Transcript behind the wall of silence - State Health Policy Conference

From Overtreatment to
Patient-Centered Care
National Academy for State Health Policy
New Orleans, LA
October 5, 2010
Rosemary Gibson, M.Sc.
Author, The Treatment Trap
and Wall of Silence
Overview of Presentation

Define overtreatment: what it is, the impact
on patients, and how to begin to address it

Discuss how reducing overtreatment can
improve patient outcomes and reduce
health care costs.

Identify action steps for states to begin to
address overtreatment
Three Overarching
Quality Challenges
 Underuse
 Misuse
 Overuse
Source: Institute of Medicine, National Roundtable on Quality, 1998
Underuse Defined

Underuse: the failure to provide a health care
service when it would have produced a favorable
outcome for a patient.

Example: missing a childhood immunization for
measles or polio is an example of underuse.

Health care reform will reduce underuse of essential
services
Source: Institute of Medicine, National Roundtable on Quality, 1998
Misuse Defined

Misuse: when an appropriate service has
been provided but a preventable
complication has occurred.

Example: a patient who suffers a rash after
receiving penicillin for strep throat despite
having a known allergy to that antibiotic is
an example of misuse.
Source: Institute of Medicine, National Roundtable on Quality, 1998
The Impact of Misuse

In 1999, the Institute of Medicine
report, To Err is Human, estimated
44,000 – 98,000 deaths from
preventable harm each year

The CDC estimates 99,000 deaths
from hospital-acquired infections
each year
Overuse Defined
 Overuse:
when the potential
for harm of a health care
service exceeds the possible
benefit.
Source: Institute of Medicine, National Roundtable on Quality, 1998

“I was troubled to read that the President's physical
examination included an electron beam computed
tomographic (CT) scan for coronary calcium. This
screening test likely exposed Mr. Obama to
significant radiation unnecessarily, increasing his
risk of future cancer…

…A single electron beam CT scan is estimated to
result in a lifetime excess cancer risk of 9 additional
cancers per 100 000 persons for men.
Dr. Rita Redberg, Editor
Archives of Internal Medicine
March 8, 2010
http://archinte.ama-assn.org/
cgi/content/full/2010.81?home
Commonwealth Fund Survey
 32%
of people surveyed for a
Commonwealth Fund report
said they have had medical
care they thought was
unnecessary
Source: Sabrina How, et al, “Public View on U.S. Health System
Organization: A Call for New Directions,” The Commonwealth
Fund, Data Brief, August 2008 p. 4.
Two Questions For You

Have you or someone you know had
medical care that you/they thought
was unnecessary?

Have you or someone you know
declined treatment recommendations because they were too
invasive, and found a medically
appropriate, less intensive
alternative?
“I’ve been getting an EKG at my
annual physical exam since I was 27.
I’m 41 now. I don’t know why. I have
no heart disease. My husband gets
one, too.”
“My knees were hurting and I went to
a well-known orthopedic surgeon.
He said he could do surgery. He
didn’t talk about me or my situation.
I left and found a personal trainer
who helped me strengthen my
muscles. I’m much better now.”
“My 83-year old mother-in-law was
having problems with her shoulder.
She went to a doctor who said he
could operate. I went with her to get
a second opinion. With physical
therapy and time for healing, she was
fine.”
Share your story:
A partnership with Consumers Union
Safe Patient Project
www.treatmenttrap.org
 For
the first time, a subset of
the population is saying
“no” to medical care, not
cavalierly but in an informed
and thoughtful way.
 Where
to begin to curb
overuse?
National Priorities Partnership:
A Roadmap to Begin
 Overuse
is one of the six
priorities of the National
Priorities Partnership which
was convened by the
National Quality Forum

Source: National Priorities and Goals, National Priorities
Partnership, November 2008.
www.nationalprioritiespartnership.org.
National Priorities Partnership:
Areas to Reduce Overuse
 Medication
use especially
antibiotics and multiple drugs
prescribed for a patient
 Lab tests
 C-sections
 Diagnostic imaging, CT scans,
x-rays
National Priorities Partnership:
Areas to Reduce Overuse
 Non-palliative
services at the
end of life
 Unnecessary doctor office visits
 Preventable ED
visits/hospitalizations
 Potentially harmful preventive
services
National Priorities Partnership:
Procedures That Are Overused
 Procedures
that are overused
include:
* heart bypass surgery
* hysterectomy
* spine surgery
* prostatectomy
National Priorities Partnership:
Procedures That Are Overused
 What
are examples of the
literature on which the
identification of overused tests,
surgeries and other services is
based?
Research on Heart Bypass Surgery

An expert panel of physicians convened by
Rand and the Harvard School of Public
Health reviewed the angiograms of patients
who were recommended for heart bypass
surgery.

One-third of the patients who were
recommended for heart bypass surgery did
not need it.
Source: Leape, Lucian, et al., “Effect of Variability in the Interpretation of Coronary Angiograms on the
Appropriateness of use of coronary Revascularization Procedures, American Heart Journal, vol 139, no
1, part 1, January 2000, 111.
Overuse of Ear Tube
Surgery in Children

Nearly 70% of ear tube surgeries
studied at a five hospital cohort were
found to have been performed on
children whose condition did not
meet criteria for surgery set by the
American Academy of Pediatrics.
Source: Salomeh Keyhani, et al., “Overuse of Tympanostomy Tubes in New York Metropolitan Area:
Evidence from Five Hospital Cohort,” British Medical Journal, vol 337, 2008 1607. See also Salomeh,
Keyhani, et al, “Clinical Characteristics of New York City children Who Received Tympanostomy Tubes,
in 2002,” Pediatrics, vol 121, no 1, 24-33.
Outcomes from Back Surgery Among
Workers’ Compensation Patients

725 patients with low back
pain had pain mgmt and
physical therapy

725 patients with low back
pain who had spine
surgery

Return-to-work status at 2
years: 67%

Return to work status at 2
years: 26%

Days off of work: 316

Days off of work: 1140

27% re-operation rate
Source: Nguyen, T. et al, “Long-Term Outcomes of
Lumbar Fusion Among Workers’ Compensation
Subjects, Spine, August 2010.
New Study Findings on
End-of-Life Care

New England Journal of Medicine
published a landmark study of
patients with metastatic lung cancer

Patients who received early palliative
care and less aggressive treatment
lived 2.7 months longer than patients
who received usual oncology care.
Source: Temel JS et al., “Early palliative care for patients with
metastatic non-small-cell lung cancer, NEJM, 2010: 363:733-742.
http://www.nejm.org/doi/full/10/1056/NEJMoa1000678.
Recent Events in Raising
Awareness About Overuse

The Archives of Internal Medicine
published by the AMA has started a
series, “Less is More” that reports
evidence of overtreatment.

They will start a series on patient
experience of overtreatment.

The American Board of Internal
Medicine Foundation has a Task
Force on Stewardship of Resources
Recent Events cont’d
 The
Radiological Society of N.
America has called for a
national plan to reduce
diagnostic imaging.
Source:
http://radiology.rsna.org/content/early/2010/08/05/radiol.10
100063.abstract
National Cancer Institute
Study of CT scans
 70
million CT scans performed
in 2007 will cause 29,000
cancers in Americans and
15,000 deaths.
 Two
thirds of the projected
cancers will occur in women.
Source: Archives of Internal Medicine, 2009
Recent Events cont’d
 Hospital
Compare is now
reporting 4 measures of
appropriate use of diagnostic
imaging
2
measures address overuse of
abdominal and chest CT scans
Recent Events

“Top 5” Project underway by the
National Physician Alliance

It asks the question of primary care
physicians: what are the top 5 things
we should stop doing in primary
care?

Plan is to spread to other medical
specialties
Factors Contributing
to Overtreatment
Uncertainty
 Belief
 Enthusiasm
 Fear/Liability
 Peers
 Knowledge
 Financial incentive
 Patient expectation

What A Health Care Insider
Says About Overuse
 “Health
insurance used to be
about giving patients access to
providers. Now it’s about giving
providers access to patients.”
Dean of a Midwest nursing school.
One way to communicate to
patients and the public about
overuse:
What is Overuse?
Green Light
 Treatment
to get
you absolutely want
Yellow Light

Mammograms for women in their 40s

Should I or shouldn’t I?

Reasonable people will weigh the
risks and benefits differently based
on medical history, tolerance for risk,
etc.
Red Light
 Treatment
you don’t want to get
because the possibility of harm
exceeds the potential benefit.
Strategies for Change

A problem cannot be fixed unless we talk
about it: ask yourself, friends and
colleagues these two questions:

Have you had medical care you thought
was unnecessary?

Have you declined recommendations and
found a less intensive, medically
appropriate alternative?
Public Reporting of
Outpatient Imaging

Can states begin to report CMS measures that are
publicly reported for Medicare beneficiaries on
outpatient diagnostic imaging?

An example of one measure is: outpatient CT scans of
the abdomen -- use of contrast material

The ratio of CT abdomen studies that are performed
both with/without contrast out of all CT abdomen
studies performed (those with contrast, those without
contrast, and those with both).
Establish a Registry for
Selected Surgeries

Can states begin a voluntary registry that
tracks the outcomes of selected
procedures?

Benefits: offers the opportunity for
learning what works in an environment
transparent to other clinicians

Areas to focus: back, knee and hip surgery
Contact:
[email protected]
www.treatmenttrap.org