Choosing Wisely Next Steps

Transcription

1 Choosing Wisely Next Steps Carter Thorne Past President CRA Sunday 24May2015

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 Choosing Wisely campaign as a framework To review the the 5 CRA Choosing Wisely recommendations and their evidence.

3 Disclosures Not Applicable

4 Issue of medical overuse

5 Medical overuse facts IOM - 30% of health care spending wasteful, no added value to patient care Saskatchewan study - pre-school children with respiratory infections 50% of prescriptions inappropriate 2 teaching hospitals in Alberta and Ontario: 28% of lumbar spine MRIs inappropriate (27% uncertain value) 9% of head scans for headache inappropriate (+ 8% questionable) CWC study - 28% of bone mineral density (DEXA) scans and 37% of pre-operative tests in Ontario inappropriate

6 Cultural factors Systems factors Physician and patient factors Overuse

7 Berwick D. JAMA

8 Physicians determine care 1. Which patients are seen and how frequently 2. Which patients are hospitalized 3. Which tests, procedures and surgical operations are administered 4. Which technologies are used 5. Which medications are prescribed Emanuel EJ. JAMA

9 I ve always done this The patient wants it $$ New tests are good I don t want to get sued Referring doctor wants it Better to do something than nothing

10 Choosing Wisely campaign

11 What is Choosing Wisely Canada? A national campaign, led by the medical profession to: Help physicians and patients engage in conversations about unnecessary tests, treatments and procedures Help physicians and patients make smart and effective choices Ensure patients get care they need and avoid tests, treatments and procedures that could cause harm 11

12 Objectives 1. To encourage physicians to engage in conversations with patients about the overuse of tests, treatments and medical procedures. 2. To empower patients to make informed choices, in consultation with their physicians, about getting the right care while limiting exposure to unnecessary tests, treatments and medical procedures. 3. To cultivate a culture of responsible stewardship of health care resources among physicians from those in medical schools to those in professional practice. 4. To engender public dialogue on the issue more is not always better, when it comes to medical tests, treatments and procedures. 5. To engage health system and non-medical stakeholders, at provincial/territorial and national levels, in the implementation of the Choosing Wisely Canada campaign. 12

13 Campaign approach Physicians Societies develop lists Disseminate through multiple channels Patients Develop patient materials Disseminate broadly through multiple channels Media Coordinated approach toward media Multiple voices, a common message Stakeholders Work through health care stakeholder organizations to implement and support adoption 15

14 Wave 1 societies (Apr 2/14 launch)

15 Canadian Association of Gastroenterology Canadian Association of Medical Oncologists* Canadian Association of Pathologists Canadian Association of Radiation Oncology* Canadian Hematology Society Canadian Society for Surgical Oncology* Canadian Society for Transfusion Medicine Canadian Society of Endocrinology and Metabolism Canadian Society of Nephrology Canadian Society of Palliative Care Physicians Canadian Urological Association Occupational Medicine Specialists of Canada Wave 2 societies (Oct 29/14 launch) The Canadian Medical Association s Forum on General and Family Practice Issues and the College of Family Physicians of Canada released six more recommendations, adding to the five they released in April * Released a joint list under the leadership of the Canadian Partnership Against Cancer (CPAC)

16 Operating principles for Top 5 lists 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 18

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18 Plain language Canadianspecific Evidencebased Patient education pamphlet characteristics Easily accessible Educational 20

19 Implementation

20 Early Adopter Collaborative National learning collaborative of those who have expressed interest in or are in the process of implementing the CWC recommendations Collaborative serves as learning platform where groups could showcase their work and create toolkits for use by future adopters

21 The Implementation Spectrum ENGAGEMENT & EDUCATION QUALITY IMPROVEMENT HARD CODING o Leadership engagement o Physician education o Patient education Soft o QI projects o Measurement o Audit and feedback o Policy changes o EMR/CPOE integration o Order set changes Hard Individuals as the change unit Engagement-oriented Lower risk Organization as the change unit Rules-oriented Higher risk

22 Evaluation

23 Multifaceted measurement Physician attitudes and self-reported experience (physician survey) Patient receptiveness to message Physician ordering this will take time to change Implementation in medical education

24 Metrics (Ontario example) 1. Rate of DEXA scans <2 years 2. Pap smears <3 years 3. Low back imaging 4. Perioperative ECG in low risk surgery 5. Preoperative CXR in low risk surgery 6. Preoperative stress tests in low risk surgery 7. Preoperative echocardiogram a in low risk surgery

25 Canadian Rheumatology Association s Choosing Wisely Recommendations On behalf of the CRA Choosing Wisely Committee

26 positive

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28 Rheumatologist (16) Rheumatology trainee (5) Allied health provider (1) Patient Consumer (3) Coordinator (1) Robert Ferrari, MD FRCPC Multidisciplinary CRA Choosing Wisely Working Group Sylvie Ouellette, MD FRCPC Chris Debow Glen Hazlewood, MD FRCPC Nadia Luca, MD FRCPC Proton Rahman, MD FRCPC Jennifer Burt Carter Thorne, MD FRCPC Christine Charnock 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

29 CRA Choosing Wisely Working Group Survey List tests, procedures and treatments which you believe are overused, misused or potentially harmful

30 CRA Top 13 items Don t perform an ANCA without suspicion of underlying vasculitis. Don t perform HLA B27 in a patient with back pain without morning stiffness, or without any evidence of spondyloarthropathy, or likely mechanical low back pain. Don t perform ANA as a "screening test" in a patient without symptoms or signs of lupus or other CTD. Don t perform a RF or anti-ccp as a "screening test" in a patient without joint swelling or in a typical osteoarthritis patient. Don t perform ANA to follow lupus disease activity Don t perform serial RF or anti-ccp Don t perform ANA sub-serologies (ENA or dsdna) without a positive ANA. Don t perform BMD more often than every 2 years in low risk patients. Don t perform X-Rays more than every year to monitor Inflammatory Arthritis. Don t perform Total Body Bone Scan to assess for SpA or arthritis. Don t perform MRI of the knee for Osteoarthritis. Don t prescribe bisphosphonates for patients at low risk of fracture or premenopausal women. Don t prescribe NSAIDs to the elderly with risk factors (i.e. Renal insufficiency, hypertension, heart disease, history of Peptic Ulcer Disease, anticoagulants, coagulopathy).

31 CRA Survey Results of Top 5 items Content agreement, raw mean + SD (1-5 scale) Content disagreement, % who disagree Impact % rating as high impact Top picks % ranking as Top 5 ANA test HLA B27 test BMD every 2 years Bisphosphonates for low risk patients Bone scan to assess for arthritis

32 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

33 ANA testing should not be used to screen subjects without specific symptoms present in many non-rheumatic conditions such as infections, medications, other medical conditions, and even in healthy people (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

34 Pre-test and Post-test Probability Mahler, Journal of Immunology Research 2014

35 ANA testing in Canada In Calgary, rheumatology referrals through central triage service 643 (4.1% of 15,357) referrals over 3 years for a positive ANA >1: (40.9%) seen by rheumatologist 63/263 (24%) a diagnosis of ANA associated rheumatic disease 69 (26.2%) no evidence of any disease

36 Evaluation of the Canadian Rheumatology Association Choosing Wisely recommendation concerning anti-nuclear antibody (ANA) testing Robert Ferrari, MD, MSc (Med), FRCPC, FACP Accepted for publication Clinical Rheumatology 2015

37 Conclusion In the evaluation of non-specific musculoskeletal symptoms, setting an a priori threshold for ordering serology in keeping with the spirit of the Canadian Rheumatology Association Choosing Wisely recommendation for antibody testing results in a very low risk of missing a case of systemic lupus erythematosus or rheumatoid arthritis.

38 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

39 HLAB27 testing HLAB27 not useful as a single diagnostic test in a patient with low back pain without further spondyloarthropathy (SpA) signs or symptoms The post-test probability of HLAB27 in a patient with chronic low-back pain alone would not exceed 30% 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

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41 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 Expected annual changes in BMD are usually close to the precision error of the BMD measurement In women 67 years and older, osteoporosis develops in less than 10% of those with normal bone density, mild osteopenia, or moderate osteopenia when a screening interval of 15 years, 5 years, and 1 year, respectively

42 Recommendation 4 4. Don t prescribe bisphosphonates for patients at low risk of fracture. Guidelines: ASSESSMENT OF 10-YEAR FRACTURE RISK Women and Men 2010 Clinical Practice Guidelines for the diagnosis and management of osteoporosis Assessment in Canada of Basal 10-year Fracture Risk: CAROC System Cochrane Database Systematic Reviews

43 No bisphosphonates in low risk There is no convincing evidence that anti-osteoporotic therapy in patients with low risk of fracture (<10%) reduces the risk of fracture The number needed to treat is much higher (NNT>100) in patients with moderate and low risk (-2.5 < T-score < -1 ) Despite this, 30-40% of a national US sample of primary care physicians report that they recommend treatment of women with mild osteopenia. In a recent survey, 15% of patients would be willing to accept osteoporosis treatment with a fracture risk of only 12% Neuner JM. J Clin Densitom 2007, 2012; Neuner JM. J Rheumatol 2013

44 Mettler, et al. Radiology, 200 Song IH et al. Ann Rheum Dis Recommendation 5 5. Don t perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adults. 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 sensitivity and specificity for diagnosis of Grade 1-3 sacroiliitis is 52% and 80% respectively The equivalent of radiation exposure of a total whole body bone scan is reported as over 40 routine chest X-rays, thus posing risk.

45 CRA Choosing Wisely Next Steps 1. Dissemination > Presentation at provincial and regional meetings > CRA website, Choosing Wisely Canada website, Rheuminfo, Arthritis newsletters, Twitter > Publication 2. Feedback and Engagement > Survey of CRA Membership > Collaborating with other societies including Arthritis Patient Alliance, Arthritis Society and Osteoporosis Canada 3. Evaluation and Implementation > Population health research > Second Survey of CRA Membership >Presentation at provincial and regional meetings May 27, 2015

46 CRA Choosing Wisely List Dissemination Survey Survey of CRA membership April /162 (77%) had heard of Choosing Wisely initiative 91/163 (56%) had heard of the CRA List It is easier not to order tests if one's medical organization is behind the decision More aware of evidence and impact incl cost, on decisions re DEXA, ANA, selective use of bisphosphonates, Just thinking about it changes culture I have already incorporated this into my medical student teaching cases and lectures

47 Goals Achieved Engage rheumatologists in a meaningful discussion about high value care Not prescriptive list as clinical judgement is paramount Relevant to current practice Constructed using current scientific evidence

48 Limitations No definitive data to show that these tests are currently overused No data to show cost-effectiveness from altered practice original ABIM Top 5 list tops $5 billion, Arch Intern Med 2011 Level of evidence for some of recommendations is variable

49 ``I don't think rheumatologists are doing these things referring GP's (family doctors) be questioned/taught about this ``ANA and sub-serology results are so variable and unreliable between the different private labs that community based physicians need some leeway here. ie neg ANA and positive antidsdna checked at university lab with antidsdna correct and in another example with incorrectly positive antidsdna at a different lab. I`ve got a drawer full of these.`` Comments from CRA Choosing Wisely survey Is this item high impact based on its prevalence, cost, or potential to reduce harm - challenging to answer as not all components are relevant to each scenario presented

50 Conclusions Rheumatology professionals must identify low-value testing 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

51 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 Special Thanks Dr. Jinoos Yazdany Dr. Wendy Levinson Karen McDonald Tai Huynh Virginia Hopkins Sharon Brinkos Tamara Rader Ekaterina Petkova Laura Corbett Corinne Holobowich Kellee Kaulback Dissemination Group Dr. Arundip Asaduzzaman Dr. Claire Barber Dr. Mary Bell Dr. Martin Cohen Dr. Robert Ferrari Dr. Natasha Gakhal Dr. Michelle Jung Dr. Chris Penney Dr. Amanda Steiman Dr. Pascale Verret Dr. Edith Veilleneuve Fellows Dr. Zarnaz Bagheri Dr. Ann-Marie Colwill Dr. Damian Frackowick Dr. Michelle Jung Dr. Tristan Boyd

52 Thank you