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Choosing Wisely

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Title: Choosing Wisely


1
Choosing Wisely Culture, Strategy and
Transformation
John Santa MD MPH Medical Director, Consumer
Reports Health April 9, 2014
2
Disclosures
  • General internist, most recent practice at the VA
    in 2008.
  • Employed by Consumers Reports
  • Independent of industry, non profit, non
    partisan, consumer advocacy organization.
  • Multimedia company, publisher of Consumer
    Reports, ConsumerReports.org
  • 20 million readers a month, older, affluent, well
    educated, savvy buyers
  • Focused for 78 years on providing an alternative
    perspective to advertising and promotion
  • All Choosing Wisely content available free at
    www.ConsumerHealthChoices.org

3
Comments on Vermont
  • Choosing Wisely physician partners
  • ACP, AAFP, AAP, ASCO, ACOG
  • Choosing Wisely consumer partners
  • AARP
  • Employers
  • Unions
  • Culture of innovation
  • Health reform
  • Overuse

4
  • A successful communication campaign
  • Focused on professionalism
  • Stimulating culture change
  • More is not better
  • Create conversations about overuse
  • Communicating what not to do

5
  • Choosing Wisely is an initiative of the ABIM
    Foundation to help physicians and patients engage
    in conversations about the overuse of tests and
    procedures and support physician efforts to help
    patients make smart and effective care choices.

6
(No Transcript)
7
ACP Foundation/ABIM Foundation/EFIM Physician
Charter
  • A Commitment to
  • Professional competence
  • Honesty with patients
  • Patient confidentiality
  • Maintaining appropriate relations with patients
  • Improving quality of care
  • Improving access to care
  • A just distribution of finite resources
  • Scientific knowledge
  • Maintaining trust by managing conflicts of
    interest
  • Professional responsibilities
  • Fundamental Principles
  • Primacy of patient welfare
  • Patient autonomy
  • Social justice

8
Medicine's Ethical Responsibility for Health Care
Reform The Top Five List
  • A Top 5 list also has the advantage that if we
    restrict ourselves to the most egregious causes
    of waste, we can demonstrate to a skeptical
    public that we are genuinely protecting patients
    interests and not simply rationing health care,
    regardless of the benefit, for cost-cutting
    purposes.
  • Howard Brody, MD, PhD
  • New England Journal of Medicine

9
The Top 5 Lists
  • Funded by an ABIM Foundation grant, the National
    Physicians Alliance conceived and piloted the
    concept through its Good Stewardship Working
    Group
  • Developed lists of top five activities in family
    medicine, internal medicine, and pediatrics where
    the quality of care could be improved
  • Published in Archives of Internal Medicine
  • Subsequent research published in Archives found a
    cost savings of more than 5 billion could be
    realized if the recommendations were put in to
    practice.

10
Components of the Campaign
  • Messengers and Collaborators
  • 60 specialty societies and Consumer Reportsand
    growing
  • Communicate Messages
  • Specialty societies, Consumer Reports, consumer
    organizations and ABIM Foundation
  • Activate
  • Concrete action around unnecessary tests and
    procedures

11
How the Lists Were Created
  • Societies were free to determine the process for
    creating their lists with the following
    requirements
  • Each item was within the specialtys purview and
    control
  • Procedures should be used frequently and/or carry
    a significant cost
  • Should be generally-accepted evidence to support
    each recommendation
  • Process should be thoroughly documented and
    publicly available upon request

12
Choosing Wisely Partners
  • Societies That Announced Lists April 2012
  • American Academy of Allergy Asthma Immunology
  • American Academy of Family Physicians
  • American College of Cardiology
  • American College of Physicians
  • American College of Radiology
  • American Gastroenterological Association
  • American Society of Clinical Oncology
  • American Society of Nephrology
  • American Society of Nuclear Cardiology
  • Societies That Announced Lists February 2013
  • American Academy of Family Physicians
  • American Academy of Hospice and Palliative
    Medicine
  • American Academy of Neurology
  • American Academy of Ophthalmology
  • American Academy of Otolaryngology-Head and Neck
    Surgery
  • American Academy of Pediatrics
  • American College of Obstetricians and
    Gynecologists
  • American College of Rheumatology
  • American Geriatrics Society
  • American Society for Clinical Pathology
  • American Society of Echocardiography
  • American Urological Association
  • Society of Cardiovascular Computed Tomography
  • Society of Hospital Medicine
  • Society of Nuclear Medicine and Molecular Imaging
  • Society of Thoracic Surgeons
  • Society of Vascular Medicine

13
  • Societies Announcing Lists Later in 2013
  • American Academy of Dermatology
  • American Academy of Family Physicians
  • American Academy of Orthopaedic Surgeons
  • American Association of Clinical Endocrinologists
  • American Association for Pediatric Ophthalmology
    and Strabismus
  • American College of Chest Physicians
  • American College of Emergency Physicians
  • American College of Rheumatology
  • American College of Surgeons
  • American Headache Society
  • AMDADedicated to Long Term Care Medicine
  • American Society of Clinical Oncology
  • American Society of Hematology
  • American Society for Radiation Oncology
  • American Thoracic Society
  • Heart Rhythm Society
  • North American Spine Society
  • Society of Critical Care Medicine
  • Society of General Internal Medicine
  • Consumer Groups
  • Through Partnership with Consumer Reports
  • AARP
  • Alliance Health Networks
  • Leapfrog Group
  • Midwest Business Group on Health
  • Minnesota Health Action Group
  • National Business Coalition on Health
  • National Business Group on Health
  • National Center for Farmworker Health
  • National Hospice and Palliative Care Organization
  • National Partnership for Women Families
  • Pacific Business Group on Health
  • SEIU
  • Union Plus
  • Univision (with HolaDoctor)
  • The Wikipedia Community

14
Measures of Success
  • Featured in Medscape's The Year in Medicine
    2012 News That Made a Difference
  • 14 Medscape articles reaching 87,171 physicians
  • More than 420,400 physicians reached through
    specialty society communications. Hundreds of
    thousands more with second release.
  • 55 journal articles reaching nearly 4 million.
    More on the way.
  • 300 million media impressions from first release
    including New York Times, Washington Post,
    Vogue, ABC, NBC, CBS, PBS. Many millions more
    from second release.
  • 40 patient-friendly translations of materials
  • More than 100 million reached through Consumer
    Reports partnerships with consumer/employer
    groups

15
Whats Next?
  • Additional specialties have joined the campaign
    and will release lists in late 2013 and into 2014
  • Advancement of campaign in local communities
    through a grant from the Robert Wood Johnson
    Foundation
  • Rollout of Consumer Reports patient-focused
    materials

16
ACP Behavior change in the physician community
  • Establish principles for driving behavior
  • Identify the specific targets for behavior change
  • Spread the word through multiple channels
  • Change the culture of the training environment
  • Collaborate with others on the common goal(s)

17
Robust Topic Themes135 Choosing Wisely Topics
  • Screening tests (20)
  • EKG
  • Exercise test
  • Pap smear
  • Bone density
  • Heart imaging
  • Colon cancer
  • Diagnostic testing (31)
  • Low back pain
  • Headache
  • Allergy
  • Fainting
  • Preoperative evaluations (11)
  • Chest Xray
  • Heart imaging
  • Common treatments (28)
  • Antibiotics (8)
  • Opioids (4)
  • Heartburn meds
  • Anti-inflammatories
  • Routine FU/Monitoring (12)
  • Disease approach
  • Cancer (21)
  • Chronic kidney failure/dialysis (4)
  • Heart disease (21)
  • Maternity (4)

18
Cross Cutting Categories
  • Imaging---55 topics
  • CT scans (19)
  • MRI/Ultrasoundno radiation (14)
  • Drugs---23 topics
  • Antibiotics (8)
  • Antipsychotics/benzos/sedatives
  • Opioids (4)
  • Several (5) actively advertised
  • Women---28 topics
  • Specific to women (14)
  • More common in women (4)
  • Important children topics (10)

19
Screening Topics
  • EKGheart disease
  • Nuclear Stress testheart disease
  • Stress Echo---heart disease
  • Pap Smear (4 topics)---cervical cancer
  • Bone Density---osteoporosis
  • Colonoscopy---colon Cancer
  • Stress, Advanced Imaging---heart disease
  • Bone Density testing intervals---osteoporosis
  • Carotid Ultrasound---stroke
  • CA125 and vaginal ultrasound---ovarian cancer
  • Vit D levels---osteoporosis
  • HPV testing---HPV in low risk women
  • Methylated Septin---colorectal cancer
  • PET/CT---cancer screening
  • Coronary artery calcium scoring---heart disease
  • Coronary computed tomographic angiography---heart
    disease

20
Drugs
  • Oral antibioticsmild moderate sinusitis
  • Immunoglobulin therapy---recurrent infections
  • PPIs---GERD
  • NSAIDS---HBP,CKD,CHF
  • Oral antibiotics---external ear infection
  • Oral antibiotics---viral infections
  • Tight glycemic control---elderly
  • Oral antibiotics---bactreria in urine, no
    symptoms
  • Benzos/sedativehypnotics---older adults
  • Antipsychotics---older adults with agitation
  • Opioids/Butalbital---migraine
  • Interferon/Glatirimir---disabled MS patients
  • Antibiotics---adenoviral conjunctivitis
  • Antibiotics---before intravitreal infections
  • Biologics---RA w/o metotrexate first
  • Testosterone---Erectile dysfunction pts with
    normal testosterone
  • Antibiotics---men with PSA
  • Anti nausea gels---hospice patients

21
Opioids
  • American College of Occupational and
    Environmental Medicine
  • Dont prescribe opioids for treatment of chronic
    or acute pain for workers who perform
    safety-sensitive jobs such as operating motor
    vehicles, forklifts, cranes or other heavy
    equipment.
  • The use of both strong and weak opioids has been
    consistently associated with increased risk of
    motor vehicle crashes as opioids produce sedation
    and hinder or impair higher cognitive function.
    Evidence suggests higher risk with acute opioid
    use, but risk remains elevated throughout
    treatment with any opioid and reverses on
    cessation.
  • American Society of Anesthesiologists Pain
    Medicine
  • Dont prescribe opioid analgesics as first-line
    therapy to treat chronic non-cancer pain.
    Physicians should consider multimodal therapy,
    including non-drug treatments such as behavioral
    and physical therapies prior to pharmacological
    intervention. If drug therapy appears indicated,
    non-opioid medication (e.g., NSAIDs,
    anticonvulsants, etc.) should be trialed prior to
    commencing opioids.
  • Dont prescribe opioid analgesics as long-term
    therapy to treat chronic non-cancer pain until
    the risks are considered and discussed with the
    patient
  • Patients should be informed of the risks of such
    treatment, including the potential for addiction.
    Physicians and patients should review and sign a
    written agreement that identifies the
    responsibilities of each party (eg urine drug
    testing) and the consequences of non-complianse
    with the agreement.
  • American Academy of Neurology
  • Dont use opioid or butalbital treatment for
    migraine except as a last resort.
  • Opioid and butalbital treatment for migraine
    should be avoided because more effective,
    migraine-specific treatments are available.
    Frequent use of opioid and butalbital treatment
    can worsen headaches. Opioids should be reserved
    for those with medical conditions precluding the
    use of migraine-specific treatments or for those
    who fail these treatments.

22
New TopicsMy Favorites
  • AMDA Long Term Care Medicine
  • Don't routinely prescribe lipid lowering
    medications in individuals with a limited life
    expectancy.
  • American College of Surgeons
  • Do not perform axillary lymph node dissection for
    clinical stages I and II breast cancer with
    clinically negative lymph nodes without
    attempting sentinel node biopsy.
  • Commission on Cancer
  • Do not perform surgery to remove a breast lump
    for suspicious findings unless needle biopsy
    cannot be done.
  • AAOS
  • Do not use glucosamine and chondroitin to treat
    patients with symptomatic osteoarthritis of the
    knee.
  • Society of General Internal Medicine
  • Dont perform routine general health checks for
    asymptomatic adults.

23
New Topics
  • American Psychiatric Association
  • Dont routinely prescribe antipsychotic
    medications as a first-line intervention for
    children and adolescents for any diagnosis other
    than psychotic disorders.  
  • American Society for Radiation Oncology
  • Dont initiate management of low risk prostate
    cancer without discussing active surveillance.
  • Dont routinely recommend proton beam therapy for
    prostate cancer outside a prospective clinical
    trial or registry.
  • American Academy of Family Physicians
  • Do not routinely screen for prostate cancer using
    a prostate-specific antigen (PSA) test or digital
    rectal exam.
  • Do not require a pelvic exam or other physical
    exam to prescribe oral contraceptive medications.
  • American College of Medical Toxicology and the
    American Academy of Clinical Toxicology
  • Do not remove mercury-containing dental amalgams

24
Robust Topics
  • Approach to poor prognosis solid cancer treatment
  • Approach to monitoring curative breast cancer
    patients post treatment
  • Prostate cancer screening and treatment
  • Approach to stenting of non culprit lesions
  • Monitoring of patients post heart procedures
  • Overall---tens of millions of decisions, tens of
    billions of dollars

25
Consumer Reports
  • Consumer Reports is a partner in Choosing Wisely
    and will support the effort by creating
    patient-friendly materials based on the society
    recommendations and engaging a coalition of
    consumer communication partners to disseminate
    content and messages about appropriate use to the
    communities they serve.
  • Tools and resources can be found at
    www.consumerhealthchoices.org.

26
Communicating What Not to Do
  • Go where people are (Wikipedia Vogue)
  • Talk about what they are talking about (usually
    benefits) and connect your dots to theirs (risk,
    waste)
  • Use safety if you can
  • Use empathic stories
  • Provide structure for decision making (consumers
    wary of not following doctor advice)

27
Stimulating Culture Change
  • Large scale information campaign focused on
    doctors and patients and their interaction
  • Use trusted brands---Consumer Reports, Physician
    specialty societies
  • Organize community consortiums willing to take on
    overuse
  • Use all appropriate distribution channels
    including carriers but focus on culture change
    that prepares for strategies.

28
Sample Content
29
Free for consumers
  • 50 brochure topics
  • All in English and Spanish
  • Two-page PDF format
  • Suited for home printing
  • Suited for email, linking
  • Suited for clinic racks

30
Consumer ReportsHeart Disease Survey
31
Consumer Response
  • Findings from a December 2012 Consumer Reports
    survey of 2,669 consumers who received Choosing
    Wisely information
  • 72 agreed that it had changed their opinion of
    the topic, taught them new information, or
    prompted them to ask more questions of their
    health provider.
  • 81 of consumers reporting interest in a Choosing
    Wisely topic said they were likely to have a
    conversation with their physician about what they
    had read.
  • In the case of one topic (back pain), 85
    intended to have a conversation with their
    doctor.

32
5 Questions to Ask Your Doctor
  • Do I really need this?
  • What are the downsides?
  • Are there simpler, safer options?
  • What happens if I do nothing?
  • How much does it cost?

33
ConsumerHealthChoices.org
34
Partner Highlights
  • AARP
  • AARP Bulletin published 7 Medical Tests and
    Treatments You May Not Really Need in its May
    2012 issue. AARP Bulletin has a circulation of
    around 28 million readers.
  • AARP has also covered Choosing Wisely in its
    radio, television, and online channels in English
    and Spanish.
  • Business Coalitions and Employer Groups
  • Consumer Reports has collaborated with a number
    of coalitions representing organizations that
    collectively represent tens of millions of
    employees, patients, and their families.
  • These include The Leapfrog Group, Midwest
    Business Group on Health (MBGH), Minnesota Health
    Action Group, National Business Coalition on
    Health (NBCH), National Business Group on Health
    (NBGH), and Pacific Business Group on Health
    (PBGH).
  • Each has developed unique channels and tools to
    explain Choosing Wisely to their members and
    communicate with employees.
  • These include popular webinars and member
    briefings (NBGH) and a new Choosing Wisely
    Employer Toolkit (PBGH with NBCH) along with
    email newsletters, speaker events, member
    websites, and other outreach.

34
www.consumerhealthchoices.org
35
Partner Highlights
  • The Wikipedia Community
  • Consumer Reports welcomed Lane Rasberry as
    Wikipedian in Residence in May 2012 with support
    from the Wikimedia Foundation.
  • This opportunity has enabled Consumer Reports to
    collaborate with the volunteer Wikipedia
    community and specialty societies to improve
    health articles on Wikipedia by including
    relevant information and citations from the
  • Top Five lists of the specialty societies
    participating in Choosing Wisely.
  • Since September 2012, there have been an
    estimated 30 million page views of Wikipedia
    articles containing information about appropriate
    use of tests, treatments, and procedureseach
    referencing Choosing Wisely.

35
www.consumerhealthchoices.org
36
ABIMF/Drexel Videos
  • Multiple videos focused on specific overuse
    situations
  • Adheres to straightforward principles
  • Empathy and alternative plan
  • Available at http//www.choosingwisely.org/resour
    ces/modules/

37
Choosing Wisely in Local Communities
Washington State Medical Association
38
What to do?
  • Continue culture change efforts
  • Educate all about these tests
  • Benefit/Risk, downstream implications
  • SAY IT SEVEN TIMES
  • Take on inappropriate demand strategies
  • Online promotion, health fairs, wellness
    screenings
  • Conversations about advertising and promotion
  • Stop incentives that rely on creating
    inappropriate demand

39
Critical Competencies
  • Independence
  • Transparency
  • Good data
  • Robust collaboration
  • Confrontation skills
  • Advocate for consumers

40
Time for Strategies??
  • Culture prepared. Leadership opportunity?
  • From single topics to broad areas of overuse
  • From one on one conversations to a practice
    dialogue. Doctors talk to doctors
  • Integrate Choosing Wisely into the purchasing
    process
  • Right size care
  • Influence the Standard of Care

41
From Single Topics to Broad Areas of Overuse
  • Screeningespecially heart disease (18 topics)
  • Preop testing in low risk folks and low risk
    surgery
  • (11 topics)
  • Drugs---especially antibiotics (12 topics) and
    those advertised
  • Imaging---especially those involving radiation
  • (19 topics)
  • Safetyespecially elective delivery,
    inappropriate induction
  • Cancer
  • Renal Failure
  • Consumer Reports preparing roll ups that cover
    multiple topics

42
Doctors Talk to Doctors
  • Two doctor approval---hard stops
  • Early elective delivery
  • Two doctor prescriptions---Opioids??
    Testosterone??
  • In the electronic record
  • Cedar Sinai
  • As part of other national campaigns
  • ACC FOCUS--Formation of Optimal Cardiovascular
    Utilization Strategies
  • Image Gently/Image Wisely
  • In the practice infrastructure
  • Henry Ford
  • Westmed Medical Group (Westchester County NY)

43
Scott Weingarten, MDSenior VP and Chief Clinical
Transformation OfficerCedars-Sinai Health System
75 of decision support interventions succeed
when the information is provided to clinicians
automatically, whereas none succeed when
clinicians are required to seek out the advice
Alerts gt 100 per day
44
Purchasing Process
  • Value Based Benefit Design
  • Tiered benefit design (like drug benefit)
  • Start with carrots, work on sticks
  • As part of transparency processes
  • Provide price and whether potential overuse
  • As part of incentives and disincentives
  • Remove overused services from production
    incentives until right sized
  • Remove upstream screening to reduce downstream
    overuse

45
Right Size Care
  • Insist that demand strategies be evidence based
    not revenue based
  • And include risk
  • Address disparities aggressively
  • Integrate into routine care

46
Change the Standard of Care
  • Standard of Care
  • the watchfulness, attention, caution and
    prudence that a reasonable person in the
    circumstances would exercise
  • Clinical Practice
  • relating to or based on work done with real
    patients
  • the learned profession that is mastered by
    graduate training in a medical school and that is
    devoted to preventing or alleviating or curing
    diseases and injuries

47
When youre through learning, youre through.
  • John Wooden
  • Former UCLA basketball coach

48
John Santa
  • santjo_at_consumer.org
  • http//consumerhealthchoices.org/campaigns/choosin
    g-wisely/
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