Choosing Wisely Wales June 24th 2016 Dr Marysia Hamilton-Kirkwood Consultant in Public Health Medicine/AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Introduction Why change? What needs to change ? How do we change? Examples from ABUHB Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Why change? Huge pressure on clinicians time Most overestimate benefit Culture of “more is better” Huge pressure on clinicians time Most overestimate benefit Underestimate harm – JAMA, 2/15 20% NHS : no effect on outcomes 10% NHS : causes harm Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

What needs to change?

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB What needs to change? Rebalance decision making Don’t do it just because you can Share options and evidence Personalise the decision Decide together: SDM Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Does SDM work? High quality evidence SDM works SDM: improves knowledge SDM: improves patient outcomes Avoids harm Does “only do what need to do” Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB How do we change? Tools to aid SDM Patient sheets + 4 key questions. Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB 4 key questions? What are my options? What are the benefits and harms? Do I really need this? What can I do myself? Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Examples Imaging: Low Back Pain Varicose Vein Intervention Chemotherapy in end stage CA Knee Replacement in OA Bunions Hysterectomy v U.A.E. Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Low Back Pain Common: 8 out of 10 people Lasts few weeks: self limiting Posture, lack of exercise, lifting Imaging doesn’t help Radiation exposure (15 x CXR) May find something Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Varicose Veins Only do what is needed 33% population - unsightly About 30% recur after Rx EB criteria: patient sheet 2012 =242 2015 = 68% ? Harm , capacity release Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine

End Stage Chemotherapy IPFR’s – 3rd, 4th + line treatments Breast CA, ovarian CA, bowel CA SDM could be better! Have to do something! “Cure me even if it kills me” Late palliative care referral - SDM Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

End stage Chemotherapy Study: Palliative Chemotherapy Evaluated QOD as function of PS Outcome : Rating of distress QOD worsened where good PS. Earlier SDM- palliative care referral Every patient different Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Summary Cultural change SDM : Tools to assist Avoids unneeded intervention Minimises harm Promotes self management Actually saves clinician time Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

If we get this right.... Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Choosing Wisely Wales “Insanity” ........ “Doing the same thing over and over again & expecting different results” Albert Einstein Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB Choosing Wisely Wales Thank you Diolch Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB