Choosing Wisely What is it and why should I know?

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1 Choosing Wisely What is it and why should I know? Tristan Boyd and Shirley Chow May 25, 2014 (10:30 11:30 a.m.)

2 Learning Objectives To discuss low-value testing, resource stewardship and barriers in providing high-quality care. To present the process for implementing and sustaining change using the CRA Choosing Wisely campaign as a framework. To review the the top 5 CRA Choosing Wisely recommendations and their evidence.

3 Disclosures None.

4 Outline for the next hour 1. Why do we overuse healthcare resources unnecessarily? - Clinical vignettes with discussion. 2. What is Choosing Wisely? - Framing the challenges: low-value testing + resource stewardship. - Background on Choosing Wisely Canada. 3. Canadian Rheumatology Association Top 5 items. 4. What can we do to advance resource stewardship? - Discussion on quality improvement strategies to bridge the gap between education and implementation.

5 Scenario 1 37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:80 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, and inflammatory markers. Comorbidities include hypertension, rosacea, fibromyalgia, and depression. Current medications: hydrochlorothiazide, duloxetine, and topical metronidazole. Is there high suspicion of SLE in this patient? Was ANA a low-value test to perform in this patient? How might this positive test lead to further unnecessary testing and harm to patient?

6 Scenario 2 24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm). Does knowing HLA-B27 status change diagnosis or influence management in this patient? If HLA-B27 was positive, would you order an x-ray or MRI to look for evidence of sacroiliitis? Would you consider starting biologic therapy? If patient had more clear-cut inflammatory back pain ( 3 months, AM stiffness >60 min., response to NSAIDs) PLUS enthesitis and history of uveitis, would HLA-B27 be helpful?

7 Scenario 3 58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (Tscores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28. Should this patient be prescribed bisphosphonate therapy? What are the risks/benefits? When should her bone mineral density be repeated?

8 Discussion What are barriers that prevent appropriate use of finite health resources? What are the enablers that promote inappropriate use of finite healthcare resources? What barriers and/or enablers pose the greatest threat to the appropriate use of finite health care resources?

9 Why do we use health care resources unnecessarily? Habit/pre-printed order forms Pre-emptive ordering Reassurance Thoroughness Referring doctor requesting test Patient requesting test Fear of litigation

10 30% of what is spent in health care does NOT add value! Berwick D. JAMA

11 What is Choosing Wisely Canada? A national campaign encouraging physicians and patients to engage in conversations about the overuse of tests, treatments and medical procedures. Help physicians and patients make informed and effective choices. Limit exposure to unnecessary or potentially harmful tests, treatments and procedures while ensuring patients get the care they need.

12 What is Choosing Wisely? Modeled after the Choosing Wisely campaign in U.S. Over 60 US and 30 Canadian societies have joined thus far (at different stages of list development). Focus is on tests, treatments and procedures for which there is concrete evidence of no benefit to patients.

13 Physician List Development Societies free to determine process List items must be within society s purview List items must be frequent Must be evidence to support list items Process must be publicly available 13

14 Dispel notion that More Care is Better Care The number of available tests, treatments and procedures in modern medicine is large and growing. Just because something is available doesn t mean we should use it. Unnecessary tests, treatments and procedures do not add value to patient care. Potentially hazardous to the health of patients.

15 Based on best available evidence. Top 5 list. NOT a list of rules!

How the List was Created July 2013 Choosing Wisely Committee Formed 16 members Aug/ Sept 2013 Item identification: Delphi Survey Round 1 n=64 items Round 2 n=24 items Round 3 n=13 items Sept/ Oct

16 How the List was Created July 2013 Choosing Wisely Committee Formed 16 members Aug/ Sept 2013 Item identification: Delphi Survey Round 1 n=64 items Round 2 n=24 items Round 3 n=13 items Sept/ Oct 2013 CRA Membership Survey (172) n=13 items Oct 2013 Methodology Subcommittee Review and Item Selection n=5 items Oct/Nov 2013 Literature and Guideline Review Nov/Dec 2013 Dec 2013 Spring 2014 Review and revision CRA Board and Patient Consumers Review Wave 1 launch Website launched Information disseminated

Multidisciplinary Working Group Rheumatologist (16) Rheumatology trainee (5) Allied health provider (1) Patient Consumer (3) Coordinator (1) Robert Ferrari, MD FRCPC Pooneh Akhavan, MD FRCPC Claire

17 Multidisciplinary Working Group Rheumatologist (16) Rheumatology trainee (5) Allied health provider (1) Patient Consumer (3) Coordinator (1) Robert Ferrari, MD FRCPC Pooneh Akhavan, MD FRCPC Claire Bombardier, MD FRCPC Vivian Bykerk, MD FRCPC Glen Hazlewood, MD FRCPC James Pencharz, MD CCFP Janet Pope, MD FRCPC John Thomson, MD FRCPC Carter Sylvie Thorne, Ouellette, MD MD FRCPC FRCPC Chris Debow Glen Hazlewood, MD FRCPC Nadia Luca, MD FRCPC Lyddiatt Carter Thorne, MD FRCPC Christine Charnock Proton Rahman, MD FRCPC Jennifer Burt Ann Marie Colwill, MD FRCPC Pooneh Akhavan, MD FRCPC Mary Bell, MD FRCPC Shirley Chow, MD FRCPC Gregory Choy, MD FRCPC Natasha Gakhal, MD FRCPC Michelle Jung, MD FRCPC Tristan Boyd, MD FRCPC Bindee Kuriya, MD FRCPC Dharini Mahendira, MD FRCPC Zarnaz Bagheri, MD FRCPC Damian Frackowick, MD FRCPC Dawn Richards Martin Cohen, MD FRCPC Edith Villeneuve, MD FRCPC Peter Tugwell, MD FRCPC Anne Lyddiatt

18 What were our Top 5 topics?

19 Recommendation 1 1. Don t order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus (SLE) or another connective tissue disease (CTD). Guidelines: American College of Pathologists British Columbia Ministry of Health American College of Rheumatology Italian Society of Laboratory Medicine Guidelines

20 Scenario 1 37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:80 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, and inflammatory markers. Comorbidities include hypertension, rosacea, fibromyalgia, and depression. Current medications: hydrochlorothiazide, duloxetine, and topical metronidazole. Is there high suspicion of SLE in this patient? Was ANA a low-value test to perform in this patient? How might this positive test lead to further unnecessary testing and harm to patient?

21 Scenario 1 Discussion 37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:160 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, inflammatory markers. Comorbidities: hypertension, rosacea, fibromyalgia, and depression. Medications include hydrochlorothiazide, duloxetine, and topical metronidazole. ANA testing should not be used to screen subjects without specific symptoms (e.g., photosensitivity, malar rash, symmetrical polyarthritis, etc.) or without a clinical evaluation that may lead to a presumptive diagnosis of SLE or other CTD. ANA reactivity is present in many non-rheumatic conditions and even in healthy control subjects (up to 20%). In patients with low-test probability, positive ANA results can be misleading and may precipitate further unnecessary testing, erroneous diagnosis or even inappropriate therapy.

22 Pre-test and Post-test Probability

23 Changes to Referral Patterns

24 Recommendation 2 2. Don t order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. Guidelines: Assessment of SpondyloArthritis International Society (ASAS) Guidelines 3e Initiative in Rheumatology

25 Scenario 2 24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm). Does knowing HLA-B27 status change diagnosis or influence management in this patient? If HLA-B27 was positive, would you order an x-ray or MRI to look for evidence of sacroiliitis? Would you consider starting biologic therapy? If patient had more clear-cut inflammatory back pain ( 3 months, AM stiffness >60 min., response to NSAIDs) PLUS enthesitis and history of uveitis, would HLA-B27 be helpful?

26 Scenario 2 Discussion 24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm). HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without further spondyloarthropathy (SpA) signs or symptoms. If HLA-B27 is used, at least 2 SpA signs or symptoms, or the presence of positive imaging findings, need to be present to classify a patient as having axial SpA. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

28 Recommendation 3 3. Don t repeat dual energy X-ray absorptiometry (DEXA) scans more often than every 2 years. Guidelines: 2010 Clinical Practice Guidelines for the diagnosis and management of osteoporosis in Canada 2013 international society for clinical densitometry position development conference on bone densitometry U.S. Preventive Services Task Force recommendation statement

29 Recommendation 4 4. Don t prescribe bisphosphonates for patients at low risk of fracture. Guidelines: 2010 Clinical Practice Guidelines for the diagnosis and management of osteoporosis in Canada FRAX WHO Fracture Risk Assessment Tool Cochrane Database Systematic Reviews

30 Scenario 3 58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (Tscores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28. Should this patient be prescribed bisphosphonate therapy? What are the risks/benefits? When should her bone mineral density be repeated?

31 Scenario 3 Discussion 58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (Tscores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28. There is no convincing evidence that anti-osteoporotic therapy in patients with osteopenia alone reduces the risk of fracture. Given the lack of proven efficacy, widespread use of bisphosphonates in patients at low risk of fracture is not currently recommended. The use of repeat DEXA scans at intervals of every 2 years is appropriate in most clinical settings, and is supported by several current osteoporosis guidelines.

32 Recommendation 5 5. Don t perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adults. The diagnosis of peripheral and axial inflammatory arthritis can usually be made on the basis of an appropriate history, physical exam and basic investigations. Whole body bone scans, such as the Tc-99m MDP scintigraphy, lack specificity to diagnose inflammatory polyarthritis and spondyloarthritis and have limited clinical utility. The equivalent of radiation exposure of a total whole body bone scan is reported as over 40 routine chest X-rays, thus posing risk.

33 Some Limitations No definitive data to show that these tests are currently overused. No data to show cost-effectiveness from altered practice. Level of evidence for some of recommendations is variable.

34 Bridging the gap How are we getting our message across?

35 Print Resources

37 Patient Materials Plain language Canadianspecific Evidencebased Specialty societies & Consumer Reports Health developed materials that are: Easily accessible Educational

40 resources/campaign-videos/ 2014/04/01/x-ray-or-mri-lets-thinkagain/

41 Implementing and Sustaining Change Twitter

42 Discussion: Implementing and Sustaining Change What can we all do in the next year to advance resource stewardship?

43 Conclusions Rheumatology professionals can and should be able to identify low-value testing, resources stewardship and barriers in providing high-quality care. Rheumatologists and healthcare providers can provide leadership in implementing and sustaining change using the CRA Choosing Wisely campaign as a framework. 43

Acknowledgements Working Group Dr. Mary Bell Jennifer Burt Christine Charnock Dr. Shirley Chow Dr. Gregory Choy Dr. Martin Cohen Dr. Robert Ferrari Dr. Natasha Gakhal Dr. Nadia Luca Dr.

44 Acknowledgements Working Group Dr. Mary Bell Jennifer Burt Christine Charnock Dr. Shirley Chow Dr. Gregory Choy Dr. Martin Cohen Dr. Robert Ferrari Dr. Natasha Gakhal Dr. Nadia Luca Dr. Dharini Mahendira Dr. Sylvie Ouellette Dr. Proton Rahman Dawn Richards Dr. Carter Thorne Dr. Edith Villeneuve Dr. Diane Wilson Methodology Dr. Pooneh Akhavan Dr. Robert Ferrari Dr. Glen Hazelwood Dr. Bindee Kuriya Dr. Peter Tugwell Fellows Zarnaz Bagheri Ann-Marie Colwill Damian Frackowick Michelle Jung Tristan Boyd Special Thanks to Dr. Jinoos Yazdany Dr. Wendy Levinson Karen McDonald Tai Huynh Virginia Hopkins Sharon Brinkos Tamara Rader Ekaterina Petkova Laura Corbett Corinne Holobowich Kellee Kaulback

45 Thank you! Questions? Comments?

Choosing Wisely Next Steps

Choosing Wisely Next Steps Carter Thorne Past President CRA Sunday 24May2015 Learning Objectives To discuss low-value testing, resource stewardship and barriers in providing high-quality care To present