Ontario Ministry of Health and Long-Term Care

  • Alison Paprica, Director (Acting), Health System Planning & Research Branch, Ontario Ministry of Health and Long-Term Care, Toronto, Ontario

Evidence-informed Changes to Funded Health Services and Products

This EXTRA Intervention Project focused on the identification of priorities for reassessment among existing services and products that may be low value – or even harmful – to patients. This project had several positive impacts over two years:

  • Five early candidates for reassessment were identified in November 2011. Two candidates, diagnostic tests for vitamin B12 and serum ferritin, have been acted on, the result being an estimated ~$39 million/year redirected to higher value laboratory tests.
  • In support of Council of the Federation Health Care Innovation Working Group (HCIWG), the following definition of appropriateness was developed:

    In the context of health care, appropriateness is the proper or correct use of health services, products and resources. Inappropriate care, in contrast, can involve overuse, underuse and/or misuse of health services, products and resources. Appropriateness is primarily determined by analyses of the evidence of clinical effectiveness, safety, economic implications, and other health system impacts. The practical application of appropriateness is made when these analyses are qualified by (a) clinician judgment, particularly in atypical circumstances and (b) societal and ethical principles and values, including patient preferences.

    This definition has been adopted by the HCIWG which is chaired by Premier Wall and Premier Ghiz and composed of all provincial and territorial health ministers.

  • Also in support of the HCIWG, three priorities for diagnostic imaging appropriateness were identified: imaging for low back pain, imaging for minor head trauma and imaging for uncomplicated headache. These priorities were accepted by Premiers at the July 2013 Council of the Federation meeting, with a recommendation to increase appropriate use for them through guidelines.
  • An Evidence Based Analysis Priorities Committee (EBAPC) was established in April 2013 as the ministry focal point for evidence-based analyses performed by external groups. The Committee work was guided by a process diagram, also developed as part of this project, which established a common understanding of the roles and responsibilities associated with reassessment. One of the first activities of the Committee was the establishment and application of a reassessment framework which identified three practices related to diagnostic testing of children as priorities for reassessment in Ontario. 

The reassessment framework developed under this EXTRA Intervention Project was deliberately kept simple and took less than one month to apply. According to the framework, priorities for reassessment were identified as they met two or more of the following triggers (some of which had quantitative criteria as indicated in brackets):

  • An evidence-based recommendation against use by an external body
  • Nominated by a local clinical expert
  • Safety concerns noted in the literature
  • Regional and/or temporal variation suggests inappropriate use
  • Change likely to provide benefit to significant number of people in Ontario (criterion: change would have positive impact for least 1000 individuals per year)
  • Change would be cost saving (criterion: change would result in cost savings of at least $1 million per year)
  • Data suggests significant percentage of cases receive service/product inappropriately (criterion: no threshold set, but a working limit of NMT 10% of the relevant of patients cases may be reasonable, except in cases where clinical experts specify a different limit)

Many of these triggers could also apply to new products or services being considered for evidence-based assessment. Current plans are to use these triggers in a process that will take suggestions from across the ministry to identify additional reassessment and assessment candidates by fall 2013. In addition, under the EBAPC, new processes and templates have been developed to gather internal expert judgement to support implementation when an evidence-based recommendation is received from an outside group. The elements sought include: impact on patient experience, alignment with ministry priorities/strategies, ease of implementation and the anticipated reactions of different stakeholder groups.

It is expected that the reassessment framework, and the processes and templates of the EBAPC, may be useful for other bodies and jurisdictions. Efforts are being undertaken to disseminate the project findings and share the templates and processes developed under the EBAPC in order maximize the impact of this EXTRA Intervention Project.