Transcript Choosing Wisely Wales

A clinician-led initiative in partnership with patients, aimed at
providing patient-centred care, reducing harm and waste and
improving healthcare outcomes for patients in Wales
Prudent Health Care – reducing unnecessary tests and
treatments 24 6 16
Paul Myres Chair AMRCW
A partnership of clinicians and patients:
 To promote conversations between clinicians and
patients which help patients to choose care that is :
◦ Supported by evidence
◦ Not duplicative of other tests or procedures already
received
◦ Provides benefit to the patient
◦ Free from harm
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To reduce inappropriate investigations and
interventions
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More is not necessarily better
Sub-optimal care for patients of low value
results from :
 Inappropriate clinical interventions
 Culture of over-medicalisation
 Poor application of evidence
 Patients not involved enough in clinical
decisions
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We don’t know about it. Evidence not easily
accessible
We don’t care about the evidence – I’ve always
done it this way
We disagree with the evidence – my experience
says otherwise
Evidence is unreliable – biased, incomplete
Evidence is irrelevant – not appropriate for this
situation
Evidence is overruled. My patient wants
something different. This treatment is not
available
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Embed a broad culture change in healthcare where clinicians and
patients regularly discuss the value of treatments and make
shared decisions
Ensure good information is available for patients and clinicians
Enable participating professional health organisations such as
the health professional colleges and societies, to produce with
patients lists of commonly used treatments/interventions whose
necessity should be questioned
Reduce harm to patients by inappropriate use of tests or
interventions
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Scepticism – rationing by another name
Over confidence – I do it already
“Doctor know best”
Fear of litigation – I’ll get done, if it doesn’t
work
Lack of time – it takes too long
Lack of consensus on what works best
Lack of good (accessible) information
Not profitable, Perverse Incentives
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Each recommendation must be within the control
of the professional association members
Intervention should be used frequently and have
significant impact on patients and/or the NHS
There should be generally accepted evidence to
support the recommendation
The process should involve patients, be well
documented and publicly available on request
Effects should be measurable
Avoid controversial areas
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Antibiotics for URTIs/bronchitis/sinusitis
Imaging for low back pain
Benzodiazepine/antipsychotics in older
patients
Cancer screening (overfrequent cervical,
regular well person testing, PSA)
Pre-operative testing in low-risk patients
(EKG, stress EKG, chest x-ray, labs)
Proton Pump Inhibitors for dyspepsia
WG support – Clinical Lead;
Evaluation
UK Colleges have identified topics
Selecting around 20 relevant to
Wales
Roll-out begins this summer
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Don't routinely continue with poly-pharmacy for those with
frailty or in the last year of life unless this is the clear wish of
the patient or their advocate
Minimising the use of chemotherapy with a minimal risk of
benefit in patients with advanced cancer.
Do not begin primary prevention of cardiovascular disease or
osteoporosis without SDM with the patient
Don't initiate drug treatment for patients with isolated mild
hypertension unless there has already been a cardiovascular
event or there are additional risk factors such as diabetes
Don't routinely check lipids in patients prescribed statins for
primary prevention of cardiovascular disease
Don’t routinely swab suspected viral conjunctivitis cases or
routinely use antibiotics for simple viral conjunctivitis
polyethylene glycol should be used in preference to lactulose
in tx of chronic constipation in children
Feedback from our CHC partners was that they found
it difficult to understand the recommendations in
their original format so we have tried to design a
more approachable format.
Each slide begins with what the conversation needs to
cover (“Discuss”), what interventions should be
avoided (“Avoid”), and finally evidence-based
management options (“Consider”).
Discuss
•How will
each result
alter care?
Avoid
•Doing tests
routinely
Consider
•Testing
only when
it will alter
care.
Psych
Measureable
Med
Do-able
GP
Expectations
Impact
Relevant
At the bottom are ‘traffic-light’ boxes to represent the
CWW core team’s assessments of the recommendedations
in terms of:
 Relevant: are they relevant to patients and
professionals?
 Impact: are they a significant enough issue for this
programme? (we also indicate here which professional
groups they will most impact on)
 Expectations: do patients at present tend to expect this
intervention?
 Do-able: is this area suitable for this approach?
 Measurable: will we be able to know if it is working?
Avoid
Discuss
Consider
•Routinely giving Aspirin,
Heparin or Progesterone
•No abnormal
investigations means
good prognosis
•Absence of evidencebased treatments
Measureable
Gynae
Do-able
GP
Expectations
Impact
Relevant
•Doing more isn't
always better
•Pre-conception Folic Acid
•Early & regular scans
Discuss
Avoid
• Need to
exclude skin
conditions
Consider
• Giving
repeated
courses of
antifungals
• Other
symptoms
• Examine
• Trial of topical
steroid
• Refer to vulval
specialist
Measureable
Gynae
Do-able
GP
Expectations
Impact
Relevant
Core
PM
MHK
PF
Discuss
Avoid
•Potential
benefits
Consider
• Assuming all
possible
treatment is
wanted.
•Potential
risks
• Treatment
aimed at
symptom
control
Do-able
Measureable
Onc
Expectations
Impact
Relevant
Core
PM
MHK
PF
Discuss
Avoid
Consider
•Routinely
continuing
multiple
medications,
especially in the
frail.
•Risks from being
on multiple
medicines
•Benefits of longterm therapies
•Medicines
reconciliation
•Medication
review
•Using STOPP and
START tools
Measureable
Do-able
GP
Expectations
Impact
Relevant
Core
PM
MHK
PF
Discuss
Avoid
• Limited
evidence of
benefit
Consider
• Automatically
starting drug
treatment
• Risk of sideeffects
• Decision Aids
• Lifestyle
changes
• Ongoing
monitoring
Measureable
Do-able
GP
Expectations
Impact
Relevant
Core
PM
MHK
PF
The Media, Education, Family
Patients /
Public
WG, Public Health Priorities
Budget
Health or
Social care
organisation
Health or social
care
practitioner
Evidence based care/Incentives
Access to tests and treatments
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International clinicianled campaign
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A partnership
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Patient-centred care
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Shared decision
making
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Reducing harm
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Increasing value
What it is
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A government initiative
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An event
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Cook book healthcare
What
it n’t
 A ‘Don’t
Do’ list
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Cost-cutting
Further Information
Dr. Paul Myres
Programme Lead for Choosing Wisely Wales
[email protected]
Mr Paul Flynn
Clinical Lead for Choosing Wisely Wales
[email protected]
Dr. Marysia Hamilton-Kirkwood
PHW Lead for Choosing Wisely Wales
[email protected]
Mrs. Helen Britton
Project Manager for Choosing Wisely Wales
[email protected]