Tran K, Rahal R, Fung S, Lockwood G, Louzado C, Xu J, Bryant H
Canadian Partnership Against Cancer, Toronto, ON.
Departments of Community Health Sciences and of Oncology, University of Calgary, Calgary, AB.
Curr Oncol. 2017 Jun;24(3):201-206. doi: 10.3747/co.24.3643. Epub 2017 Jun 27.
Value-based care, which balances high-quality care with the most efficient use of resources, has been considered the next frontier in cancer care and a means to maintain health system sustainability. Created to promote value-based care, Choosing Wisely Canada-modelled after Choosing Wisely in the United States-is a national clinician-driven campaign to identify unnecessary or harmful services that are frequently used in Canada. As part of the campaign, national medical societies have developed recommendations for tests and treatments that clinicians and patients should question. Here, we present baseline indicator findings about current practice patterns associated with 7 cancer-related recommendations from Choosing Wisely Canada and about the effects of those practices on patients and the health care system. Indicator findings point to substantial variations in cancer system performance between Canadian jurisdictions, most notably for breast cancer screening practices, treatment practices for men with low-risk localized prostate cancer, and radiation therapy practices for early-stage breast cancer and bone metastases. Extrapolating indicator findings to the entire country, it was estimated that 740,000 breast and cervical cancer screening tests were performed outside of the recommended age ranges, and within 1 year of diagnosis, 17,000 patients received treatments that could be low-value. A 15% reduction in the use of the 7 screening and treatment practices examined could lead to multiple benefits for patients and the health care system: 9000 false-positive results and 3000 treatments and related side effects could be avoided, and 4500 hours of linear accelerator capacity could be freed up each year. Interjurisdictional performance variations suggest potential differences in clinical practice patterns in the planning and delivery of cancer control services, and in some cases, in disease management outcomes. Although the cancer screening and treatment practices described might be unnecessary for some patients, it is important to realize that they could, in fact, be necessary for other patients. Further research into appropriate rates of use could help to determine how much cancer care represents overuse of practices that are not supported by evidence or underuse of practices that are supported by evidence.
基于价值的医疗，即在高质量医疗与资源的最有效利用之间取得平衡，被视为癌症医疗的下一个前沿领域以及维持医疗系统可持续性的一种手段。为促进基于价值的医疗而创建的“明智选择加拿大”（仿照美国的“明智选择”）是一项由临床医生主导的全国性运动，旨在识别加拿大经常使用的不必要或有害服务。作为该运动的一部分，全国性医学协会已针对临床医生和患者应质疑的检查和治疗制定了建议。在此，我们展示了与“明智选择加拿大”的7项癌症相关建议相关的当前实践模式的基线指标结果，以及这些实践对患者和医疗系统的影响。指标结果表明，加拿大各司法管辖区之间的癌症系统表现存在很大差异，最明显的是乳腺癌筛查实践、低风险局限性前列腺癌男性的治疗实践以及早期乳腺癌和骨转移的放射治疗实践。将指标结果推算至全国，估计有74万例乳腺癌和宫颈癌筛查检查在推荐年龄范围之外进行，并且在诊断后的1年内，有1.7万名患者接受了可能价值不高的治疗。减少所检查的7种筛查和治疗实践的使用量15%，可能会为患者和医疗系统带来多重益处：可以避免9000例假阳性结果、3000次治疗及相关副作用，并且每年可以腾出4500小时的直线加速器容量。跨司法管辖区的表现差异表明，在癌症控制服务的规划和提供方面，以及在某些情况下在疾病管理结果方面，临床实践模式可能存在差异。尽管所描述的癌症筛查和治疗实践对某些患者可能不必要，但重要的是要认识到，实际上它们对其他患者可能是必要的。对适当使用率进行进一步研究有助于确定多少癌症医疗代表了对无证据支持的实践的过度使用或对有证据支持的实践的使用不足。
