Transcript Right Care Rounds: Conducting A High

RightCare Rounds
How to conduct a conference promoting “as much as possible for the
patient and as little as possible to the patient.”
Presented at: 4th Annual Lown Conference, April 15, 2016
Chicago, IL
Presenters:
Edward Murphy, MD University of Colorado School of Medicine
Brandon Combs, MD University of Colorado School of Medicine
Harry Cho, MD, Mount Sinai Hospital
Workshop Agenda:
• Introduction (Facilitators and group)
• Prime the Pump: Why do this?
• Scholarship opportunities in right care/value
• RightCare Rounds: basic background
• Sample Presentation and Facilitated Discussion
• Right Care Rounds: Conferences and Case Type and
Selection
• Wrap-up/Bringing it back home
• Tool kit and Q&A
Meet Bill
Overuse and underuse often occur together!
The Value Equation
Value = Quality / Cost
Some Relevant Background
1/3 of the pie
WASTED
1/4 of this waste
OVERUSE
$210
Institute of Medicine, the Healthcare Imperative
Why does overuse (& low value care) matter?
1. It’s harmful
2. It’s not about the $$
The Value Equation
A different paradigm:
Value
=
Quality
/
Cost
1. Best possible care
2. Avoid unnecessary stuff
“As much as possible for the patient and as little as possible to the
patient.”
Bernard Lown, MD
Filling a gap in medical
education/scholarship
• Instances of well-intended overuse an everyday occurrence
• An opportunity to change shape the discussion
“Teachable Moments”
An example from JAMA IM…
• A man
in his 20s with
1 DM, HTN,in
CKDthis
presents
with osteomyelitis,
What’s
thetype
overuse
case?
worsened renal function & anasarca
• GFR not improving with supportive measures, plan for renal bx
• Hgb 7.5, transfused 1 unit red cells for goal Hgb 8 prior to bx
• Yeast found in urine and procedure deferred for 1 week  AIN &
diabetic nephropathy noted, bx uncomplicated
Mehta HN, Chi X, Buckhold FR. Hidden Risks of Blood Transfusions: A Teachable Moment. JAMA Intern Med.
Published online July 13, 2015.
Potential teaching points…
• Renal bx generally safe, serious complications uncommon
• Benefits of higher Hgb before bx? UNKNOWN
• KNOWN harms of transfusion?
-The terrible T’s: TRALI, TRIM, TACO
-Transfusion reactions
• Bloodborne infections are rare
• Less is usually more with RBCs
RightCare Rounds: the basics
• Case-based conference – similar to
morning report or noon conference
• Highlight harms/near harms from
“reasonable” overuse/underuse
• Engage wisdom of the crowd  local
solutions  better care next time
• Familiar cognitive tools
• RightCare Fishbone
The RightCare Fishbone applied to “Hidden Risks of Transfusion”
Industry factors
Clinical factors
Advertising/marketing
Indication creep
Incomplete evidence
base
Preference
misdiagnosis
Disease mongering
OVERUSE
Uncertainty/knowledge Insufficient time
gaps
Satisfaction scores
Ignore
harms
Clinician factors
Supply sensitive
tx
Fee for service
Economic factors
“it [harm] won’t happen to me”
“More is better”
Patient factors
HARM
Why RightCare Rounds?
• Traditional conferences focus on rare
diagnoses, errors, or “high tech”
• RCR calls attention to “business as
usual” medicine where
overuse/underuse ignored
• Hard to recognize  “it’s in the air
we breathe”
• Bring “values” to value
Let’s Do One!
How It’s Done
• The start: facts of the case
• Patient problem and history
• Not comprehensive; enough to set the table.
Patient Presentation:
43 y.o. man with chronic LBP treated with opioids, major depression,
diagnosed with hypogonadotrophic hypogonadism
Medical Hx:
Major depressive disorder
Traumatic back injury
Labs:
Testosterone: 88
LH & FSH < 0.1
Symptoms:
Pertinent Patient Beliefs:
Fatigue
Quality of life paramount
Decreased libido
Opioids & testosterone required to maintain QOL
Erectile dysfunction
insomnia
Privileged & Confidential: Subject to Peer Review and Medical
Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et
seq.
Timeline
1 year ago: Initial endo eval.
Dx of hypogonadism, T
injections started
Mood swings on T
OFF testosterone
PCP weans opioid dose. Rerefers to endo
6 mo ago: Urinary
retention. T stopped.
Urology: retention due
to opioids.
Present: endo reevaluation. Hypogonadism
confirmed. T resumed
with gel.
ON testosterone
Privileged & Confidential: Subject to Peer Review and Medical Review Protections, O.C.G.A. § 31-7-130 et seq. and § 31-7-140 et seq.
How It’s Done
• The intervention in question
• Brief review of the evidence related to the
intervention
• Review of potential harms and benefits
Data Review (brief): Mechanism
•Opioid medications cause decreased
testosterone by multiple mechanisms
•Hypogonadism resolves linearly with decreased
opioid dose
Proposed benefits of replacement
Journal of Clinical Endocrinology and Metabolism Clinical Practice Guideline
2010:
All men:
Libido: Perhaps improved in trials including men with testosterone
less than 300 ng/dL but data inconsistent.
Erectile dysfunction: not significantly improved when testosterone <
300 or when compared to control (testosterone >300)
Old men:
Depression: ambiguous, some trials favor testosterone, others without
benefit.
Potential Harms
Erythrocytosis, Acne, Prostate Cancer, OSA, DVT. Others?
Cardiovascular:
• RCT of T in frail older men stopped early due to
increased CV events in tx group
• Retrospective study of hypogonadal men undergoing
coronary angiography, then started on T  increased
risk of CV events (25.7% in T group vs 19.9% control)
How It’s Done
• Non-medical factors?
• In this case direct to consumer advertising was important
• This portion may be unique to each case.
• Can be tailored to system level concerns at national or local
level
• Exploring these is a way to expand analysis beyond the
immediate issue
ANY 3 and it could be low T!
Outside Pressures: The “Low T” Campaign
•Direct to consumer advertising  BIG business
•Testosterone rx: $2.4 billion 2013
•$3.8 billion by 2018
•Independent clinics: “Low T Center” 49 clinics
in 11 states (3 in CO)
Campaign of Success:
2000 to 2011 in the US:
• Testosterone testing increased > 4 fold
• Testosterone Rx increased 3.7 fold
• Therapy started in patients with “normal or high”
testosterone: 4-9%
How It’s Done
• Bringing it home
• Opportunity for audience involvement
• Complete the fishbone
• Tap the experience and expertise of the group
• “RightCare Fishbone”
• Adaptation of root cause analysis diagram from M&M conferences
• repurposed to evaluate overuse/underuse
Right Care Fishbone:
What are the drivers of overuse?
OVERUSE/
HARM
One way to think of it…
Industry factors
Clinical factors
OVERUSE
Clinician factors
Economic
Patient factors
HARM
One way to think of it…
Industry factors
Advertising/marketing
Disease mongering
Clinical factors
Indication
creep
Insufficient evidence
Preference
misdiagnosis
OVERUSE
Diagnostic
uncertainty
Fear of litigation
HARM
Insufficient time
Satisfaction scores
Supply sensitive tx
Reliance on a “medical” solution
Fee for service
Clinician factors
Economic
Support network
Patient factors
E Murphy, D Tad-y, B Combs (2015) Exploring Drivers of Medical Overuse Through Transformation of Grand
Rounds Into “Right Care Rounds”. Journal of Graduate Medical Education: June 2015, Vol. 7, No. 2, pp. 283284.
Potential Teaching Points:
• Confluence of factors contribute to overuse (using the
fishbone)
• Industry—advertising
• Patient – medical solution
• Clinical--- indication creep
• Breaking the cycle:
• Decreased opioid dosing could improve hypogonadism
• Not a benign treatment:
• Possible serious harm
How Have We Done?
• Data thus far from residents and faculty at University of Colorado
Division of GIM, Denver VAMC and St. Louis University
• Audiences Surveyed post presentation:
• “This Conference effectively discussed the drivers of
overuse/underuse
• 32/33 respondents chose “agree or somewhat agree”
• “This Conference Uncovered Opportunities for Improving Quality of
Care”
• 31/33 respondents chose “agree” rpr Sp,ewhat agree”
• 29/33 respondents found this applicable to their practice
Bringing it all back home
Running the Conference
• Similar to morning report or noon conference
• Key difference: discuss harms from unnecessary
care or a missed opportunity
• Cite supporting evidence: suggest what SHOULD
have happened
• Consider the many drivers, systematic approach
Wrapping Up, Engaging the Group
• TEACH:
• How can we do better for patients
like this next time?
• What’s the evidence say?
• ASK:
• What systems can we put in place
to do better?
• What are the barriers to change?
Who can help?
Where to Start? Thoughts and Tips
• Identify a Case
• Have any trainees submitted a Teachable Moments
Vignette?
• Perhaps encourage a submission?
• Identify the venue that best serves the institutional
goal
• If a Morning Report or M&M?
• Identify Housestaff or Chief Resident Leader
• Sign up for the Right Care Educator Program!!
References:
• Basaria, S, Coviello, AD, Travison, TG, et al. Adverse Effects Associated With Testosterone Administration. New England Journal of Medicine.
2010; 363: 109-122.
• Bhasin, S, Cunningham GR et al. Testosterone Therapy in Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice
Guideline. Journal of Clinical Endocrinology and Metabolism. 2010; 96 (6) 2536-2559
• Brennan, MJ. The Effect of Opioid Therapy on Endocrine Function. The American Journal of Medicine. 2013; 126 (3A): S12-S18
• Drehle, D. Manopause?!: Aging Insecurity and the $2 Billion Testosterone Industry. Time. 2014; 184 (6): 36-43
• Layton, B, Li, D, Meier, CR et al. Testosterone Lab Testing and Initiation in the United Kingdom and The United States, 2000-2011. Journal of
Clinical Endocrinology and Metabolism. 2014; 99(3): 835-842
• Mehta HN, Chi X, Buckhold FR. Hidden Risks of Blood Transfusions: A Teachable Moment. JAMA Intern Med. Published online July 13, 2015.
• Mendelson JH, Mendelson JE, Patch, VD. Plasma Testosterone Levels in Heroin Addiction and During Methadone Maintenance. Journal of
Pharmacology and Experimental Therapeutics. 1975; 192: 211-217
• Murphy EN, D Tad-y, B Combs (2015) Exploring Drivers of Medical Overuse Through Transformation of Grand Rounds Into “Right Care Rounds”.
Journal of Graduate Medical Education: June 2015, Vol. 7, No. 2, pp. 283-284.
• Rhoden, EL and Morgentaler, A. Risks of Testosterone Replacement Therapy and Recommendations for Monitoring. New England Journal of
Medicine. 2004; 350 482-92.
• Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The Association Between Residency Training and Internists Ability to Practice Conservatively.
JAMA Internal Medicine 2014; 174 (10): 1640-1648
• Shores, Molly M, Smith NL, Forsberg CW, et al. Testosterone Treatment and Mortality in Men with Low Testosterone Levels. Journal of Clinical
Endocrinology and Metabolism 2012; 97 (6): 2050-2080
• Society of Hospital Medicine: Five Things Physicians and Patients Should Question. Choosing Wisely, ABIM. February 21, 2013. Web .
September 17, 2015
• Vigen, R, O’Donnell, CI, Baron AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels.
2013; 310 (17): 1829-1836.
JAMA
http://lowninstitute.org/toolkit/
THANK YOU
Edward Murphy, MD
Brandon Combs, MD
Harry Cho, MD
[email protected]
[email protected]
[email protected]