Environmental impacts of clinical practice: reducing unnecessary care

Please note: This is the second article in a series on Planetary Health. See the first article on Introduction to planetary health in primary care.

Author

Dr. Ilona Hale MD, FCFP (biography and disclosures)

Disclosures: Received honoraria from Divisions of Family Practice, Cascades Canada, Therapeutics Initiatives, Health Quality BC, Interior Health Authority (in role as Medical Director for Climate Change and Sustainability), RCCBC, UBC, Alberta Pharmacists’ Association and UBC Sauder School of Business Physician Leadership Program. None of these have influenced the information in the article or represent any potential conflict of interest. Received funding from Interior Health, Health Research BC, RCCBC and UBC Department of Family Medicine. These grants were for work unrelated to the current article. Received sessional support for creating the Planetary Health in Primary Care Toolkit from the Division of Family Practice. Mitigating potential bias: Recommendations are consistent with Choosing Wisely and other standard practice guidelines.

What I did before

Like most physicians, I have always been aware that the medications we prescribe can have harmful adverse effects and that imaging can be associated with harmful exposure to radiation and contrast. I have always tried to follow evidence-based prescribing guidelines and recommendations for careful resource stewardship, such as those produced by Choosing Wisely Canada, to reduce unnecessary burdens on patients and the system.

But until recently, I had never really considered that all of these tests and treatments also have an environmental cost.

What changed my practice

I learned that about 80% of the substantial carbon footprint of health care comes from the upstream supply chain, where they make the products needed for the tests and treatments we order; 25% of greenhouse gases in Canadian health care come from medications alone.^1,2 Hospital labs are some of the most energy-intensive parts of the hospital and a single MRI scanner uses as much energy per year as 26 family homes.^3,4 One Australian study found that the annual carbon footprint of unnecessary Vitamin D testing alone was the same as driving 160,000-230,000 km and cost $87,000,000 AUD.⁵

I also learned that the burden of overuse is not trivial: up to 30% of all tests and treatments we order are unnecessary and an additional 10% are harmful to our patients.⁶ So, as clinicians, we have a great opportunity to reduce our environmental impact and improve patient care by eliminating unnecessary care.

For example, a 2023 study from Alberta found that 40% of antibiotics are still being prescribed when not required, in most cases for minor viral respiratory illness.⁷ Another 2023 study found that 24-31% of X-rays for low back pain and 33% of paediatric CT scans for minor head injuries were ordered without appropriate indications.⁸ An Ontario study found that 46% of selective serotonin reuptake inhibitors (SSRIs), 45% of proton pump inhibitors (PPIs) and 14% of bisphosphonates were “legacy prescriptions”—continuously refilled although no longer needed.⁹ Up to 16.5% of hospital admissions in one UK study were attributable to medication-related adverse events.¹⁰

In addition to the environmental costs, these unnecessary tests and treatments also come with other harms: adverse effects of medications, anxiety induced by false positive results leading to more investigations and treatments (exposing patients to additional risk), costs to patients and insurers, wasted time and resources for patients, health-care providers and administrative staff, and increased wait times for patients who need urgent care.

Studies have found that there are simple ways to reduce this unnecessary care through shared decision-making and better patient information. Well-informed patients will often choose less, rather than more, intervention. The next article in this series will focus on empowering patients.

What I do now

I have realized that if I really want to make a difference to my carbon footprint at work, reducing unnecessary care has a greater impact than recycling clinic waste or powering down my computer. For prescriptions, I use the mnemonic ECO-Rx.:

Evidence: use high-quality evidence to guide diagnosis and treatment.
Collaboration: involve patients in all treatment decisions.
Options: always consider non-pharmacologic or more sustainable pharmacologic options.
Review Rx: Regularly review existing prescriptions and deprescribe appropriately using tools from the Canadian Deprescribing Network.

I have started to pay more attention to ‘routine’ lab panels like “CBC, BUN, creatinine, lytes, LFTs, TSH…” and avoid these unless there is a specific indication for each test. I am following the new PEER Lipid Guidelines¹¹ to avoid statins for primary prevention in patients at low risk, screening for lipids every 5-10 years and not ordering follow-up testing once patients are taking statins. I have compiled a list of all of the Choosing Wisely recommendations that are relevant to family practice¹² and I try to follow these and use other resources like the BC Guidelines. I look at my Doctors of BC Mini Practice Profile now with more interest to see how I’m doing compared to my peers in terms of testing. I rely more on team members like pharmacists, radiologists and pathologists when I have questions and want to ensure I’m ordering the best test or treatment. When making referrals, I am more careful about sharing previous lab results or medication trials to avoid unnecessary duplication or confusion.

I am trying to embrace some of the principles of slow medicine described in an earlier TCMP article. The new Longitudinal Family Practice payment system now rewards us for working smarter and more thoughtfully, not just faster. Although it may seem like we don’t have time for slow medicine, I have found that it can actually save time in the long run by reducing visits for unnecessary medications, iatrogenic illnesses, test results and false positives.

Using an environmental lens to look at my practice has made me feel more optimistic and hopeful, knowing that there are many things I can do to make a difference every day at work. But it is also helping provide better, more appropriate care to my patients, reducing costs for them and the system, avoiding avoidable harms to patients and reducing burdens on health-care providers (including making my own task box 30% smaller).

Resources

• Choosing Wisely Guidelines
• BC Guidelines
• Planetary Health for Primary Care Toolkit
• Health Data Coalition Current Measures Availability List
• Therapeutics Initiatives Prescribing Portraits provides BC clinicians with timely evidence, personalized prescribing data and recommendations to support better prescribing and better health for patients

References

1. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5(2):e84-e92. doi:10.1016/S2542-5196(20)30271-0 (View)
2. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med. 2018;15(7):e1002623. doi:10.1371/journal.pmed.1002623 (View)
3. McAlister S, Grant T, Forbes M. An LCA of hospital pathology testing. Int J Life Cycle Assess. 2021;26(9):1753-1763. doi:10.1007/s11367-021-01959-1 (View with UBC)
4. Heye T, Knoerl R, Wehrle T, et al. The energy consumption of radiology: energy- and cost-saving opportunities for CT and MRI operation. Radiology. 2020;295(3):593-605. doi:10.1148/radiol.2020192084 (View)
5. Breth-Petersen M, Bell K, Pickles K, McGain F, McAlister S, Barratt A. Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare. BMJ Open. 2022;12(8). doi:10.1136/bmjopen-2021-056997 (View)
6. Barratt AL, Bell KJ, Charlesworth K, McGain F. High value health care is low carbon health care. Med J Aust. 2022;216(2):67-68. doi:10.5694/mja2.51331 (View)
7. Leslie M, Fadaak R, Lethebe BC, Szostakiwskyj JH. Assessing the appropriateness of community-based antibiotic prescribing in Alberta, Canada, 2017-2020, using ICD-9-CM codes: a cross-sectional study [published correction appears in CMAJ Open. 2023;11(4):E734. doi:10.9778/cmajo.20230050]. CMAJ Open. 2023;11(4):E579-E586. doi:10.9778/cmajo.20220114 (View)
8. Canadian Institute for Health Information. Overuse of tests and treatments in Canada. November 10, 2022. Accessed January 19, 2023. (View)
9. Mangin D, Lawson J, Cuppage J, et al. Legacy drug-prescribing patterns in primary care. Ann Fam Med. 2018;16(6):515-520. doi:10.1370/afm.2315 (View)
10. Osanlou R, Walker L, Hughes DA, Burnside G, Pirmohamed M. Adverse drug reactions, multimorbidity and polypharmacy: a prospective analysis of 1 month of medical admissions. BMJ Open. 2022;12(7):e055551. doi:10.1136/bmjopen-2021-055551 (View)
11. Kolber MR, Klarenbach S, Cauchon M, et al. PEER simplified lipid guideline 2023 update: prevention and management of cardiovascular disease in primary care. Can Fam Physician. 2023;69(10):675-686. doi:10.46747/cfp.6910675 (View)
12. Hale I. Sustainable Primary Care Toolkit. Accessed March 24, 2025. (View)

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Environmental impacts of clinical practice: Reducing unnecessary care

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