Transcript Supplemental Content - Annals of Internal Medicine

© 2015 American College of Physicians
The information contained herein should never be
used as a substitute for clinical judgment.
BEYOND THE GUIDELINES:
Should patients see their doctors for regular check-ups?
Medicine Grand Rounds
September 17, 2015
Discussants
Ateev Mehrotra,
MD, MPH
Series Assistant Editor
Eileen Reynolds, MD
James Heffernan,
MD, MPH
The Series Editors have no conflicts of interest to disclose.
Moderator
Howard Libman, MD
Conflict of Interest Disclosure
The speakers have no financial relationships with a
commercial entity producing healthcare-related
products and/or services.
Dr. Reynolds is President-Elect of SGIM but did not
participate in the creation or approval of this guideline.
Eileen Reynolds, MD
Ateev Mehrotra, MD, MPH
James Heffernan, MD, MPH
Howard Libman, MD
OUR PATIENT
Medical History
• Healthy 70 year old woman
• Sees her PCP once a year for a check-up
OUR PATIENT
Past Medical and Surgical History
• Mild atypical neuropathy
• Osteoarthritis s/p hip replacement
• Elevated risk of breast cancer due to strong
family history
• In the past 5 years, has been seen 6 times in
PCP’s office
– 5 check ups
– 1 visit for self limited abdominal pain
Year
2011
2012
2013
Interval
2014
2015
Exam/Test
Results
Pap/HPV
Pneumovax
BMD
Sx: varicose vein pain
Referred to genetic
counseling for breast
cancer risk
Normal
Atypical skin finding
Referred to derm
Abnormal mammogram
and MRI
Again discussed breast
cancer risk in light of bx
and re-referred
Hepatitis C and lipids
checked
Ordered repeat BMD
Given PCV13
pneumococcal vaccine
Fall, cognition,
depression screens
negative
Osteopenia
Referred to vascular
Gail Model: 8% 5 year
risk
Bx: benign
Gail Model risk now
10.2%
Outcome
Had procedure
Deferred medication;
plan annual MRI and
mammo
Cryotherapy for 8 lesions
Routine follow up; all
handled by phone
Started exemastane 25
mg qd; annual follow up
planned
Tests normal/negative
Osteopenia stable
6
CONTEXT, EVIDENCE, & GUIDELINES
• Annual check-ups / Periodic Health Exams
(PHE) are covered by private insurance
• Affordable Care Act (ACA) provides for
Wellness Exams under Medicare (2011)
• Costs are high
• Benefits not convincingly shown
• 2 attempts at comprehensive review
CONTEXT, EVIDENCE, & GUIDELINES
• Systematic review for AHRQ (2007)
• Reviewed 7039 articles; included 50 publications
from 33 studies
– 10 RCTs, 23 observational studies
• “Overall the strength and consistency of the
evidence varied widely among outcomes, as did the
magnitude and direction of the results”
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review:
the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.
CONTEXT, EVIDENCE, & GUIDELINES
• Findings:
– PHE has beneficial effect on receipt of cervical cancer,
pap, colon cancer screening
– PHE reduces patient worry
– No effects found on cost, clinical outcomes, mortality
• Authors of AHRQ review concluded:
– Findings “provide health care providers and payors with
justification for the continued implementation of the
PHE”
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review:
the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.
CONTEXT, EVIDENCE, & GUIDELINES
• Cochrane review and meta analysis (2012)
– Evaluate benefit to morbidity/mortality reduction
– 14 RCTs included; total 182,880 subjects
• Primary endpoints: total and disease specific mortality
• Secondary endpoints: morbidity; cost + utilization (admissions,
disability,referrals, tests/procedures, work absence)
– No benefit of PHE found in any outcome
– No heterogeneity in mortality results across 9 best trials
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and
mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.
CONTEXT, EVIDENCE, & GUIDELINES
Forest plot showing effect of general health checks on total mortality
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and
mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.
CONTEXT, EVIDENCE, & GUIDELINES
• Cochrane review weaknesses
– Age of the studies
• 10 of 14 RCTs published before 1973
– Outcomes other than mortality often not
reported
– Concern about bias in study populations
CONTEXT, EVIDENCE, & GUIDELINES
ABIM Foundation and SGIM: 2013
• “Choosing Wisely” campaign
– “Things Providers and Patients Should Question”
– Aims to raise awareness about high cost, low benefit
interventions
• “Don’t perform routine general health checks for
asymptomatic adult patients”
– Joins USPSTF (1985) and
– Canadian Task Force (1979) suggesting targeted
approaches
*www.choosingwisely.org
QUESTIONS TO DISCUSSANTS
To help us decide how to apply this recommendation to our
patient’s case we asked our discussants the following questions:
• What are the potential benefits of the periodic
health exam?
• What are the potential costs of the periodic
health exam?
• What patients should have a periodic health
exam?
• What do you recommend for Ms. M?
OUR MODERATOR & DISCUSSANTS
Howard Libman, MD (Moderator)
Director, HIV Program, Healthcare Associates, BIDMC
Chief, Education Section, Division of General Medicine & Primary Care, BIDMC
Professor of Medicine, Harvard Medical School
Ateev Mehrotra, MD, MPH
Associate Professor of Health Care Policy, Harvard Medical School
Associate Professor of Medicine, Division of General Medicine & Primary Care, BIDMC
James Heffernan, MD, MPH
Primary Care Section Chief, Division of General Medicine & Primary Care, BIDMC
Associate Professor of Medicine, Harvard Medical School
Ateev Mehrotra, MD, MPH
Standard to Judge Any Intervention
Benefits
Harms
& Costs
Need to challenge long-standing
practices and beliefs
•
•
•
•
•
Hormone-replacement therapy
Antibiotics for bronchitis
Anti-arrythmics after a myocardial infarction
CABG superior to medical therapy
Ulcers as an infectious disease
What am I not arguing against?
• Targeted evidence-based preventive services
• Targeted counseling for smoking, weight-loss
• Health coaching and care coordination for chronic and
complex conditions
• Visits with new symptoms
• Having patients who have not seen their doctor for several
years come in for a visit to initiate or maintain a relationship
What am I arguing against?
• A specialized visit at some periodic basis focused on nonspecific screening for illness or risk factors
Benefits of PHE
• Mortality – no benefit
• Morbidity – no benefit
• Surrogate outcomes - ?
Should we even consider
surrogate outcomes?
• “We also chose not to focus on surrogate outcomes such as
changes in risk factors or delivery of preventive services, as
these may be misleading because an improvement does not
necessarily benefit the participant and because they do not
measure harms.”
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and
mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.
Surrogate outcomes
• Decreasing patient worry
– Evidence mixed and placebo effect
• Increase delivery of preventive care
– PHE inefficient method of delivering preventive care
– Need for active outreach
*Boulware LE, Marinopoulos S, Phillips KA, Hwang CW, Maynor K, Merenstein D, et al. Systematic review:
the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.
Harms of overdiagnosis and
treatment are important
considerations
“…we know that all medical interventions can lead to harm.
Possible harms from health checks are overdiagnosis,
overtreatment, distress or injury from invasive follow-up tests,
distress due to false positive test results, false reassurance due
to false negative test results.”
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing
morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ. 2012;345:e7191.
Costs
• #1 reason an adult sees a physician
• $10 billion in direct medical costs & $3 billion in patient time
• PCP time is a scare national resource
– ~10% of PCP visits for PHE
– In Massachusetts: ~50 day wait time for an appointment
*Mehrotra A, Zaslavsky AM, Ayanian JZ. Preventive health examinations and preventive gynecological
examinations in the United States. Arch Intern Med. 2007;167:1876-83.
*Ray KN, Chari AV, Engberg J, Bertolet M, Mehrotra A. Opportunity costs of ambulatory medical care in
the United States. Am J Manag Care. 2015;21:567-74.
Addressing Common Criticisms
• Criticisms
– Prior research looked at wrong outcomes
– Prior research is too old & PHEs are different now
• Response
– Correct next step is a new trial, not continuing to encourage PHE
• Rescue bias
– “Discounts data by selectively finding faults in the experiment.”
– “Suspicious of evidence that is inconsistent with apparently wellconfirmed principles.”
*Kaptchuk TJ. Effect of interpretive bias on research evidence. BMJ. 2003;326:1453-1455.
Relationships
% PCPs who strongly agree or agree with the following
views on the annual physical examination
•
•
•
•
•
94% believe:
94% believe:
74% believe:
66% believe:
63% believe:
• 55% disagree:
improves relationship
provides valuable time for counseling
improves detection of subclinical illness
covered by insurance
has proven value
not recommended
*Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ. Support of Evidence-Based Guidelines for the
Annual Physical Examination: A Survey of Primary Care Providers. Arch Intern Med. 2005;165:1347-1352.
Periodic Health Examination
Benefits
Mortality
Morbidity
Preventive care
Relationships
Harms &
Costs
Overdiagnosis
Spending
PCP time
How to move forward?
• Eliminate PHEs
• Create “Primary care maintenance” visits
– Limited to those with no PCP visits for several years
– Focus on relationships and not on screening/testing
• Focus on better methods of delivering preventive care
• Use savings for primary care interventions that have been shown
to been effective such as health coaching
• To Ms. M.
– Come in when she feels ill
James Heffernan, MD, MPH
“Not everything that can be counted
counts, and not everything that counts
can be counted.”
*Cameron WB. Informal Sociology: a Casual Introduction to Sociological Thinking. Random House.
1963, p.13.
So what ’s wrong with the evidence cited
by SGIM, especially the Cochrane review?
• The “health checks” were NOT primary care visits
– Screening took place in a usual care site in only 4/14 studies
• The
number
of “health
varied
from
1-4, with in
more
The
Bottom
Linechecks”
-- What
was
counted
the
than half the studies limited to one check
Cochrane
review
is
largely
irrelevant
in
the
context
• Most studies were initiated in the 1960s and 70s, and none
oflater
current
primary
care practice, and the review by
than the
90s
al. actually
endorsed
implementation
•Boulware
Many of theet
screening
tests known
now to be
ineffective
CXRs, spirometry,
ECGs,PHE
urine analyses,
variouspractice.
blood tests
of the
in clinical
• Geriatric trials were not included
• Loss to follow up not well described
*Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in
adults for reducing morbidity and mortality from disease: Cochrane systematic review
and meta-analysis. BMJ. 2012;345:e7191.
What does count, and what are the
potential benefits of the periodic
health evaluation?
Valued Elements of the PHE
Convenience survey, academic primary care faculty members 8/2015
•
•
•
•
•
•
•
Continuity relationship
Screening/counseling
Identification of new clinical issues
Care coordination
Education around emerging health information
Opportunity to focus attention on family and social issues, and
goals of care
Provide a haven for patients to discuss sensitive issues,
embarrassing concerns and, most importantly, matters of
safety
The Value of the PHE for Ms. M
• Ms. M. has received outstanding care
• Age-appropriate preventive measures over time, based
on evolving evidence/recommendations
– PCV and pharmacological breast cancer risk reduction
• Interventions for actinic skin lesions, varicose veins
• Referral for abdominal pain when it arose
• Evolution of an abiding and trusting relationship with
her PCP
The Nature of Continuity
Continuity of care is an iterative and cumulative
process, a point missed entirely in SGIMs admonition
against the PHE and not addressed by the studies cited
The Value of Continuity
Study Evidence…
• 51 of 81 separate care outcomes were significantly improved
with significantly lower cost and utilization for 35 of 41 cost
variables in association with interpersonal continuity
• In review of preventable admissions, increase in continuity
metric of 0.1 associated with 2% reduction of preventable
hospitalization
• 0.1 increase in COC score  7% overall reduction in “overused
procedures”
*Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam
Med. 2005;3:159-166.
*Nyweide DJ, Anthony DL, Bynum JP, Strawderman RL, Weeks WB, Casalino LP, et al. Continuity of care
and the risk of preventable hospitalization in older adults. JAMA Intern Med. 2013;173:1879-1885.
*Romano MJ, Segal JB, Pollack CE. The Association Between Continuity of Care and the Overuse of
Medical Procedures. JAMA Intern Med. 2015;175:1148-1154.
The Value of Continuity
…and more study evidence…
• Retrospective cohort review of hospitalizations, ED visits,
complications and costs of care associated with the BiceBoxerman continuity-of-care (COC) index
– Based on claims data of Medicare beneficiaries experiencing
a 12-month episode of care for CHF, COPD or DM
• Higher levels of continuity associated with lower odds of
inpatient hospitalization, ED visits, complications and total
costs for CHF, COPD and DM
* Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the Costs
of Care for Chronic Disease. JAMA Intern Med. 2014:174:742-748.
Continuity & Costs of Care
OR for Hospitalizations, ED Visits, and
Complications with 0.1 Increase in COC Index
CHF
COPD
DM
Inpatient Hospitalization
0.94
0.95
0.95
ED Visits
0.92
0.93
0.94
Complications Related to CHF/COPD/DM, Comorbidities, &
Patient Safety
0.92-0.96
Percentage Change in Costs with 0.1 Increase in
COC Index
Total Costs
4.7 – 6.3% lower
Inpatient Hospitalization
4.6 - 6.1% lower
ED Visits
5.8 - 6.2% lower
Complications Related to CHF/COPD/DM, Comorbidities, &
Patient Safety
4.1 - 9.8% lower
Odds ratios for incidence, all P < .0001
Cost reductions, all P < .01
*Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the Costs of Care
for Chronic Disease. JAMA Intern Med. 2014:174:742-748.
The Value of Continuity
• Continuity of care and the PHE are not strictly
synonymous, but the PHE remains the anchor of the
continuity relationship
• Studies of the value of continuity are far better
evidence of the worth of the PHE than the outdated
and off-point studies cited by SGIM
Other Benefits of the PHE
• There are 55 USPSTF Grade A and B recommendations for screening
• Many of the screens do not require a visit, but where better to
oversee, discuss and counsel than through the PHE?
• “There is always something…”
– Nevus  malignant melanoma
– Low anterior cervical lymph node  Hodgkins disease
– Patient who feels comfortable enough to share history of childhood
abuse only after 3 years of care
• Personal bond benefiting both the patient and the PCP
*U.S. Preventive Services Task Force. A and B Recommendations. Available from:
http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
*Wong CJ, Gaster B, Dugdale DC. Choosing Wisely: In defense of the preventive health visit. Am J Prev Med.
2014;47:653-655.
What are the potential costs of the
periodic health evaluation?
Costs of the PHE
Direct and indirect costs of the PHE itself
• Cost of an individual PHE is modest, but the aggregate annual
cost of PHEs exceeds $10 billion
• Indirect costs: time off from work, parking, etc.
But, compared to what?
• Total US health expenditures in 2013  $2.9 trillion
– Hospital care: $936 billion 5% reduction = $46.8 billion
– Physician and clinical services: $586.7 billion (PHE = 1.7%)
• Impressive growing evidence of cost savings related to COC…
*Centers for Medicare & Medicaid Services. National Health Expenditure Data - Historical 2014. Available from:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
Costs of the PHE
Direct and indirect costs of the PHE itself
More, compared to what?
• What is the value, and what are the costs of…?
– Six month in-office “OCP checks” by a gynecologist for a
26 year old woman
– Radiographs/MRI before a patient is seen in an orthopedic
office, before assessment of the clinical issue
– Annual follow up with an oncologist 7 years after surgical
cure of a low-grade malignancy
– Annual follow up with a cardiologist (likely with an
echocardiogram) for low grade aortic stenosis
Other Costs of the PHE:
•
•
•
Non-evidence based testing does occur…
These costs appear to be more than offset by the reduction in
more expensive procedures when there is higher continuity of
care
The “crowding out phenomenon”
•
Providing access to timely care is far better addressed in global
redesign into modern care models such as the PCMH
The Workload of Primary Care in the
Traditional (Pre -PCMH) Model
• 7.4 hr/day to do prevention
• 10.6 hr/day to do chronic disease management
• 5.6 hr/day to manage acute issues…
*Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for
prevention? Am J Public Health. 2003;93:635-641.
*Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of
patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209-214.
The Putative Evolving Solution
Practice Transformation to Modern Care Models, e.g., PCMH
1. Team-based care
2. Proactive population management
•
•
•
3.
4.
5.
6.
Preventive and wellness services for all patients
Chronic disease management
Increased use of technology
Care management of our sickest patients
Patient engagement
Aggressive panel/roster/schedule mgt.
Continuing important role for the PHE
GroupHealth, Seattle
•
•
•
•
•
•
Mature PCMH, arguably most successful in the US
Strong commitment to proactive population and chronic
disease management
Innovative use of and reimbursement for non-office based
care – email, phone, etc.
Better access, longer visits, fewer patients/session
Improved physician retention
The PHE – “Well-Care Visit” -- is a cornerstone of the care
package offered and delivered
GroupHealth, Seattle
Recommended Interval for Well-Care Visits (years)
Age
Women
Men
18-21
1
1
22-49
4
4
50-64
2
2
65+
1
1
*GroupHealth. Adult Well-Care Visits, Screenings, and Immunizations 2014 . Available from:
http://www.ghc.org/healthAndWellness/index.jhtml?item=/common/healthAndWellness/tests/recommended
Tests/adultTests.html
What patients should have a periodic
health evaluation?
Everyone should have an initial health evaluation with
a primary care provider and then follow up PHEs at
intervals determined by the patient’s evolving risk
profile, needs and wishes.
What do you recommend for Ms. M?
Ms. M. has received outstanding care and has a
wonderful partnership with her primary care
physician. Happily, she has no chronic conditions for
which she needs to be routinely seen. I would
encourage her to continue PHEs on a schedule that
works for her and for her PCP.
Final Thoughts…
•
•
•
•
SGIM’s admonition against the PHE is celebrated more in the breach
than in the performance
Patients and PCPs continue to value and benefit in a multifaceted
way from the PHE
The PHE has not been shown to be of low value, high risk or high
cost and should not have been singled out for abandonment; rather,
the PHE should continue to serve as a high-level capstone activity in
evolving models of primary care
Cutting this core activity out of primary care will not materially
improve access and will poison the well for existing PCPs and for
trainees interested in primary care
We would like to thank…
Our Patient, Ms. M
Ateev Mehrotra, MD, MPH & James Heffernan, MD, MPH
Risa Burns, MD, MPH
Deborah Cotton, MD, MPH
Howard Libman, MD
Eileen Reynolds, MD
Gerald Smetana, MD
Last Minute Productions
BIDMC Media Services
Lizzie Williamson
© 2015 American College of Physicians
The information contained herein should never be
used as a substitute for clinical judgment.