Transcript Choosing Wisely in Perinatal Health

Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients
engage in conversations about the overuse of tests and procedures and support
physician efforts to help patients make smart and effective care choices.
In West Virginia Choosing Wisely is an initiative of West Virginian’s for Affordable Health
Care.
In Kanawha County the initiative is funded by the Greater Kanawha Valley Foundation.
Choosing Wisely
• Promote efficient use of
healthcare resources
• Stimulate physician and
patient conversation about
appropriate and necessary
treatments
Why now?
• Health care expenditures are increasing at unsustainable rates
•
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011
• There is waste in the health care system—some say as much
as 30%

Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences.
• One third of all physicians acquiesce to patient requests for
tests and procedures—even when they know they are not
necessary

Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann
Intern Med. 2007; 147(11):795-802
• Physician decisions account for 80% of all health care
expenditures

Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund
[Internet]. 2009; Apr 27
PEJ - Physician Executive Journal of Medical Management
May-June 2014
The management of medical care has become too important to leave to doctors,
who, after all, are not managers to begin with.
FORTUNE Magazine, 1970
I’ll fix it if you don’t…
Deficit pressures are making cost control inevitable. It will only be
successful if physicians stop looking to others to find solutions and
focus on approaches that improve the care for patients with chronic
illnesses.
-Ezekiel J. Emanuel, MD, PhD
How the lists were created
• Societies were free to determine the process for creating their lists
• Each item was within the specialty’s purview and control
• Procedures should be used frequently and/or carry a significant cost
• Should be generally-accepted evidence to support each
recommendation
• Process should be thoroughly documented and publicly available upon
request
ACOG Choosing Wisely Recommendations
David Jude, MD, OB GYN
•
Don’t schedule elective, non-medically indicated inductions of labor or Cesarean
deliveries before 39 weeks 0 days gestational age.
•
Don’t schedule elective, non-medically indicated inductions of labor between 39
weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
•
Don’t perform routine annual cervical cytology screening (Pap tests) in women
30–65 years of age.
•
Don’t treat patients who have mild dysplasia of less than two years in duration.
•
Don’t screen for ovarian cancer in asymptomatic women at average risk.
Cervical Cancer Incidence Rates/100,000
Women by State, 2011†
†Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–
2011 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health
and Human Services, Centers for Disease Control and Prevention, and National Cancer
Institute; 2014. Available at: www.cdc.gov/uscs. (full site)
Cervical Cancer Death Rates/100,000
Women by State, 2011†
†Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics:
1999–2011 Incidence and Mortality Web-based Report. Atlanta (GA):
Department of Health and Human Services, Centers for Disease Control and
Prevention, and National Cancer Institute; 2014. Available at:
www.cdc.gov/uscs. (full site)
Cervical Cancer Screening
• Prevent morbidity and mortality from cervical
cancer
• Prevent overly aggressive management of
abnormal cervical cytology and CIN
– Most precursor lesions likely to regress or
disappear
– Risks of management outweigh the benefits of
aggressive evaluation or treatment
• Inadequate screening is the major risk factor
contributing to cervical cancer deaths in the
US
– Minorities
– Low socioeconomic status
– No usual source of health care
– Foreign born
• Living in the US for <10 years
Objective of Screening
• NOT on finding and treating all precancerous
lesions
• Is on identifying lesions that have higher
changes to progress to cancer
– Persistent infection with high risk HPV
– CIN 3
– CIN 2 in older women
– Persistent CIN 2 in younger women
Natural History of HPV Infection
CIN 1
6-24
months
10-13 year average
CIN 2/3
HPV
Infection
6-12
months
HPV Clearance
Invasive Cancer
Natural History of Cervical Neoplasia
• CIN 1
– 57% Spontaneous Regression
– 1% Progress to Invasive Disease
• CIN 3
– 32% Spontaneous Regression
– 12-36% Progress to Invasive Disease
• CIN (Any Grade)
– 1.7% Progress to Invasive Disease
Onset and Frequency of Screening
• Onset of screening
– Do not do before risk of invasive cancer unlikely
• Interval of screening
– Risk of developing invasive cancer before next
screening unlikely
– Early detection of CIN 3 is beneficial
What is the harm in over screening?
• Anxiety
• Stigma of positive
HPV test
• Discomfort from
procedures
• Pregnancy
complications from
overly aggressive
treatment
Rates of Invasive Cervical Cancer by
Age in the United States: 1998–2002
Data From the National Program of Cancer Registries and
the Surveillance, Epidemiology, and End Results Program
Rate per 100,000 Patients
18
16.5
15.4
16
N=59,848
14
13.9
14.6
12
10
8
6
4.5
4
2
0.1
0
0–19
20–29
30–39
40–49
50–64
65+
Age Group, Years
Saraiya M et al. Obstet Gynecol. 2007;109(2):360–370.
17
What are the potential risks of
treatment?
Odds Ratio
3
2.7
2.5
2
1.7
1.8
Preterm
Birth
PPROM
1.5
1
0.5
0
LBW
• May be association
with perinatal death
due to incompetent
cervix
• Risk rises with depth
and number of LEEP’s
• No difference in LEEP,
cone, laser, etc.
ACS/ASCCP/ASCP Guidelines
• When to begin screening
• How often do you screen
• How do you screen
– Is HPV testing useful
• When do you stop
• Special situations
Begin Screening at age 21
• Onset of sexual activity does not determine
when to begin screening
• Focus on:
– Contraception
– Chlamydia screening
– No need for speculum exam in asymptomatic
women
– Counseling
How often do you screen?
How do you screen?
• Ages 21-29
– Cytology only every 3 years
– HPV testing as screen not
beneficial in this age group
• Ages 30-65
– Cotesting with cytology and
testing for high risk HPV every
5 years (preferred)
–OR
– Cytology only every 3 years
(acceptable)
Why not to screen for HPV in women
ages 21-29
• Prevalence of high risk HPV ≈20% in teens and
early 20’s
• Most HPV infections resolve without
treatment
– Finding these infections
• Anxiety
• Stigma of STI
• Interventions without benefit
When do you stop screening?
• Stop at age 65 IF
– Adequate prior screening
• 3 consecutive negative
Paps
• 2 consecutive negative
HPV tests
• Tests within 10 years of
stopping, most recent
within past 5 years
– No CIN2+ within past 20
years
• Stop after
hysterectomy IF
– Removal of cervix
– No history of CIN2+
• If CIN 2/3 or AIS
continue screening
for at least 20 years
even if screening over
age 65
American Academy of Nursing
Choosing Wisely Recommendations
Georgia Narsavage, PhD, CPRN, FAAN
• Don’t automatically initiate continuous electronic
fetal heart rate (FHR) monitoring during labor for
women without risk factors; consider intermittent
auscultation (IA) first.
• Don’t place or maintain a urinary catheter in a
patient unless there is a specific indication to do so.
American Academy of Nursing
• Process: Academy fellows who represent 11 professional nursing
organizations were invited to participate in the selection process for
the first 5 items.
• The group produced 16 interventions commonly used that do not
contribute to improved outcomes or high value.
• Extensive literature and practice guidelines with evidence were
reviewed for support and consensus on importance.
• "Don't" beginning of each statement - requirement of ABIM
(American Board of Internal Medicine)
• Focuses specifically on nursing interventions or practices that are
NOT supported by evidence.
Don’t automatically initiate continuous electronic fetal heart rate
(FHR) monitoring during labor for women without risk factors;
Consider intermittent auscultation (IA) first.
Continuous electronic FHR monitoring during labor, a routine
procedure in many hospitals, is associated with
• An increase in cesarean and instrumental births without
improving Apgar score, NICU admission or intrapartum fetal
death rates.
• IA allows women more freedom of movement during labor,
enhancing their ability to cope with labor pain and utilize
gravity to promote labor progress.
• Upright positions and walking have been associated with
shorter duration of 1st stage labor, fewer cesareans, reduced
epidural use.
Don’t place or maintain a urinary catheter
in a patient unless there is a specific
indication to do so.
• Catheter-associated urinary tract infections (CAUTIs) are
common health care-associated infections in the US.
• Most CAUTIs are related to urinary catheters so the
infections can largely be prevented by reduced use of
indwelling urinary catheters and catheter removal as soon
as possible.
• CAUTIs can lead to more serious complications in
hospitalized patients & are responsible for an increase in
health care costs.
AAP Choosing Wisely Recommendations
Raheel Khan, MD, FAAP
• Antibiotics should not be used for apparent viral respiratory illnesses
(sinusitis, pharyngitis, bronchitis).
• Don’t prescribe high-dose dexamethasone (0.5mg/kg per day) for the
prevention or treatment of bronchopulmonary dysplasia in pre-term
infants.
• Avoid using acid blockers and motility agents such as metoclopramide
(generic) for physiologic gastroesophageal reflux (GER) that is effortless,
painless and not affecting growth. Do not use medication in the so-called
“happy-spitter.”
• Infant home apnea monitors should not be routinely used to prevent
sudden infant death syndrome (SIDS).
Choosing Wisely in Kanawha
County Pilot Project Campaign
• Invite societies and organizations to become Partner
Organizations and encourage their members to participate.
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WV Nurses Association
Kanawha Medical Society
WV State Medical Association
WV Primary Care Association
Cabin Creek Health System
WV Partners For Elder Living
FamilyCare Health Center
Thomas Hospital System
• Invite individual practitioners to sign on as Participating Providers.
(Physicians, APRNs, PAs, SW are eligible)
– To utilize Choosing Wisely materials with patients for 3 months
– To respond to on line survey regarding experience
– To receive 3 MEUs, CEUs for participating
• Ultimately, Choosing Wisely is focused on supporting
conversations between physicians and patients about
what care is necessary.
Starting Conversations
Go to
www.consumerhealthchoices.org/choosingwisely-west-virginia/