Transcript Choosing Wisely

Choosing Wisely
Culture, Strategy and Transformation
John Santa MD MPH
Medical Director,
Consumer Reports Health
May 8, 2014
Disclosures
• General internist, most recent practice at the VA
in 2008.
• Employed by Consumers Reports:
– Independent of industry, non profit, non partisan,
consumer advocacy organization.
– Multimedia company, publisher of Consumer Reports,
ConsumerReports.org
• 20 million readers a month, older, affluent, well
educated, “savvy buyers”
• Focused for 78 years on providing an alternative
perspective to advertising and promotion
• All Choosing Wisely content available free at
www.ConsumerHealthChoices.org
• A successful communication campaign
– Focused on professionalism
• Stimulating culture change
– More is not better
• Create conversations about overuse
– Communicating what not to do
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.
ACP Foundation/ABIM Foundation/EFIM
Physician Charter
A Commitment to
• Professional competence
• Honesty with patients
• Patient confidentiality
• Maintaining appropriate relations with
patients
• Improving quality of care
• Improving access to care
• A just distribution of finite resources
• Scientific knowledge
Fundamental Principles • Maintaining trust by managing
conflicts of interest
•Primacy of patient welfare
• Professional responsibilities
•Patient autonomy
•Social justice
Medicine's Ethical Responsibility for Health Care
Reform — The Top Five List
“A Top 5 list also has the advantage that if we
restrict ourselves to the most egregious
causes of waste, we can demonstrate to a
skeptical public that we are genuinely protecting
patients’ interests and not simply ‘rationing’
health care, regardless of the benefit, for costcutting purposes.”
Howard Brody, MD, PhD
New England Journal of Medicine
The “Top 5 Lists”
• Funded by an ABIM Foundation grant, the
National Physicians Alliance conceived and
piloted the concept through its Good
Stewardship Working Group
• Developed lists of top five activities in family
medicine, internal medicine, and pediatrics
where the quality of care could be improved
• Published in Archives of Internal Medicine
• Subsequent research published
in Archives found a cost savings of more than
$5 billion could be realized if the
recommendations were put in to practice.
Components of the Campaign
• Messengers and Collaborators
 60+ specialty societies and Consumer Reports—and
growing
• Communicate Messages
 Specialty societies, Consumer Reports, consumer
organizations and ABIM Foundation
• Activate
 Concrete action around unnecessary tests and
procedures
How the Lists Were Created
• Societies were free to determine the process for
creating their lists with the following requirements:
• 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
Choosing Wisely Partners
Societies That Announced Lists April 2012
• American Academy of Allergy Asthma &
Immunology
• American Academy of Family Physicians
• American College of Cardiology
• American College of Physicians
Societies That Announced Lists February 2013
• American Academy of Family Physicians
• American Academy of Hospice and
Palliative Medicine
• American Academy of Neurology
• American Academy of Ophthalmology
• American Academy of OtolaryngologyHead and Neck Surgery
• American Academy of Pediatrics
• American College of Obstetricians and
Gynecologists
• American College of Rheumatology
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American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
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American Geriatrics Society
American Society for Clinical Pathology
American Society of Echocardiography
American Urological Association
Society of Cardiovascular Computed
Tomography
Society of Hospital Medicine
Society of Nuclear Medicine and
Molecular Imaging
Society of Thoracic Surgeons
Society of Vascular Medicine
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Societies Announcing Lists Later in 2013
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American Academy of Dermatology
American Academy of Family Physicians
American Academy of Orthopaedic Surgeons
American Association of Clinical Endocrinologists
American Association for Pediatric Ophthalmology
and Strabismus
American College of Chest Physicians
American College of Emergency Physicians
American College of Rheumatology
American College of Surgeons
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American Headache Society
AMDA—Dedicated to Long Term Care Medicine
American Society of Clinical Oncology
American Society of Hematology
American Society for Radiation Oncology
American Thoracic Society
Heart Rhythm Society
North American Spine Society
Society of Critical Care Medicine
Society of General Internal Medicine
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National Hospice and Palliative Care
Organization
National Partnership for Women &
Families
Pacific Business Group on Health
SEIU
Union Plus
Univision (with HolaDoctor)
The Wikipedia Community
Consumer Groups
Through Partnership with Consumer Reports
• AARP
• Alliance Health Networks
• Leapfrog Group
• Midwest Business Group on Health
• Minnesota Health Action Group
• National Business Coalition on Health
• National Business Group on Health
• National Center for Farmworker Health
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Measures of Success
• Featured in Medscape's “The Year in Medicine 2012: News That
Made a Difference”
• 14 Medscape articles reaching 87,171 physicians
• More than 420,400 physicians reached through specialty society
communications. Hundreds of thousands more with second release.
• 55 journal articles reaching nearly 4 million. More on the way.
• 300 million media impressions from first release – including New
York Times, Washington Post, Vogue, ABC, NBC, CBS, PBS. Many
millions more from second release.
• 40+ patient-friendly translations of materials
• More than 100+ million reached through Consumer Reports
partnerships with consumer/employer groups
What’s Next?
• Additional specialties have joined the
campaign and will release lists in late 2013
and into 2014
• Advancement of campaign in local
communities through a grant from the
Robert Wood Johnson Foundation
• Rollout of Consumer Reports patientfocused materials
ACP Behavior change
in the physician community
• Establish principles for driving behavior
• Identify the specific targets for behavior
change
• Spread the word through multiple channels
• Change the culture of the training
environment
• Collaborate with others on the common
goal(s)
Robust Topic Themes
135 Choosing Wisely Topics
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Screening tests (20)
– EKG
– Exercise test
– Pap smear
– Bone density
– Heart imaging
– Colon cancer
Diagnostic testing (31)
– Low back pain
– Headache
– Allergy
– Fainting
• Preoperative evaluations (11)
– Chest Xray
– Heart imaging
• Common treatments (28)
– Antibiotics (8)
– Opioids (4)
– Heartburn meds
– Anti-inflammatories
• Routine FU/Monitoring (12)
• “Disease” approach
– Cancer (21)
– Chronic kidney failure/dialysis (4)
– Heart disease (21)
– Maternity (4)
Cross Cutting Categories
• Imaging---55 topics
– CT scans (19)
– MRI/Ultrasound—no radiation (14)
• Drugs---23 topics
– Antibiotics (8)
– Antipsychotics/benzos/sedatives
– Opioids (4)
– Several (5) actively advertised
• Women---28 topics
– Specific to women (14)
– More common in women (4)
– Important children topics (10)
Screening Topics
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EKG—heart disease
Nuclear Stress test—heart disease
Stress Echo---heart disease
Pap Smear (4 topics)---cervical cancer
Bone Density---osteoporosis
Colonoscopy---colon Cancer
Stress, Advanced Imaging---heart disease
Bone Density testing intervals---osteoporosis
Carotid Ultrasound---stroke
CA125 and vaginal ultrasound---ovarian cancer
Vit D levels---osteoporosis
HPV testing---HPV in low risk women
Methylated Septin---colorectal cancer
PET/CT---cancer screening
Coronary artery calcium scoring---heart disease
Coronary computed tomographic angiography---heart disease
Drugs
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Oral antibiotics—mild moderate sinusitis
Immunoglobulin therapy---recurrent infections
PPIs---GERD
NSAIDS---HBP,CKD,CHF
Oral antibiotics---external ear infection
Oral antibiotics---viral infections
Tight glycemic control---elderly
Oral antibiotics---bactreria in urine, no symptoms
Benzos/sedativehypnotics---older adults
Antipsychotics---older adults with agitation
Opioids/Butalbital---migraine
Interferon/Glatirimir---disabled MS patients
Antibiotics---adenoviral conjunctivitis
Antibiotics---before intravitreal infections
Biologics---RA w/o metotrexate first
Testosterone---Erectile dysfunction pts with normal testosterone
Antibiotics---men with + PSA
Anti nausea gels---hospice patients
Opioids
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American College of Occupational and Environmental Medicine
Don’t prescribe opioids for treatment of chronic or acute pain for workers who perform
safety-sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy
equipment.
The use of both strong and weak opioids has been consistently associated with increased risk of
motor vehicle crashes as opioids produce sedation and hinder or impair higher cognitive function.
Evidence suggests higher risk with acute opioid use, but risk remains elevated throughout
treatment with any opioid and reverses on cessation.
American Society of Anesthesiologists – Pain Medicine
Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain.
Physicians should consider multimodal therapy, including non-drug treatments such as behavioral
and physical therapies prior to pharmacological intervention. If drug therapy appears indicated,
non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing
opioids.
Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain
until the risks are considered and discussed with the patient
Patients should be informed of the risks of such treatment, including the potential for addiction.
Physicians and patients should review and sign a written agreement that identifies the
responsibilities of each party (eg urine drug testing) and the consequences of non-complianse
with the agreement.
American Academy of Neurology
Don’t use opioid or butalbital treatment for migraine except as a last resort.
Opioid and butalbital treatment for migraine should be avoided because more effective, migrainespecific treatments are available. Frequent use of opioid and butalbital treatment can worsen
headaches. Opioids should be reserved for those with medical conditions precluding the use of
migraine-specific treatments or for those who fail these treatments.
New Topics—My Favorites
• AMDA – Long Term Care Medicine
– Don't routinely prescribe lipid lowering medications in individuals
with a limited life expectancy.
• American College of Surgeons
– Do not perform axillary lymph node dissection for clinical stages I
and II breast cancer with clinically negative lymph nodes without
attempting sentinel node biopsy.
• Commission on Cancer
– Do not perform surgery to remove a breast lump for suspicious
findings unless needle biopsy cannot be done.
• AAOS
– Do not use glucosamine and chondroitin to treat patients with
symptomatic osteoarthritis of the knee.
• Society of General Internal Medicine
– Don’t perform routine general health checks for asymptomatic
adults.
New Topics
• American Psychiatric Association
– Don’t routinely prescribe antipsychotic medications as a first-line
intervention for children and adolescents for any diagnosis other
than psychotic disorders.
• American Society for Radiation Oncology
– Don’t initiate management of low risk prostate cancer without
discussing active surveillance.
– Don’t routinely recommend proton beam therapy for prostate
cancer outside a prospective clinical trial or registry.
• American Academy of Family Physicians
– Do not routinely screen for prostate cancer using a prostatespecific antigen (PSA) test or digital rectal exam.
– Do not require a pelvic exam or other physical exam to prescribe
oral contraceptive medications.
• American College of Medical Toxicology and the American
Academy of Clinical Toxicology
– Do not remove mercury-containing dental amalgams
Robust Topics
• Approach to poor prognosis solid cancer
treatment
• Approach to monitoring curative breast cancer
patients post treatment
• Prostate cancer screening and treatment
• Approach to stenting of “non culprit” lesions
• Monitoring of patients post heart procedures
• Overall---tens of millions of decisions, tens of
billions of dollars
Consumer Reports
• Consumer Reports is a partner in
Choosing Wisely and will support the effort
by creating patient-friendly materials based
on the society recommendations and
engaging a coalition of consumer
communication partners to disseminate
content and messages about appropriate
use to the communities they serve.
• Tools and resources can be found at:
www.consumerhealthchoices.org.
Communicating
“What Not to Do”
– Go where people are (Wikipedia & Vogue)
– Talk about what they are talking about
(usually benefits) and connect your dots to
theirs (risk, waste)
– Use safety if you can
– Use empathic stories
– Provide structure for decision making
(consumers wary of not following doctor
advice)
Stimulating Culture Change
• Large scale information campaign focused on
doctors and patients and their interaction
• Use trusted brands---Consumer Reports,
Physician specialty societies
• Organize community consortiums willing to take
on overuse
• Use all appropriate distribution channels
including carriers but focus on culture change
that prepares for strategies.
Sample Content
Free for consumers
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50 brochure topics
All in English and Spanish
Two-page PDF format
Suited for home printing
Suited for email, linking
Suited for clinic racks
Consumer Reports
Heart Disease Survey
Issues discussed with doctor prior to getting a heart-specific screening test
High cholesterol
and/or High Blood 'Healthy'
Issues discussed with Doctor Prior to Getting Screening Test
Pressure
The type of heart problem the test was screening for
31%
17%
What you would need to do if the test showed something abnormal
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11
The accuracy of the test
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What types of treatments would be available if the test indicated a problem
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Cost and insurance coverage
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How much discomfort you should expect
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Potential complications from the test
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Whether or not medical studies have shown the test saves lives
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None of the above
Base:
2309
521
Consumer Response
• Findings from a December 2012 Consumer Reports survey of
2,669 consumers who received Choosing Wisely information:
• 72% agreed that it had changed their opinion of the topic, taught
them new information, or prompted them to ask more questions
of their health provider.
• 81% of consumers reporting interest in a Choosing Wisely topic
said they were likely to have a conversation with their physician
about what they had read.
• In the case of one topic (back pain), 85% intended to have a
conversation with their doctor.
5 Questions to Ask Your Doctor
• Do I really need this?
• What are the
downsides?
• Are there simpler, safer
options?
• What happens if I do
nothing?
• How much does it cost?
ConsumerHealthChoices.org
Partner Highlights
AARP
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AARP Bulletin published “7 Medical Tests and Treatments You
May Not Really Need” in its May 2012 issue. AARP Bulletin has
a circulation of around 28 million readers.
AARP has also covered Choosing Wisely in its radio, television,
and online channels in English and Spanish.
Business Coalitions and Employer Groups
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Consumer Reports has collaborated with a number of coalitions
representing organizations that collectively represent tens of
millions of employees, patients, and their families.
These include The Leapfrog Group, Midwest Business Group on
Health (MBGH), Minnesota Health Action Group, National
Business Coalition on Health (NBCH), National Business Group
on Health (NBGH), and Pacific Business Group on Health
(PBGH).
Each has developed unique channels and tools to explain
Choosing Wisely to their members and communicate with
employees.
These include popular webinars and member briefings (NBGH)
and a new Choosing Wisely® Employer Toolkit (PBGH with
NBCH) along with email newsletters, speaker events, member
websites, and other outreach.
www.consumerhealthchoices.org
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Partner Highlights
The Wikipedia Community
– Consumer Reports welcomed Lane Rasberry as Wikipedian in Residence in
May 2012 with support from the Wikimedia Foundation.
– This opportunity has enabled Consumer Reports to collaborate with the
volunteer Wikipedia community and specialty societies to improve health articles
on Wikipedia by including relevant information and citations from the
Top Five lists of the specialty societies participating in Choosing Wisely.
– Since September 2012, there have been an estimated 30 million page views of
Wikipedia articles containing information about appropriate use of tests,
treatments, and procedures—each referencing Choosing Wisely.
www.consumerhealthchoices.org
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ABIMF/Drexel Videos
• Multiple videos focused on specific
overuse situations
• Adheres to straightforward principles
• Empathy and alternative plan
• Available at:
http://www.choosingwisely.org/resources/
modules/
What to do?
• Continue culture change efforts
– Educate all about these tests
• Benefit/Risk, downstream implications
• SAY IT SEVEN TIMES
– Take on inappropriate demand strategies
• Online promotion, health fairs, “wellness”
screenings
• Conversations about advertising and promotion
– Stop incentives that rely on creating
inappropriate demand
Critical Competencies
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Independence
Transparency
Good data
Robust collaboration
Confrontation skills
– Advocate for consumers
Time for Strategies??
• “Culture” prepared. Leadership opportunity?
• From single topics to broad areas of overuse
• From one on one conversations to a “practice
dialogue.” Doctors talk to doctors
• Integrate Choosing Wisely into the purchasing
process
• Right size care
• Influence the Standard of Care
From Single Topics to Broad Areas of
Overuse
– Screening—especially heart disease (18 topics)
– Preop testing in low risk folks and low risk surgery
(11 topics)
– Drugs---especially antibiotics (12 topics) and those
advertised
– Imaging---especially those involving radiation
(19 topics)
– Safety—especially elective delivery, inappropriate
induction
– Cancer
– Renal Failure
Consumer Reports preparing “roll ups” that cover
multiple topics
Doctors Talk to Doctors
• Two doctor approval---”hard stops”
– Early elective delivery
– Two doctor prescriptions---Opioids?? Testosterone??
• In the electronic record
– Cedar Sinai
• As part of other national campaigns
– ACC FOCUS--Formation of Optimal Cardiovascular Utilization
Strategies
– Image Gently/Image Wisely
• In the practice infrastructure
– Henry Ford
– Westmed Medical Group (Westchester County NY)
Scott Weingarten, MD
Senior VP and Chief Clinical Transformation Officer
Cedars-Sinai Health System
75% of decision support interventions
succeed when the information
is provided to clinicians automatically,
whereas none succeed when clinicians
are required to seek out the advice
Alerts > 100 per day
Purchasing Process
• Value Based Benefit Design
– Tiered benefit design (like drug benefit)
– Start with carrots, work on sticks
• As part of transparency processes
– Provide price and whether potential overuse
• As part of incentives and disincentives
– Remove overused services from production
incentives until right sized
– Remove upstream screening to reduce
downstream overuse
Right Size Care
– Insist that demand strategies be evidence
based not revenue based
• And include risk
– Address disparities aggressively
– Integrate into routine care
Change the Standard of Care
• Standard of Care
– “the watchfulness, attention, caution and prudence
that a reasonable person in the circumstances would
exercise”
• Clinical Practice
– “relating to or based on work done with real patients”
– “the learned profession that is mastered by graduate
training in a medical school and that is devoted to
preventing or alleviating or curing diseases and
injuries”
“When you’re through learning,
you’re through.”
John Wooden
Former UCLA basketball coach
John Santa
[email protected]
http://consumerhealthchoices.org/
campaigns/choosing-wisely/