harmful and (or) wasteful. ⁷ The American Psychiatric Association (APA) is a participating member of Choosing Wisely and the 5 items and directives submitted all relate to antipsychotic (AP) prescribing. The Canadian Psychiatric Association is currently developing its own list of recommendations for Choosing Wisely Canada. The list the APA submitted to Choosing Wisely reflects the disturbing trend of off-label use of APs, particularly among children and adolescents, ^8,9 and an equally troubling trend of prescribing multiple APs in the absence of evidence for effectiveness and the potential for additive side effects. ¹⁰

The APA’s participation and recommendations to Choosing Wisely are laudable and grounded in good evidence. However, the most urgent problem facing psychiatry is not reducing unnecessary tests or potentially harmful treatments. The biggest challenge for psychiatry today is to address the poor access to care. Patients can only choose wisely and avoid the potential harms put forward in the APA list if they have access to care. There is a growing body of evidence that access to mental health care is a considerable quality issue in psychiatry. For example, the National Comorbidity Survey Replication revealed that 52% of depression cases received treatment, but only 42% of these treatments were deemed adequate, resulting in only 22% of all depression cases being adequately treated. ¹¹ This low rate of depression treatment has persisted despite an incredible increase in the number of prescriptions for antidepressants (ADs). For example, in the United Kingdom between 1998 and 2012, there has been a 165% increase in AD prescriptions, an increase that is not nearly accounted for by depression or anxiety disorder prevalence trends. ¹² Poor access to care and treatment is not restricted to depression; postdischarge physician follow-up for people with schizophrenia is alarmingly poor. ¹³

One reason for the low treatment rates and poor access to care is the challenges both patients and primary care physicians face trying to access psychiatrists. A Canadian study ¹⁴ had a research coordinator simulate a referral from a primary care physician office and attempt to contact every psychiatrist in Vancouver, British Columbia. Among the 230 psychiatrists who have clinical practices in Vancouver, only 6 were available to provide a consultation in a timely manner. This study ¹⁵ has been replicated in the United States with very similar findings. Finally, a recent study ¹⁶ of regional psychiatrist supply and associated practice patterns in Ontario revealed that as the number of psychiatrists increases regionally, the average psychiatrist’s outpatient volume decreases. Because practice volumes decrease with increasing numbers of psychiatrists regionally, access to psychiatrists is challenging independent of psychiatrist supply. Based on this data, it is not surprising psychiatrists are rated the most challenging to access by primary care physicians in Canada. ¹⁷

While there are a number of evidence-based treatments, both pharmacologic and psychotherapeutic, for a range of psychiatric conditions that could be addressed by the Choosing Wisely initiative, the emerging evidence on access to psychiatrists indicates that the critical quality issue in psychiatry is the absence of an accessible mental health-care system framework. Limited and poorly organized access to mental health care limits the extent to which evidence-based treatment can reach the largest number of people possible. Before we can choose wisely in conversation with individual patients, we need to work wisely to develop care systems to address difficulties with access to psychiatrists specifically, and mental health and addictions services generally, that plague many jurisdictions.

We believe that the Choosing Wisely initiative in psychiatry should be expanded to working wisely. Working wisely would encapsulate numerous issues related to addressing access to psychiatric care and psychiatrists, including (but not limited to) defining the population who require psychiatric services, defining psychiatric services that should be available, and defining patient value outcomes ¹ that can be used to determine whether we are moving in the right direction. Finally, the mandate needs input from a broad range of stakeholders, including patients, psychiatrists, the primary care community, the broader community service delivery agencies, and government funding agencies to ensure that the mandate is truly representative of the needs of the people psychiatrists serve.

Currently, we do not have a good way of aligning access to specialty mental health services with need. Without alignment structures, people who need services do not receive them and people who do not require specialty services have access. A rationalization of the finite resources, including psychiatrists, requires centralized intake structures and processes where an objective measure of need can be administered. With such a process, we would begin to understand the existing need for services and where such services can best be delivered (for example, community-based, primary care, psychiatrist, and stepped care within hospital settings) and the criteria for accessing these services. In other areas of health care delivery (for example, cancer, stroke, and acute myocardial infarction), people are diagnosed and undergo an extensive work-up, with the following treatments dictated by evidence on what is required based on the presenting illness severity. This ensures that people with cancer get the intensity of treatment they need, and that the care that they receive is evidence-informed. Efforts to create a similar stepped care system for mental health and addictions service delivery is needed to ensure that the intensity of resources provided to people is evidence-based and equitable. Such a framework is described in the Mental Health Strategy proposed by the Mental Health Commission of Canada (MHCC). ¹⁸ Equitable access is critical when considering mental health system reform. Certain populations, such as children, the elderly, and First Nations or Aboriginal populations (specifically identified in the MHCC’s national strategy ¹⁸ ), have well-described access challenges. For these populations, deliberate outreach and specific models of care are needed to address these inequities.

With a system-level triage system in place, the next step would be to consider the types of treatment that provide the most cost-effective way to relieve the burden of mental illness and addiction for the entire population. Treatments should be based on existing evidence and should address gaps between actual practice and evidence-informed, guideline-oriented care. ¹⁹ Moreover, a proper, centralized or regionalized triage system will facilitate the development of new evidence because of the capacity to describe all people and to longitudinally follow treatment trajectories. Evidence for systematic identification and a stepped care approach to depression treatment exists. ²⁰ More recent meta-analyses ²¹ and randomized controlled trials ²² suggest that emerging collaborative care interventions integrated into primary care with systematic identification and treatment alignment processes provide better results and greater patient satisfaction than usual care. Collaborative care requires psychiatrists to shift their practices to be more integrated with primary care. There are likely many barriers to such a shift in practice, with the current fee-for-service payment system being but one. Beyond depression and anxiety, we need intervention evidence to guide treatment for people with severe mental illnesses as they have a great deal of complexity and comorbidity, both medical and psychiatric. There is limited evidence of what is needed to achieve good outcomes with increasing patient complexity.

Finally, we must be able to measure outcomes to properly evaluate the performance of the mental health system and to further inform the development of mental health care delivery models. In most provinces, there are numerous initiatives aimed at increasing the capacity to measure mental health system performance as a way to enhance system accountability (for example, British Columbia, ²³ Alberta, ²⁴ Manitoba, ²⁵ and Ontario ²⁶ ). However, the capacity to use existing data or to capture new data remains limited. A 2014 report ²⁷ on wait times in Canada described the current limitations in mental health performance measurement and the need to develop a common set of indicators by which all jurisdictions are measured within the mental health system. Put simply, you cannot change what you cannot measure—we must do a better job at describing what services we are providing and what kinds of meaningful patient outcomes are being achieved. Valid, relevant, and feasibly measured performance indicators provide infrastructure for quality-based funding—funding that provides incentives for service delivery that has been shown to produce the best outcomes. Quality-based funding models would be in stark contrast to current provincial psychiatry fee schedules where the most prominent fee-for-service models provide little direction or accountability to individual psychiatrists’ practice.

The triple aim outlined by Berwick et al ² highlights the experience of care as the first of 3 aims, and patient experience is a key attribute of Porter’s ¹ health care value framework. We know that mental health and addictions care is woefully inaccessible in its current form and the level of disability associated with mental health and addictions, in light of the poor access to care, means that patients and their families struggle to cope. Indeed, the extent to which mental health care is delivered without a well-defined system of service delivery explains much of our current state. There are many benefits to imposing structure on existing efforts to deliver mental health and addictions care, not least of which is providing a framework whereby existing practices can be evaluated and inefficiencies identified. The only way to move forward is by working wisely. The goals of Choosing Wisely will be achieved only if we have a mental health system built so that people with mental illnesses and addictions finally have the opportunity to make meaningful choices about the care they need.