Choosing Wisely. Objectives. Payal Sen PGY 1 Internal Medicine Residency Program University of New Mexico

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1 Choosing Wisely Payal Sen PGY 1 Internal Medicine Residency Program University of New Mexico Financial Disclosure I have no relationships with any entity producing, marketing, reselling or distributing, health care goods or services, consumed by or used on, patients. Objectives Review practices involving some routine tests Cost conscious high value care 1

2 60 year old M Started smoking 5 years ago due to life stressors Currently smokes 2 cigarettes a week Best friend, a long time smoker recently died of lung cancer Doc, please check me out for lung cancer What do you do? Do NOT perform CT screening for lung cancer among patients at low risk for lung cancer. Guidelines based on single trial: National Lung Screening Trial (NLST) Greatest benefit HIGHEST risk patients 55 80y, > 30 PY, current or quit smoking <15y NO evidence for low risk patients Several recent European trials no benefit NLST 96.4% false positive on CT (screening) Adverse effects radiation exposure, high false positive rate, harm due to incidental finding of pulmonary nodules and their downstream evaluation, anxiety and distress 2

3 Average cost of a CT scan of the thorax with contrast 700 dollars Cost of groceries in my family for THREE MONTHS!!! A 60 year old Male patient No significant past medical history An annual health check He keeps hearing about prostate cancer screening by a simple blood test while golfing with his friends Doc, should I get screened? Do you do the simple blood test aka PSA? Do not routinely perform PSA based screening for prostate cancer. 3

4 PSA has low sensitivity and low specificity No trial showed benefit in all cause mortality Half of detected cancers will never cause symptoms 85 % patients with detected cancers will die of OTHER causes in 15 years Side effects of screening : adverse effects of prostate biopsy, over diagnosis, overtreatment, anxiety Side effects of treatment? Shared decision making Average cost of PSA 100 dollars Cost of TWO MONTHS of Gas!!! 4

5 55 year old female Recently diagnosed with hypothyroidism Started on Levothyroxine 2 months ago. You have asked her to return to the clinic so that you can do thyroid labs to figure out whether the dose of Levothyroxine is correct. You order TSH, Free T4 and Free T3 Lab calls you thrice asking if you REALLY need to do the Free T3 test. Do NOT order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients T4 is converted into T3 at the cellular level Intracellular T3 levels regulate pituitary secretion and blood levels of TSH Therefore, normal TSH indicates an adequate T4 dose Conversion of T4 to T3 at the cellular level is not reflected in the T3 level in the blood Hence, patients taking T4 may have higher blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be misleading (low normal or slightly low ) 5

6 Cost of T3 in USA 90 dollars Cost of electricity in my apartment for a MONTH!!! 62 y/o overweight F has unexplained fatigue, muscle and bone pain. You suspect she has Vitamin D deficiency and would like to order the relevant blood test. You try ordering it via the EMR and get two options A) 1, 25 dihydroxyvitamin D B) 25 dihydroxyvitamin D Since we are all smart physicians and always order the correct lab, which one do we order? Answer: 25 hydroxyvitamin D Do not routinely measure 1,25 dihydroxyvitamin D ( the 1 version ) unless the patient has hypercalcemia or decreased kidney function. 6

7 1, 25 dihydroxyvitamin D is the active form of vitamin D Serum levels of 1,25 dihyroxyvitamin D have little or no relationship to vitamin D stores. Regulated primarily by parathyroid hormone levels, which in turn are regulated by calcium and/or vitamin D. THUS In vitamin D deficiency, 1,25 dihydroxyvitamin D levels go up, not down!!! When trying to assess vitamin D stores or diagnose vitamin D deficiency (or toxicity) 25 hydroxyvitamin D is the correct test. When do we measure the 1 version? Answer: In ESRD, hypercalcemia Cost of Vitamin D test (either version) 200 dollars Took me ONE WEEK to convince my husband to buy my a 200 dollar graduation dress! 7

8 A 67 year old Female patient comes to your office Complains of passing out. She said she passed out yesterday whilst shopping. She came out of it without problems soon after Medically knowledgeable lawyer friend said she urgently needed a CT scan and an ultrasound of a neck artery. Should you do CT/MRI of the brain and a Carotid Doppler? In the evaluation of simple syncope and a normal neurological examination DO NOT obtain brain imaging studies (CT or MRI) In patients with witnessed syncope but no seizure, no report of other neurologic symptoms the likelihood of a central nervous system cause of the event is extremely low Patient outcomes are not improved with brain imaging studies ( CT / MRI ) Carotid ultrasound also not indicated if no focal neurological deficit or carotid bruit Evidence shows lack of utility only 1 % changed their management! 8

9 Average cost of CT Head $1,200 Average cost of MRI Brain $2,500 More than a MONTH of my salary!!! Take Home Points Choosing Wisely benefits physicians, patients and communities High value recommendations consensus among different societies Thank you to the organizers events like this keep us updated References Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, Gareen IF, Gatsonis C, Marcus PM, Sicks JD. Reduced lung cancer mortality with low dose computed tomographic screening. N Engl J Med. 2011;365 National Institute for Health and Clinical Excellence. Transient loss of consciousness ( Blackouts ) Management in adults and young people. [Internet]. London: Royal College of Physicians (UK); 2010 [cited 2012 Oct 25 Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357: Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah Pollack R, Singer PA, Woeber KA. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012; Sep 11: Early detection of prostate cancer: American Urological Association guideline, 2013 [Internet]. Linthicum (MD): American Urological Association; 2013 [cited 2014 Nov 4]. 9

10 THANK YOU! Questions??? 10