Choosing Wisely: Further Engaging Genetic Professionals In Effective Test Selection and Use

Transcription

1 Choosing Wisely: Further Engaging Genetic Professionals In Effective Test Selection and Use Lee H. Hilborne, MD, MPH, FASCP David Geffen School of Medicine University of California, Los Angeles Quest Diagnostics This program is made possible by the Choosing Wisely campaign with support from + We must continue to push the envelope as we think and work Beyond the Lab. Our health care system is moving to a new model that maximizes efficiency, with changes to delivery and reimbursement approaches. Doing the right thing for patients will always be what is most important, requiring the right diagnostic insights That depends on our laboratories and laboratorians We must lead when it comes to diagnostic services Advance patient centered care Improve overall healthcare quality Reduce unnecessary utilization And we will be regarded (and rewarded) as much for what we don t do as what we do actually do There s a big opportunity for effective use of laboratory services in new delivery models. Effective and timely use of laboratory diagnostic services will be a cornerstone of ACO success Optimizes quality More rapid diagnosis and treatment Patient centered management Allows for effective treatments Reduces Costs Reduced unnecessary (and potentially dangerous) interventions Shortened times to treatment

2 When Less is More: The Choosing Wisely Campaign The Choosing Wisely campaign is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Choosing Wisely: The Consumer Perspective Consumer Reports has developed many resources to help inform and empower consumers to make wise choices: Pamphlets (many available in Spanish) Videos PSAs Posters Newsletter Wallet card All are free to use and distribute! consumerhealthchoices.org/campaigns/choosing wisely Today, we want to engage in a dialogue between AGT members and others. Discuss why Choosing Wisely is a unique opportunity for laboratory medicine leadership to impact positive clinical outcomes and cost reduction Identify techniques for influencing clinical best practices in test ordering Identifying methods for overcoming communication, organizational, and systems barriers to implementing Choosing Wisely Best Practices

3 ABIM Foundation There are many organizations on board. American Academy of Allergy, Asthma & Immunology American Academy of Clinical Toxicology American Academy of Dermatology American Academy of Family Physicians American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of Otolaryngology Head and Neck Surgery American Academy of Pediatrics American Association of Blood Banks American Association of Clinical Endocrinologists American Association of Neurological Surgeons American Association for Pediatric Ophthalmology and Strabismus American College of Cardiology American College of Chest Physicians American College of Emergency Physicians American College of Medical Toxicology American College of Obstetricians and Gynecologists American College of Occupational and Environmental Medicine American College of Physicians American College of Radiology American College of Rheumatology American College of Surgeons American Gastroenterological Association American Geriatrics Society American Headache Society AMDA Dedicated to Long Term Care Medicine American Psychiatric Association American Society of Anesthesiologists American Society of Clinical Oncology American Society for Clinical Pathology American Society of Colon and Rectal Surgeons American Society of Echocardiography American Society of Hematology American Society of Nephrology American Society of Nuclear Cardiology American Society of Plastic Surgeons American Society for Radiation Oncology American Society for Reproductive Medicine American Thoracic Society American Urological Association Commission on Cancer Consumer Reports Health The Endocrine Society Heart Rhythm Society National Physicians Alliance North American Spine Society Robert Wood Johnson Foundation Society for Cardiovascular Angiography and Interventions Society of Cardiovascular Computed Tomography Society for Cardiovascular Magnetic Resonance Society of Critical Care Medicine Society of General Internal Medicine Society of Gynecologic Oncology Society of Hospital Medicine Society for Maternal-Fetal Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Society for Vascular Medicine Inefficiency in U.S. Health Care Institute of Medicine Report: 30% of U.S. health care is duplicative or unnecessary. Paul O Neill recognized this when he was CEO of Alcoa. Inefficiency threatens our nation s ability to deliver the highest care possible to all patients. ASCP + Choosing Wisely Lab professionals (including pathologists, cytogenetic professionals, medical technologists) and our laboratories need to play a leadership role in addressing these challenges. This is why ASCP joined the Choosing Wisely campaign in 2012 and announced its first five tests in February 2013.

4 Laboratory Professionals, Pathologists and Clinicians Choosing Wisely Pathologist, Dr. Lundburg discusses encouraging clinicians to choose wisely at the California Society for Pathology annual meeting in December George Lundberg, M.D. Cytogenetic Professionals as Leaders Our laboratories constantly contribute to improving patient care and reducing the high cost of health care. In hospitals, lab professionals and pathologists serve on many committees and task forces. Unnecessary testing = inappropriate treatment decisions and consumption of finite resources. U.S. Health Care Spending is Out of Control The US Spends More On Care But People Don t Live Longer 84 $6, Life Expectancy Per Capita Expenditure $5, $4, $3, $2, $1, $0 Andorra Singapore Japan Sweden Australia Canada Italy Spain Germany United United Kingdom States

5 Choosing Wisely is one initiative that seeks to reverse the trend. Choosing Wisely: To reduce cost that provides no benefit To help mitigate tough decisions about how care is delivered in the future Take Charge of Reducing Costs Most doctors have no idea what these tests cost, so they have no way of knowing they are contributing to the astronomical cost of health care. Dr. Leonard Feldman Johns Hopkins University School of Medicine Many Dimensions to Appropriate Test Utilization Center appropriate test utilization on good patient care and include both the cancellation of inappropriate tests and the addition of appropriate tests for the best patient outcomes. Five tests that ASCP recommends for Choosing Wisely are an important dimension of appropriate test utilization in the lab. Patients should learn firsthand about these tests, so they can make informed choices.

6 Choosing Wisely Experts The ASCP Institute Advisory Committee spearheaded the selection of ASCP s 5 tests for Choosing Wisely. A review panel examined hundreds of options based on both the practice of pathology and evidence available through literature. The five initial tests were selected to be illustrative of common situations we confront. We only were allowed to have five! Common situations Tests with merit in some circumstances but are not appropriate in others Tests with no clinical utility Tests that have been generally replaced by better tests New and emerging diagnostics Envision this as the beginning Do not perform populationbased screening for 125 OH Vitamin D deficiency.

7 2 for Do not perform low risk HPV testing cervical disease. 3 without Avoid routine preoperative testing for low risk surgeries a clinical indication. 4 Only order Methylated Septin 9 (SEPT9) on patients for whom conventional diagnostics are not possible. Note: FDA reviewed an application for this test in March with mixed reviews.

8 5 to Do not use bleeding time guide patient care. Although there is only one primary lab organization involved Many of the organizations shown earlier have developed recommendations that involve laboratory testing Laboratory testing is so critical to the practice of medicine That s why other organizations talk about testing appropriateness There are lots of examples in other organizations recommendations. American Academy of Allergy, Asthma, and Immunology (AAAAI) Don t perform unproven diagnostic tests, such as IgG testing or an indiscriminate battery of IgE tests, in the evaluation of allergy Don t routinely do diagnostic testing in patients with chronic urticaria Endocrine Society and AACE Don t routinely measure 1,25 dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function Don t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency

9 And some of them are consistent with ASCP. American Academy of Family Physicians Don t perform Pap smears on women younger than 21 or who have had a hysterectomy for non cancer disease Don t screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology Don t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer Don t routinely screen for prostate cancer using a prostate specific antigen (PSA) test or digital rectal exam American Academy of Ophthalmology Don t perform preoperative medical tests for eye surgery unless there are specific medical indications Many address women s health issues. American Academy of Clinical Toxicology Don t order heavy metal screening tests to assess non specific symptoms in the absence of excessive exposure to metals American Congress of Obstetrics and Gynecology Don t perform routine annual cervical cytology screening (Pap tests) in women years of age Don t screen for ovarian cancer in asymptomatic women at average risk American College of Rheumatology Don t test ANA sub serologies without a positive ANA and clinical suspicion of immune mediated disease Don t test for Lyme disease as a cause of musculoskeletal symptoms w/o an exposure history & exam findings Many focus on avoiding tests where the likelihood of a false positive is high. American College of Surgeons Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia American Gastroenterological Association Do not repeat colorectal cancer screening (by any method) for 10 years after a high quality colonoscopy is negative in average risk individuals American Society of Clinical Oncology (ASCO) Don t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent

10 And the benefit is low Commission on Cancer Don t perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done Society of General Internal Medicine Don t perform routine general health checks for asymptomatic adults Don t perform routine pre operative testing before low risk surgical procedures Don t recommend cancer screening in adults with life expectancy of less than 10 years Society of Hospital Medicine Don t perform repetitive CBC and chemistry testing in the face of clinical and lab stability You can review the entire list at choosingwisely.org Genomic Testing: New Challenges 5,000 new genomic lab tests available in next 5 to 10 years Patients may want all tests available but not understand the consequences or costs of inappropriate testing Laboratorians must lead balanced discussions and recommend appropriate tests for individual patients You and your colleagues are going to be asked more and more to weigh in here

11 Diagnostic Tests & Patients Diagnostic tests = crucial link to patient quality and safety Assure there is a valid medical reason to order a particular test and know how the test result contributes to guiding patient management Ask why is this test necessary for this patient. Are there better alternatives? Including no test? Appropriate The benefits exceed the risks by a sufficient margin that the test is worth doing and is better than the alternatives, including not performing a test (RAND) Next Steps for Choosing Wisely Educate clinicians and patients about when patients need these 5 tests and when they do not. Examine local utilization and determine other Choosing Wisely priorities based on local practice. Build on our discussion this morning We are looking to expand and create further, possibly discipline specific lists Molecular and genetic testing Clinical chemistry Surgical pathology Cytopathology Microbiology Hematopathology Immunohematology Become Consultants Lab tests are usually so reliable, but they have limitations. We can improve the diagnostic value of lab tests while preventing the misuse of resources.

12 Collaborating with Internists Internist, Dr. Richard Kravitz discusses laboratory leadership at the California Society for Pathology annual meeting in December Richard Kravitz, M.D. Collaborating with Internists Internist, Dr. Richard Kravitz discusses how pathologists can help internists choose wisely at the California Society for Pathology annual meeting in December Haya Rubin, M. D. Thank you for participating in the Choosing Wisely program. Now what? Lee H. Hilborne, MD, MPH, FASCP David Geffen School of Medicine University of California, Los Angeles Quest Diagnostics This symposium is made possible by the Choosing Wisely campaign with support from +

13 We Are Interested In Expanding Input To Pathology s Choosing Wisely Campaign It would be great if AGT members can provide input to our next set of recommendations Options for expressing interest Please feel free to leave your address and we will contact you Write me directly: lhilborn@ucla.edu Contact ASCP staff: andrea.bennett@ascp.org We are planning a Choosing Wisely discussion page on ASCP s One Lab Portal See ASCPolicy If you want to hear more from the other California speakers, a two hour presentation with CME is available on the ASCP website Thank you for participating in the AGT Choosing Wisely discussion. Let s talk! Lee H. Hilborne, MD, MPH, FASCP David Geffen School of Medicine University of California, Los Angeles Quest Diagnostics lhilborn@ucla.edu This symposium is made possible by the Choosing Wisely campaign with support from +