Choosing wisely

Presentation at the Virginia Academy of Family Physicians 2013 Annual Meeting, focused on the Good Stewardship project of National Physicians Alliance, and the ABIM Foundation's Choosing Wisely initiative.

1. VAFP 2013 Annual Meeting Choosing Wisely: Evidence-Based Medicine and Good Stewardship

2. Mark Ryan, MD, FAAFP Assistant Clinical Professor, VCU DFMPH VP Communications, National Physicians Alliance

3. 1. Participants will describe how medical treatment decisions increase healthcare costs and risk patient harm. 2. Participants will describe specialty-specific evidence-based recommendations to reduce medical care that may not benefit patients. 3. Participants will propose how to use these guidelines in discussing care decisions with patients. Objectives

4. American medical care is expensive. A large amount of medical care provided in the US is unnecessary. Overtreatment and excess testing risks harm. We can do something to avoid unnecessary testing and excess costs, and potentially avoid harming patients. The bottom line

5. American healthcare is expensive

6. American healthcare is expensive

7. We do not get good return on our investment WHO rankings in 2000 ranked the US 37 th . IOM "U.S. Health in International Perspectives” report in 2013 showed that Americans had poorer health than 16 other wealthy nations. ( U.S. Health in International Perspective: Shorter Lives, Poorer Health )

8. We do not get good return on our investment

9. We do not get good return on our investment

10. We do not get good return on our investment

11. We do not get good return on our investment

12. “The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems .” There were 6 categories of excess healthcare costs. Unnecessary services accounted for $210 billion (28% of excess costs and 8% of all healthcare costs). Other categories: Inefficiently delivered services ($130 billion), excess administrative costs ($190 billion), prices that are too high ($105 billion), missed prevention opportunities ($55 billion), fraud ($75 billion). ( Best Care at Lower Cost: The Path to Continuously Learning Health Care in America) 1/3 of healthcare spending in the United states is wasted

13. Overuse —beyond evidence-established levels Discretionary use beyond benchmarks Unnecessary choice of higher- cost services ( Best Care at Lower Cost: The Path to Continuously Learning Health Care in America) Unnecessary services

14. Medical care is not necessarily safe An estimated 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays -- HHS Office of the Inspector General report Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries ) 1 in 20 hospitalized patients risk a hospital-associated infection -- ( CDC data ) In 1999, the IOM estimated between 44,000 and 98,000 Americans died yearly from medical errors, while a 2009 investigation by Hearst newspapers suggested 200,000 annual deaths. There is increasing attention being paid to the risk of excess radiation exposure and cancer due to advanced imaging. High-profile concerns about adverse effects from medications (e.g. Vioxx , Avandia, etc.) Harms of excess medical care

15. Primum non nocere More care is not necessarily better care or safer care. The right care for every person every time. Safe Effective Efficient Patient-centered Timely Equitable (CMS Quality Improvement Roadmap Executive Summary ) Our Responsibility

16. Triple Aim : “a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance” Elements of the Triple Aim: Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care. Clinical decisions made by patients and physicians can help attain the Triple Aim. Our Responsibility

17. In 2009, the American Board of Internal Medicine (ABIM) Foundation launched its “Putting the Charter into Practice” grants, with a goal to “advance professional values and behaviors among practicing physicians”. National Physicians Alliance was one of 5 grant recipients. Dr. Stephen Smith (Brown Alpert Medical School Department of Family Medicine) was the lead physician on the project. Putting the charter into practice

18. National Physicians Alliance (NPA) is a multi-specialty physician organization with several areas of interest, including limiting the impact of pharmaceutical and medical device companies on medical practice, ensuring access to healthcare for all Americans, and good stewardship of limited resources. NPA sought the grant with the intent to “ identify five steps primary care physicians could take in their daily practices to achieve the highest goals of doctors and patients alike: excellent care that we can afford together” The focus was on primary care specialties: family medicine, internal medicine, and pediatrics. Putting the charter into practice

19. “ Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice , that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks , harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities . A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians .” The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism Good Stewardship

20. “The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities . The family medicine and internal medicine groups independently selected 3 activities that were the same , so the final lists reflect 12 unique activities that could improve clinical care .” Lists were released in 2010, and included a short summary and discussion of the evidence-based recommendations. The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism Good Stewardship

21. Family Medicine: Don't do imaging for low back pain within the first 6 weeks unless red flags are present. Don't routinely prescribe antibiotics for acute mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions AND maxillary pain or facial or dental tenderness to percussion) last for 7 or more days OR symptoms worsen after initial clinical improvement. Don't order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients. Don't perform Pap tests on patients younger than 21 years or in women status post hysterectomy for benign disease. Don't use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors . The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism Good Stewardship

22. Internal Medicine: Don't do imaging for low back pain within the first 6 weeks unless red flags are present. Don't obtain blood chemistry panels ( eg , basic metabolic panel) or urinalyses for screening in asymptomatic, healthy adults. Don't order annual ECGs or any other cardiac screening for asymptomatic, low-risk patients. Use only generic statins when initiating lipid-lowering drug therapy. Don't use DEXA screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors . The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism Good Stewardship

23. Pediatrics Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus . Don't obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors . Don't refer OME early in the course of the problem . Advise patients not to use cough and cold medications . Use inhaled corticosteroids to control asthma appropriately . The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism Good Stewardship

24. Analysis using the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS ) suggested that adoption of the Top 5 lists could save approximately $6.7 billion. (Kale MS, Bishop TF, Federman AD, Keyhani S. “Top 5” Lists Top $5 Billion. Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed. 2011.501) Good Stewardship

25. Date of download: 7/5/2013 Copyright © 2012 American Medical Association. All rights reserved. From: “ Top 5 ” Lists Top $5 Billion Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed.2011.501

26. Routine CBCs were done in 56% of eligible visits and accounted for $32 million in costs. Prescribing name brand instead of generic statins (before atorvastatin went generic) accounted for $5.8 billion in excess costs. Bone density scans in women under 65 happened rarely (1.4% of visits) but accounted for $527 million in excess costs. 41% of children seen for non-strep, non-febrile pharyngitis were given antibiotics ($116 million) Good Stewardship

27. The ABIM Foundation awarded NPA a second grant to select 3 practices to serve as demonstration sites for implementing the Top 5 lists. A training video was created to help physicians discuss these issues with patients. The ABIM Foundation used the approach piloted by the Good Stewardship project to launch their ongoing Choosing Wisely initiative. The AAFP endorsed the Good Stewardship list for family medicine. Good Stewardship

28. “ Choosing Wisely ® aims to promote conversations between physicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary” “national organizations representing medical specialists have been asked to “choose wisely” by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed” ( ABIMF Choosing Wisely website ) Choosing Wisely

29. Choosing Wisely is a collaboration between the ABIM Foundation and Consumer Reports. In 2013, the National Research Center for Women and Families honored NPA, the ABIM Foundation, and Consumer Reports as 2013 Health Policy Heroes . Choosing Wisely

30. Thus far there have been two rounds of lists generate by specialty societies, and 35 specialty organizations have submitted lists. The lists include evidence-based discussions backing the recommendations, and are referred to as “ Five Things Physicians and Patients Should Question” The AAFP has submitted lists in both rounds, meaning that there are 10 interventions that the AAFP considers as good opportunities to reduce costs and unnecessary medical care. The AAFP’s first Choosing Wisely list was the endorsement of the Good Stewardship list. Choosing Wisely

31. 1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits. Choosing Wisely: AAFP

32. 2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement . ( Also listed by AAAAI and AAP ) Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs . Choosing Wisely: AAFP

33. 3. Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors . DEXA is not cost effective in younger, low-risk patients, but is cost effective in older patients. Choosing Wisely: AAFP

34. 4. Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. ( Also listed by ACP ) There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit. Choosing Wisely: AAFP

35. 5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. Most observed abnormalities in adolescents regress spontaneously, therefore Pap smears for this age group can lead to unnecessary anxiety, additional testing and cost. Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes . Choosing Wisely: AAFP

36. 6. Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age . (Collaborative with ACOG ) Delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery. Choosing Wisely: AAFP

37. 7. Avoid elective, non-medically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable . (Collaborative with ACOG ) Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care clinicians should discuss the risks and benefits with their patients before considering inductions of labor without medical indications. Choosing Wisely: AAFP

38. 8. Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients . There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction. Choosing Wisely: AAFP

39. 9. Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer. There is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit. Choosing Wisely: AAFP

40. 10. Don’t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology. There is adequate evidence that the harms of HPV testing, alone or in combination with cytology, in women younger than 30 years of age are moderate. The harms include more frequent testing and invasive diagnostic procedures such as colposcopy and cervical biopsy. Abnormal screening test results are also associated with psychological harms, anxiety and distress. Choosing Wisely: AAFP

41. The central role of primary care—especially family medicine—includes forming long-term relationships with our patients to be able to discuss these recommendations with them. We must also work to improve communication within medicine in order to avoid duplicating tests. If an in integrated system, remember to check the EHR before ordering anything! The role of primary care

42. Consumer Reports involvement allows outreach to patients via a trusted organization. Many common medical tests and treatments are unnecessary Choosing Wisely: How to avoid unnecessary tests and treatments Video outlining the purpose and goal of Choosing Wisely Patient-friendly resources and campaign promotional materials from Choosing Wisely and Consumer Reports. Focus on various recommendations and areas of interest. English and Spanish Training videos from the Good Stewardship project. Engaging patients in choosing wisely

43. The concept of patient-centered care places the patient at the center of the decision-making process. Good Stewardship/Choosing Wisely should allow us to move further in those directions. Patients increasingly want a voice in their treatment decisions. We should continue to encourage this, both to avoid patient harm and to be good stewards of precious resources. Engaging patients in choosing wisely

44. Your next steps? This year, at NPA’s National Conference the pilot projects from the Good Stewardship project will be presenting their findings. This is a great opportunity to get involved: http://www.npalliance.org [email protected] [email protected]

45. EXTRA CREDIT

46. In total, 35 specialty groups have submitted recommendations, many of which will be relevant to family medicine. My quick review of these recommendations follows. This if based somewhat on how relevant the different recommendations are for my practice, and is not comprehensive. Choosing wisely: other organizations

47. Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis . ( Aligns with AAFP, AAP ) Don’t diagnose or manage asthma without spirometry . Choosing Wisely: AAAAI

48. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding . ( Aligns with AGS) Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment. Choosing Wisely: AAHPM

49. Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms . ( Aligns with ACP ) Don’t use opioid or butalbital treatment for migraine except as a last resort. Don’t recommend CEA for asymptomatic carotid stenosis unless the complication rate is low (<3%). Choosing Wisely: AAN

50. Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications. Don’t order antibiotics for adenoviral conjunctivitis (pink eye). Choosing Wisely: AAO

51. Don’t prescribe oral antibiotics for uncomplicated acute external otitis. Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis . ( Also listed by AAAAI ) Don’t obtain computed tomography (CT) or magnetic resonance imaging (MRI) in patients with a primary complaint of hoarseness prior to examining the larynx. Choosing Wisely: AAO-HNS (ENT)

52. Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis ) . ( Aligns with AAFP, AAAAI) Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure. Computed tomography (CT) scans are not necessary in the routine evaluation of abdominal pain . ( Aligns with ACR ) Choosing Wisely: AAP

53. Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present . ( Aligns with ACP) Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients. Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery . Choosing Wisely: ACC

54. Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age . ( Collaborative with AAFP) Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable . ( Collaborative with AAFP ) Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age. Don’t screen for ovarian cancer in asymptomatic women at average risk. Choosing Wisely: ACOG

55. Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease . ( Aligns with ACC ) Don’t obtain imaging studies in patients with non-specific low back pain . ( Aligns with AAFP ) In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI) . ( Similar to AAN ) In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. ( Aligns with ACR ) Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. Choosing Wisely: ACP

56. Don’t do imaging for uncomplicated headache. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. ( Aligns with ACP ) Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam . ( Similar to ACP ) Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option . ( Aligns with AAP ) Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. Choosing Wisely: ACR

57. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. Don’t routinely repeat DXA scans more often than once every two years . Choosing Wisely: ACR (Rheum)

58. For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals. Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals. Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy. Choosing Wisely: AGA

59. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding . ( Also listed by AAHPM ) Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Choosing Wisely: AGS

60. Don’t perform population based screening for 25-OH-Vitamin D deficiency. Avoid routine preoperative testing for low risk surgeries without a clinical indication . Choosing Wisely: ASCP

61. Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms . Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/ dL without symptoms of anemia. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes. Choosing Wisely: ASN

62. Don’t prescribe testosterone to men with erectile dysfunction who have normal testosterone levels . Choosing Wisely: AUA

63. Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who develop first episode of deep vein thrombosis (DVT) in the setting of a known cause. Don’t reimage DVT in the absence of a clinical change. Avoid cardiovascular testing for patients undergoing low-risk surgery . (Aligns with ACC) Choosing Wisely: SVM

64. Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications. Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke. Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability. Choosing Wisely: SHM-adult

65. Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. Don’t routinely use bronchodilators in children with bronchiolitis. Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy. Choosing Wisely: SHM- peds

66. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present . (ASNC) Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely. (ASNC) Avoid using a computed tomography angiogram to diagnose pulmonary embolism in young women with a normal chest radiograph; consider a radionuclide lung study (“V/Q study”) instead . (SNMMI) Choosing Wisely: Advanced Imaging

67. Don’t use coronary artery calcium scoring for patients with known coronary artery disease (including stents and bypass grafts). Don’t order coronary artery calcium scoring for preoperative evaluation for any surgery, irrespective of patient risk. Don’t order coronary artery calcium scoring for screening purposes on low risk asymptomatic individuals except for those with a family history of premature coronary artery disease. Don’t routinely order coronary computed tomography angiography for screening asymptomatic individuals. Choosing Wisely: SCCT