Choosing Wisely Easier Said Than Done

1. NPA Good Stewardship Project Director Stephen R. Smith, MD, MPH Professor Emeritus of Family Medicine Warren Alpert Medical School of Brown University Choosing WiselyEasier Said Than Done

2. 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.

3. 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”)

4. The Physician Charter the wise and cost-effective management of limited clinical resources

5. Stewardship Protecting resources for future generations

6. Health Care Costs Billions $

7. What Physicians Can Do

8. Physician’s Role • Overuse • Too soon • Too often • Too easily • Misuse • Not indicated • Not supported by evidence • Not the first choice

9. Physician’s Role • Overuse • Too soon MRI for low back pain • Too often • Too easily • Misuse • Not indicated • Not supported by evidence • Not the first choice

10. Physician’s Role • Overuse • Too soon • Too often Yearly Paps, colonoscopy • Too easily • Misuse • Not indicated • Not supported by evidence • Not the first choice

11. Physician’s Role • Overuse • Too soon • Too often • Too easily“Belly aches” to GI • Misuse • Not indicated • Not supported by evidence • Not the first choice

12. Physician’s Role • Overuse • Too soon • Too often • Too easily • Misuse • Not indicated Antibiotics for colds • Not supported by evidence • Not the first choice

13. Physician’s Role Coronary Calcium Scans for Screening for Heart Disease in Asymptomatic Patients • Overuse • Too soon • Too often • Too easily • Misuse • Not indicated • Not supported by evidence • Not the first choice

14. Physician’s Role • Overuse • Too soon • Too often • Too easily • Misuse • Not indicated • Not supported by evidence • Not the first choice Xopenex vs albuterol

15. NPA Project • 5 Things You Can Do in Your Practice (Family Medicine, Internal Medicine, & Pediatrics) • 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

16. 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….”

17. Top 5 List—Family Medicine • Don't do imaging for low back pain within the first six weeks unless “red flags” are present • Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis within the first 7 days • Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors • Don't order annual EKGs or any other cardiac screening for asymptomatic, low-risk patients • Don't perform Pap smears under the age of 21 or in women status post hysterectomy for benign disease

18. Top 5 List—Internal Medicine • Don't do imaging for low back pain within the first six weeks unless “red flags” are present • Don't obtain blood chemistry panels (e.g. CMP, SMA-7, BMP) or urinalyses for screening in asymptomatic, healthy adults • Don't order annual EKGs 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 or men under 70 with no risk factors

19. Top 5 List—Pediatrics • Don’t obtain imaging for minor head injuries without loss of consciousness or other risk factors • Advise parents not to use cough and cold medications • Use inhaled corticosteroids to control asthma appropriately • Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus • Don't refer otitis media with effusion (OME) early in the course of the problem

20. Published “Top 5” Lists

21. 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

22. Training videos Clarify patient’s true concerns Provide information Be courteous and respectful Provide clear contingency plan Assure patient agreement with plan Phase 2 YouTube: Good Stewardship http://www.youtube.com/watch?feature=endscreen&NR=1&v=FbEjy_QVRXA

23. 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

24. Good Stewardship Demonstration

25. Choosing Wisely Campaign • ABIM Foundation • 70+ Specialty Societies • 500,000+ physicians • More societies to join soon • Each develops their own “Top 5” list Choosingwisely.org

26. Choosing Wisely International

27. Consumer Reports

28. Recent Article

29. Some Courageous “Top 5” Items • 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

30. Challenges to Change • 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. • Fear of not being able to refer to specialist without more testing.

31. Potential Solutions • 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)

32. Caveats