Transcript Misuse

Choosing Wisely
Easier Said Than Done
NPA Good Stewardship Project Director
Stephen R. Smith, MD, MPH
Professor Emeritus of Family Medicine
Warren Alpert Medical School of Brown University
Disclosure
I receive fees for reviewing articles on the Choosing
Wisely recommendations for Consumer Reports.
I have no other relationships of any kind with any
company whose products or services are in any way
related to the practice of medicine, medical education
or research.
Case Studies

Annual Pap smear

Penicillin from the ER for a sore throat

GI recommends repeat colonoscopy in 3 years

Scoliosis screening in adolescent boy

Pre-op request for cataract surgery with EKG

PA prescribes antibiotics for mild acute sinusitis

Antibiotics for viral conjunctivitis (“pink eye”)
The Physician Charter
the wise and
cost-effective
management
of limited
clinical
resources
Stewardship
Protecting
resources for
future
generations
Billions $
Health Care Costs
What Physicians Can Do
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
MRI for low back pain
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
Yearly Paps, colonoscopy
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
“Belly aches” to GI
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
Misuse
o
o
o
Not indicated
Antibiotics for colds
Not supported by evidence
Not the first choice
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Coronary
Calcium Scans
for Screening for
Heart Disease in
Asymptomatic
Patients
Physician’s Role
o
Overuse
o
o
o
o
Too soon
Too often
Too easily
Misuse
o
o
o
Not indicated
Not supported by evidence
Not the first choice
Xopenex vs albuterol
NPA Project
o
5 Things You Can Do in Your Practice
(Family Medicine, Internal Medicine, & Pediatrics)
o
o
o
o
o
Commonly ordered or performed
Not recommended or preferred action
Carries some risk of harm
If not done would improve health and reduce costs
Strong evidence supporting
Brody Perspective Piece
“A Top 5 list…(restricted) to the most egregious causes of
waste…can demonstrate…that we are genuinely protecting
patients’ interests and not simply ‘rationing’ care….”
Top 5 List—Family Medicine
1.
Don't do imaging for low back pain within the first
six weeks unless “red flags” are present
2.
Don't routinely prescribe antibiotics for acute
mild-to-moderate sinusitis within the first 7 days
3.
Don't use DEXA screening for osteoporosis in women
under age 65 or men under 70 with no risk factors
4.
Don't order annual EKGs or any other cardiac screening
for asymptomatic, low-risk patients
5.
Don't perform Pap smears under the age of 21 or in women
status post hysterectomy for benign disease
Top 5 List—Internal Medicine
1.
Don't do imaging for low back pain within the first
six weeks unless “red flags” are present
2.
Don't obtain blood chemistry panels (e.g. CMP, SMA-7, BMP)
or urinalyses for screening in asymptomatic, healthy adults
3.
Don't order annual EKGs or any other cardiac screening
for asymptomatic, low-risk patients
4.
Use only generic statins when initiating lipid-lowering
drug therapy
5.
Don't use DEXA screening for osteoporosis in women
under age 65 or men under 70 with no risk factors
Top 5 List—Pediatrics
1.
Don’t obtain imaging for minor head injuries without
loss of consciousness or other risk factors
2.
Advise parents not to use cough and cold medications
3.
Use inhaled corticosteroids to control asthma appropriately
4.
Don't prescribe antibiotics for pharyngitis unless the
patient tests positive for streptococcus
5.
Don't refer otitis media with effusion (OME) early in
the course of the problem
Published “Top 5” Lists
Good Stewardship Demonstration
•
3 Practices
• Yale Primary Care Center
• Long Beach Memorial Family Medicine
Residency
• Harborview Medical Center Family
Medicine Clinic, University of
Washington Medical School
Phase 2
o
Training videos
o
o
o
o
o
Clarify patient’s true
concerns
Provide information
Be courteous and
respectful
Provide clear
contingency plan
Assure patient
agreement with plan
YouTube: Good Stewardship
http://www.youtube.com/watch?feature=endscreen&NR=1&v=FbEjy_QVRXA
Significant Changes
•
•
•
Sinusitis (LB, S and combined) 55% vs.
0% inappropriate, p <.0001
DEXA (combined) 33% vs. 10%
inappropriate, p <.05
Pap smears (LB only) 3% vs. 0%
inappropriate, p <.05
Good Stewardship Demonstration
Clinical Parameter
Pre-training
Post-training
Appropriate (%) Appropriate (%)
DEXA screening
67
90
Sinusitis treatment
45
100
EKG screening
99
99
Pap smear screening
99
99
Low Back Pain imaging
88
88
100
57
Routine labs
94
84
All parameters
93
96
Statin prescribing
Choosing Wisely Campaign
o
ABIM Foundation
o
o
o
o
70+ Specialty
Societies
500,000+
physicians
More societies to
join soon
Each develops
their own “Top 5”
list
Choosingwisely.org
Choosing Wisely International
Consumer Reports
Recent Article
Some Courageous “Top 5” Items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Urology: don’t do extensive w/u for overactive bladder
ENT: no ear tubes in kids for 1st OME < 3 mos.
Neuro: don’t do EMG for neck or back pain after MVA
Path: only order TSH initially to evaluate suspicion of thyroid problems
Heme: don’t treat ITP in absence of bleeding or very low platelets
Sleep: don’t use hypnotics for chronic insomnia
Dentists: no need for routine 6-mo. care for everyone
Renal: don’t start on dialysis without shared decision-making
Rad Onc: don’t initiate non-curative radiation Rx without defining goals
Cardio: avoid angiography to assess risk in asymptomatic pts
PM&R: don’t repeat epidurals if previous ones didn’t help
Challenges to Change
1.
2.
3.
4.
5.
6.
7.
Discomfort with diagnostic uncertainty engenders an inappropriate drive to
leave no question unanswered.
Overconfidence in the effectiveness of medical science results in patients
experiencing greater risks and costs in pursuit of even slight clinical benefits
or even when there is no benefit at all—the “therapeutic illusion.”
Fear of opening “Pandora’s Box” and being too busy to deal with the
consequences.
Perception of pressure from patients and not knowing how to handle it.
Fear of malpractice.
Deference to specialists who may have financial conflicts of interest.
Lack of knowledge.
Potential Solutions
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Administrative controls
(ex. Vitamin D testing)
Denial of payment
without justification
More hard evidence
Peer comparisons
(lower lab testing)
Focus on outliers
More education (PAs)
Caveats