Inappropriate use of clinical practices in Canada: a systematic review

Abstract

Background: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. Methods: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. Results: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9). Interpretation: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

What problems in health care quality should we target as the world burns around us?

“…In related research, Squires and colleagues provide contemporary estimates of these twin problems of underuse and overuse in Canada. 4 Using Canadian data from 174 studies published from 2007 to 2021, they found a median proportion of inappropriate care (either underuse or overuse) of 30%. This inventory of shortfalls in the delivery of effective care comes after decades of efforts to address such quality problems, 5 begging the question, “What should we be doing to deliver better quality care?”…”

“…The authors of the related systematic review 4 identified glycosylated hemoglobin (HbA 1c ) testing as the most frequently underused diagnostic test in Canada. Addressing underuse of HbA 1c testing might prompt use of the many effective therapies for diabetes that have become available in recent years.…”

“…This prioritization might depend on the anticipated health benefits from closing any particular shortfall in recommended care. Statins, the most frequent therapeutic example of underuse in the systematic review, 4 provides a telling example. Among patients with established atherosclerotic cardiovascular disease, 33–100 must take a statin for 10 years to prevent 1 cardiovascular death, myocardial infarction, stroke or recurrent ischemic event.…”

À quels problèmes liés à la qualité des soins de santé faut-il s’attaquer en priorité?

“…Dans une recherche connexe, la D re Janet Squires et ses collègues fournissent des estimations plus récentes du problème double de sous-utilisation et de surutilisation des soins au Canada 4 . À partir de données canadiennes tirées de 174 études publiées entre 2007 et 2021, ces chercheurs concluent que la proportion médiane de soins inappropriés (sous-utilisation ou surutilisation) est de l’ordre de 30 %.…”

“…Les auteurs de l’étude systématique dirigée par la D re Squires mentionnée ci-dessus 4 ont déterminé que l’analyse de l’hémoglobine glyquée (HbA 1c ) est le test diagnostique le plus fréquemment sous-utilisé au Canada. Aborder cet enjeu de sousutilisation pourrait mener à l’administration de nombreux traitements efficaces contre le diabète élaborés ces dernières années.…”