Transcript Choosing Wisely - American College of Physicians

Choosing Wisely
Richard Honsinger, MACP
Past Governor, ACP
Council of Subspecialty Societies
President, Joint Council of Allergy, Asthma and
Immunology
American Board of Internal Medicine
• National Physicians
Alliance
• ABIM Foundation
• Consumer Reports
• Robert Wood Johnson
Christine Cassel, MACP
President ACP, ABIM, NQF
Consumer Reports Foundation
As part of Choosing Wisely®, each participating specialty society has
identified its own list of five common tests or procedures whose use in their
profession should be discussed or questioned. The societies were given the
following parameters to develop the lists:
Each item should be within the specialty’s purview and control;
Procedures should be used frequently and/or carry a significant cost;
There needs to be evidence to support each recommendation.
Consumer Reports then is creating consumer education materials for each
item, intended for patients and their families.
• 30% of Health Care is Unnecessary!
• Five Billion Dollar Savings
– Arch IM 2012
Charter Commitments
Professional competence
Honesty with patients
Patient confidentiality
Maintaining appropriate relations with
patients
Improving quality of care
Improving access to care
Just distribution of finite resources
Scientific knowledge
Maintaining trust by managing conflicts of
interest
Professional responsibility
• Endorsed by 104 societies
Five Things Physicians and Patients Should Question
• Supported by Evidence
• Not Duplicative of Other Tests or
Procedures
• Free from Harm
• Truly Necessary
2012 – Nine Societies
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AAAAI (Allergy/Imm)
AAFP
ACP
ACC (Cardiology)
ACR (Radiology
AGA (Gastroenterology)
ASN (Nephrology
ASNC (Nuclear Cardiol)
ASCO (Clinical Oncology
• Patient Centered Performance Management
– JAMA 310:137 July 10, 2013
• Choosing Wisely – low value services
– Volpp JAMA 308:1635 (2012)
Medical Professionalism in the New Millennium
A Physician Charter Project of the ABIM Foundation, ACP–ASIM Foundation, and
European Federation of Internal Medicine*
Annals of Internal Medicine Volume 136 • Number 3 243-6, 5 February 2001
The Lancet, Volume 359, Issue 9305, Pages 520 - 522, 9 February 2002
Allergy Number One
• Don’t perform unproven diagnostic tests,
such as immunoglobulin G (IgG) testing or an
indiscriminate battery of immunoglobulin E
(IgE) tests, in the evaluation of allergy.
• Appropriate diagnosis and treatment of allergies requires specific
IgE testing (either skin or blood tests) based on the patient’s clinical
history. The use of other tests or methods to diagnose allergies is
unproven and can lead to inappropriate diagnosis and treatment.
Appropriate diagnosis and treatment is both cost eective and
essential for optimal patient care.
Allergy Number Two
• Don’t order sinus computed tomography (CT) or
indiscriminately prescribe antibiotics for
uncomplicated acute rhinosinusitis.
• Viral infections cause the majority of acute rhinosinusitis and
only 0.5 percent to 2 percent progress to bacterial infections.
Most acute rhinosinusitis resolves without treatment in two
weeks. Uncomplicated acute rhinosinusitis is generally
diagnosed clinically and does not require a sinus CT scan or
other imaging. Antibiotics are not recommended for patients
with uncomplicated acute rhinosinusitis who have mild illness
and assurance of follow-up. If a decision is made to treat,
amoxicillin should be first-line antibiotic treatment for most
acute rhinosinusitis.
Allergy Number Three
• Don’t routinely do diagnostic testing in patients
with chronic urticaria.
• In the overwhelming majority of patients with chronic
urticaria, a definite etiology is not identified. Limited
laboratory testing may be warranted to exclude underlying
causes. Targeted laboratory testing based on clinical
suspicion is appropriate. Routine extensive testing is
neither cost eective nor associated with improved clinical
outcomes. Skin or serum-specific IgE testing for inhalants or
foods is not indicated, unless there is a clear history
implicating an allergen as a provoking or perpetuating
factor for urticaria.
Allergy Number Four
• Don’t recommend replacement immunoglobulin
therapy for recurrent infections unless impaired
antibody responses to vaccines are
demonstrated.
• Immunoglobulin (gammaglobulin) replacement is expensive and does not
improve outcomes unless there is impairment of antigen-specific IgG
antibody responses to vaccine immunizations or natural infections. Low
levels of immunoglobulins (isotypes or subclasses), without impaired
antigen-specific IgG antibody responses, do not indicate a need for
immunoglobulin replacement therapy. Exceptions include IgG levels
<150mg/ dl and genetically defined/suspected disorders. Measurement of
IgG subclasses is not routinely useful in determining the need for
immunoglobulin therapy. Selective IgA deficiency is not an indication for
administration of immunoglobulin.
Allergy Number Five
• Don’t diagnose or manage asthma without
spirometry.
• Clinicians often rely solely upon symptoms when diagnosing and
managing asthma, but these symptoms may be misleading and be
from alternate causes. Therefore spirometry is essential to confirm
the diagnosis in those patients who can perform this procedure.
Recent guidelines highlight spirometry’s value in stratifying disease
severity and monitoring control. History and physical exam alone
may over- or under-estimate asthma control. Beyond the increased
costs of care, repercussions of misdiagnosing asthma include
delaying a correct diagnosis and treatment.
How This List Was Created
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The American Academy of Allergy, Asthma & Immunology (AAAAI) Executive
Committee created a task force to lead work on Choosing Wisely consisting of
board members, the AAAAI President and Secretary/Treasurer and AAAAI
participants in the Joint Task Force on Practice Parameters. Through multiple
society publications and notifications, AAAAI members were invited to offer
feedback and recommend elements to be included in the list. A targeted email
was also sent to an extended group of AAAAI leadership inviting them to
participate.
The work group reviewed the submissions to ensure the best science in the
specialty was included. Based on this additional members were recruited for
their expertise. Suggested elements were considered for appropriateness,
relevance to the core of the specialty, potential overuse of resources and
opportunities to improve patient care. They were further refined to maximize
impact and eliminate overlap, and then ranked in order of potential importance
both for the specialty and for the public. Finally, the work group chose its top five
recommendations which were then approved by the Executive Committee.
References at www.choosingwisely.org
Videos on consumerreports.org
Sinusitis
AAFP
chose from the National Physicians Alliance 2002 Publication “Less is
More” and Field Tested. Board approved.
• 1 Don’t do imaging for low back pain within the first six
weeks, unless red flags are present.
• 2 Antibiotics for sinusitis
• 3 Don’t DEXA screen for osteoporosis in women younger
than 65 or men younger than 70 with no risk factors.
• 4 Don’t order annual electrocardiograms (EKGs) or any
other cardiac screening for low-risk patients without
symptoms.
• 5 Don’t perform Pap smears on women younger than 21
or who have had a hysterectomy for non-cancer disease.
Am College of Cardiology
Each Clinical Council submitted items, a steering committee narrowed
down to 5 for Exec Committee approval
• 1 Don’t perform stress cardiac imaging or advanced non-invasive imaging
in the initial evaluation of patients without cardiac symptoms unless
high-risk markers are present.
• 2 in asymptomatic patients.
• 3 as a pre-operative assessment in patients scheduled to undergo low-risk
non-cardiac surgery
• 4 Don’t perform echocardiography as routine follow-up for mild,
asymptomatic native valve disease in adult patients with no change in
signs or symptoms.
• Don’t perform stenting of non-culprit lesions during percutaneous
coronary intervention (PCI) for uncomplicated hemodynamically stable STsegment elevation myocardial infarction.
ACP
11 man workgroup put together multiple scenarios. Sent to 1% of ACP
members to pick 5 best
• 1 Stress ECG
• 2 Low Back Pain Imaging
• 3 In the evaluation of simple syncope and a normal
neurological examination, don’t obtain brain imaging
studies (CT or MRI).
• 4 In patients with low pretest probability of venous
thromboembolism (VTE), obtain a high-sensitive D-dimer
measurement as the initial diagnostic test; don’t obtain
imaging studies as the initial diagnostic test.
• 5 Don’t obtain preoperative chest radiography in the
absence of a clinical suspicion for intrathoracic pathology.
Am College of Radiology
7 commission chairs passed on to Board of Chancellors
• 1 Don’t do imaging for uncomplicated headache.
• 2 Don’t image for suspected pulmonary embolism (PE)
without moderate or high pre-test probability of PE.
• 3 Avoid Routine Admission or Pre-op Chest Xrays
• 4 Don’t do computed tomography (CT) for the evaluation of
suspected appendicitis in children until after ultrasound has
been considered as an option.
• 5 Don’t recommend follow-up imaging for clinically
inconsequential adnexal cysts.
AGA
• 1 For pharmacological treatment of patients with gastroesophageal reflux
disease (GERD), long-term acid suppression therapy (proton pump
inhibitors or histamine2 receptor antagonists) should be titrated to the
lowest effective dose needed to achieve therapeutic goals.
2 Do not repeat colorectal cancer screening (by any method) for 10 years
after a high-quality colonoscopy is negative in average-risk individuals.
3 Do not repeat colonoscopy for at least five years for patients who have
one or two small (< 1 cm) adenomatous polyps, without high-grade
dysplasia, completely removed via a high-quality colonoscopy.
• 4 For a patient who is diagnosed with Barrett’s esophagus, who has
undergone a second endoscopy that confirms the absence of dysplasia on
biopsy, a follow-up surveillance examination should not be performed in
less than three years as per published guidelines.
• 5 For a patient with functional abdominal pain syndrome (as per ROME III
criteria) computed tomography (CT) scans should not be repeated unless
there is a major change in clinical findings or symptoms.
Am Society of Nephrology
• Don’t perform routine cancer screening for dialysis patients
with limited life expectancies without signs or symptoms.
• Don’t administer erythropoiesis-stimulating agents (ESAs) to
chronic kidney disease (CKD) patients with hemoglobin levels
greater than or equal to 10 g/dL without symptoms of
anemia.
• Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in
individuals with hypertension or heart failure or CKD of all
causes, including diabetes.
• Don’t place peripherally inserted central catheters (PICC) in
stage III–V CKD patients without consulting nephrology.
• Don’t initiate chronic dialysis without ensuring a shared
decision-making process between patients, their families, and
their physicians.
Am Soc Nuclear Cardiology
• 1 Don’t perform stress cardiac imaging or coronary
angiography in patients without cardiac symptoms unless
high-risk markers are present.
• 2 Don’t perform cardiac imaging for patients who are at low
risk.
• 3 Don’t perform radionuclide imaging as part of routine
follow-up in asymptomatic patients.
• 4 Don’t perform cardiac imaging as a pre-operative
assessment in patients scheduled to undergo low- or
intermediate-risk non-cardiac surgery.
• 5 Use methods to reduce radiation exposure in cardiac
imaging, whenever possible, including not performing such
tests when limited benefits are likely.
Am Soc Clinical Oncology
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Don’t use cancer-directed therapy for solid tumor patients with the
following characteristics: low performance status (3 or 4), no benefit
from prior evidence-based interventions, not eligible for a clinical trial,
and no strong evidence supporting the clinical value of further anticancer treatment.
Don’t perform PET, CT, and radionuclide bone scans in the staging of
early prostate cancer at low risk for metastasis.
Don’t perform PET, CT, and radionuclide bone scans in the staging of
early breast cancer at low risk for metastasis.
Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and
radionuclide bone scans) for asymptomatic individuals who have been
treated for breast cancer with curative intent.
Don’t use white cell stimulating factors for primary prevention of febrile
neutropenia for patients with less than 20 percent risk for this
complication.
Delphi Method
• The method entails a group of experts who
anonymously reply to questionnaires and
subsequently receive feedback in the form of a
statistical representation of the "group
response," after which the process repeats itself.
The goal is to reduce the range of responses and
arrive at something closer to expert consensus.
• Questionnaires to team of experts. Review and
discuss the results and then question again until
consensus.
Am College of Rheumatology
Delphi Method and then submitted to 90% of members
1.
Don’t test ANA sub-serologies without a positive ANA and clinical
suspicion of immune-mediated disease.
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Don’t test for Lyme disease as a cause of musculoskeletal
symptoms without an exposure history and appropriate exam
findings.
Don’t perform MRI of the peripheral joints to routinely monitor
inflammatory arthritis.
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Don’t prescribe biologics for rheumatoid arthritis before a trial of
methotrexate (or other conventional non-biologic DMARDs).
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Don’t routinely repeat DXA scans more often than once every two
years.
Society of General Internal Medicine
1. Don’t recommend daily home finger glucose testing in
patients with Type 2 diabetes mellitus not using
insulin.
2. Don’t perform routine general health checks for
asymptomatic adults.
3. Don’t perform routine pre-operative testing before
low-risk surgical procedures.
4. Don’t recommend cancer screening in adults with life
expectancy of less than 10 years.
5. Don't place, or leave in place, peripherally inserted
central catheters for patient or provider convenience
Society of Hospital Medicine
• PPI
• Foley Cath
• BOTH CAUSE MORE INFECTIONS
Organizations publishing 5 Choosing
Wisely Recommendations
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Allergy
Clinical Toxicology
Derm
FP
Hospice
Neurology
Ophthalmology
Orthopedic Surgery
ENT
Pediatrics
Blood Banks
Endocrine
Neuro Surgery
Pediatric
Ophthalmology
Cardiology
Chest Physicians
Emergency Physicians
Medical Toxicology
Ob-Gyn
Occupational Med
ACP
Radiology
Rheumatology
Surgery
Gastroenterology
Headache
Long Term Care
Psychiatry
Anesthesia
Clinical Oncology
Clinical Pathology
More than 80 societies
Colon Rectal Surgery
Echocardiography
Hematology
Nephrology
Nuclear Cardiology
Radiation Oncology
Am Thoracic Soc
Urology
Heart Rhythm Soc
Spine Soc
Critical Care
Gyn Oncology
Hosp Medicine
Maternal-Fetal Med
Thoracic Surgery
Vascular Medicine
From: “Top 5” Lists Top $5 Billion
Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed.2011.501
Date of download: 8/18/2013
Copyright © 2012 American Medical
Association. All rights reserved.
Potential Savings-$5 Billion
• Cost of unnecessary services was a function of
both the frequency and the reimbursement rates
for each service.
• The practice activity associated with the highest
cost was the prescribing of brand instead of
generic statins, resulting in excess expenditures
of $5.8 billion per year (95% CI, $4.3-$7.3 billion).
• Bone density testing in women younger than 65
years was the least prevalent activity but
accounted for $527 million (95% CI, $474-$1054
million) in costs.
WHAT NEXT?
The Patient-Centered Medical Home
Neighbor: The Interface of the PatientCentered
Medical Home with Specialty/Subspecialty
Practices
Referral Guidelines
• High Value Care Coordination
– ACP workgroup
– Designing Referral Templates
• NCQA
– Patient Centered Medical Home
– Specialty Recognition
Referral Template
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Specialty Out-Patient Referral Request Checklist
(This information, which is recommended to be included with all referrals, can be communicated through any of
several means including a paper-based referral form, detailed clinical note from last appointment or a template
within the Electronic Medical Record)
1. Patient demographics and scheduling information
a. Patient name, demographics, and contact information (including surrogate if appropriate)
b. Special considerations such as vision loss, hearing loss, language preference, cognitive
deficits, cultural factors, preference regarding who to include in treatment planning
c. Insurance company name/type of coverage
d. Referring provider name and contact information (including method for direct contact for
urgent issues)
e. Indicate that patient (or surrogate) understands and agrees with the purpose of the
referral, the type of referral (e.g. consultation or co-management) and the expected
process and division of responsibilities (e.g. patient to contact specialty practice or
specialty practice to call the patient; need for additional testing prior to visit)
f. If a face-to-face appointment is requested, indicate whether: (Choose one)
_______ the patient will call to schedule an appointment
_______ the specialty practice should contact the patient
2. Referral information
a. What is the specific clinical question?
b. Urgency: (Choose one)
_______Urgent: (local definition; often 1-2 days) Recommend direct communication
between referring and referral practice; Minimally provide written justification for
urgency
_______Subacute (local definition; often 1-2 weeks)
_______Routine
c. Pending subspecialist/specialist evaluation, the anticipated referral-type is: (Choose one)
______ Previsit Advice *
______ Non Face-to-Face (information-only) consultation **
______ Consultation (Evaluate and Advise, with the goal to managing the problem
remaining with the referring clinician)
______ Procedural Consultation
______ Co-Management with Shared Care (Referring clinician (e.g. PCP)
maintains first call for the referral disorder) ***
______ Co-Management with Principal Care (Referred to subspecialist/specialist
assumes first call for the referral disorder) ****
______ Please assume Full Responsibility for Complete Transfer of all Patient Care
d. A brief summary of case details pertinent to the referral, include related co-morbidities
e. Pertinent data set: Clinical information directly relevant to the specific referral question.
May include:
Office notes
Care summaries
Lab and imaging results
Specialty Templates
Nephrology
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NEPHROLOGY REFERRAL FORM
(If not noted elsewhere) Patient’s age_____ sex ______ race _____
Why did you refer the patient to us?
____ concern about the severity of kidney disease
____ concern about the rapidity of progression of kidney disease
____ concern about the severity and rapidity of kidney disease
____ other reason:___________________________________________
What is the most recent serum creatinine? _____ What was it a year ago? _____
Does the patient have proteinuria/albuminuria?____ If so, how much?_____
Does the patient have diabetes? _________
Does the patient have hematuria? _________
What is the recent average office blood pressure? ________________
(If not noted elsewhere) Current medication list:__________________________
If available, it would be helpful to include recent and past:
Blood chemistry results, including BUN and creatinine levels
Kidney imaging study results
Urinalysis and urine chemistry (i.e. urine protein, creatinine) results
Serological or autoimmunity tests (HIV, Hepatitis B and C, ANA, complements, etc.)
Office blood pressure measurements
SOME WEB RESOURCES FOR PHYSICIANS AND PATIENTS
http://nkdep.nih.gov/index.shtml
http://kdigo.org/home/guidelines/
http://www.kidney.org/index.cfm
https://www.aakp.org/education/resourcelibrary/ckd-resources.html
Endocrinology
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yperthyroidism—Pertinent Data Set
2d. A brief summary of case details pertinent to the referral, include related co-morbidities.
Please indicate in the summary if the patient has any of the following signs, symptoms or
conditions as that may impact the urgency of the referral:
Persistent tachycardia
Significant change in Weight
New onset Atrial Fibrillation
Cardiovascular Disease
New onset or Exacerbation of Congestive Heart Failure
Myopathy (difficulty getting up from sitting position or ambulating)
Ophthalmopathy with vision changes
Thyroid pain
Amiodarone therapy
IV contrast (? Time frame)
Tests to Prepare for Consult
TSH
Free T4
Not necessary for referral but Include if Already Performed
CBC
Liver Function Test
Any additional thyroid function tests
Chemistry Panel
Thyroid Antibodies
Thyroid Imaging (Ultrasound, Thyroid Nuclear Medicine Scan)
Avoid if possible
Radiocontrast Studies (due to iodine load which can exacerbate some forms of
hyperthyroidism and interfere with imaging and therapy; if study needed/needs to be
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Suspected neurological symptom: Spells
Core Data Elements:
A brief summary of the case details pertinent to the referral, including family
history. Please indicate in the summary if the patient has any of the following:
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Prolonged altered consciousness
Abnormal movements with episodes
Inability to stand at all due to orthostasis
Chest pain or palpitations
Any reported focal signs during the episode
Prior to the consult:
– Check orthostatic vital signs if fainted with standing
– Consider cardiac causes: Check EKG and review history. If cardiac mechanism suggested,
consider Holter Monitor or refer to cardiology.
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Not necessary for referral but include if already performed:
– Imaging and EEG (often of little value).
– Do not check Ultrasound of carotids for syncope (choosing wisely campaign point).
What Next?
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Providers
Patients
Hospitals and Clinics
Payers