Choosing Wisely Easier Said Than Done NPA Good Stewardship Project Director Stephen R. Smith, MD, MPH Professor Emeritus of Family Medicine Warren Alpert Medical School of Brown University

Disclosure I receive fees for reviewing articles on the Choosing Wisely recommendations for Consumer Reports. I have no other relationships of any kind with any company whose products or services are in any way related to the practice of medicine, medical education or research.

Case Studies Annual Pap smear Penicillin from the ER for a sore throat GI recommends repeat colonoscopy in 3 years Scoliosis screening in adolescent boy Pre-op request for cataract surgery with EKG PA prescribes antibiotics for mild acute sinusitis Antibiotics for viral conjunctivitis (“pink eye”)

the wise and cost-effective management of limited clinical resources The Physician Charter the wise and cost-effective management of limited clinical resources In 2009, the American Board of Internal Medicine Foundation launched “Putting the Charter into Practice,” a program providing small grants to advance principles of professional commitment in medicine, in keeping with the Physician Charter, a document jointly issued in 2002 by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine and now widely endorsed by most physicians’ organizations. The charter calls upon physicians to work towards the wise and cost-effective management of limited clinical resources as an ethical commitment to professionalism. We applied for the ABIMF grant and received it in the fall, 2009. Our program, whose name you can see in the lower right-hand corner of the slide, was “Promoting Good Stewardship in Clinical Practice.”

Stewardship Protecting resources for future generations The concept of stewardship comes from the idea of managing a valuable social resource to make it sustainable and thus available for future generations. We know how our National Park Service manages the national forests in a way to preserve them for the public now and in the future.

Health Care Costs Billions $ In medicine, the threat to sustainability has been rising costs. Health care costs rose 5.3 percent in 2014, reaching $3.0 trillion or $9,523 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 17.5 percent. The current rate of spending on our nation’s health care system is unsustainable and will require innovative strategies to reduce cost and improve care. A new grant from the ABIM Foundation will help advance these efforts. 6

What Physicians Can Do What can physicians do about this? In a take-off on the old TV quiz show, “The $64,000 Question,” Fuchs and Milstein posed the $640 billion question. They noted that there are individual physicians and health care organizations that deliver high-quality care at a cost roughly 20% lower than average. If the rest of the U.S. health care industry followed their example, we could save $640 billion annually.

Physician’s Role Overuse Misuse Too soon Too often Too easily Not indicated Not supported by evidence Not the first choice Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol.

Physician’s Role Overuse Misuse Too soon MRI for low back pain Too often Too easily Misuse Not indicated Not supported by evidence Not the first choice Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 9

Physician’s Role Overuse Misuse Too soon Too often Yearly Paps, colonoscopy Too easily Misuse Not indicated Not supported by evidence Not the first choice Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 10

Physician’s Role Overuse Misuse Too soon Too often Too easily “Belly aches” to GI Misuse Not indicated Not supported by evidence Not the first choice Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 11

Physician’s Role Overuse Misuse Too soon Too often Too easily Not indicated Antibiotics for colds Not supported by evidence Not the first choice Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 12

Physician’s Role Overuse Misuse Too soon Too often Too easily Not indicated Not supported by evidence Not the first choice Coronary Calcium Scans for Screening for Heart Disease in Asymptomatic Patients Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 13

Physician’s Role Overuse Misuse Too soon Too often Too easily Not indicated Not supported by evidence Not the first choice Xopenex vs albuterol Overuse: too soon, such as getting an MRI for low back pain in the first few days or week of acute back pain; too often, such as repeating Pap smears every year when they are normal; too easily, such as referring patients with abdominal pain to a gastroenterologist before a proper work-up has been completed (10X as costly as primary care doctor) Misuse: not indicated, such as treating a viral URI with antibiotics; not supported by evidence, such as obtaining coronary calcium scans on asymptomatic patients to screen for heart disease; and not the first choice, such as using an expensive drug like Xopenex (levalbuterol) for asthma before trying generic albuterol. 14

NPA Project 5 Things You Can Do in Your Practice (Family Medicine, Internal Medicine, & Pediatrics) Commonly ordered or performed Not recommended or preferred action Carries some risk of harm If not done would improve health and reduce costs Strong evidence supporting Ideal candidate item: The ideal item would be an intervention (drug, test, consultation or other), commonly ordered, performed or prescribed by primary care doctors, that is not the recommended or preferred action. The ideal item would carry a not insignificant risk of harm and, would, if ordered or performed differently, improve the health of patients and communities and substantially reduce costs. The evidence supporting this would be very strong and substantial 15

Brody Perspective Piece Proving that great minds work alike, Howard Brody published a Perspective piece in the New England Journal of Medicine in January 2010 shortly after we received our grant from the ABIM Foundation in the fall 2009. This helped set the stage for what was to come. “A Top 5 list…(restricted) to the most egregious causes of waste…can demonstrate…that we are genuinely protecting patients’ interests and not simply ‘rationing’ care….”

Top 5 List—Family Medicine Don't do imaging for low back pain within the first six weeks unless “red flags” are present Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis within the first 7 days Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors Don't order annual EKGs or any other cardiac screening for asymptomatic, low-risk patients Don't perform Pap smears under the age of 21 or in women  status post hysterectomy for benign disease

Top 5 List—Internal Medicine Don't do imaging for low back pain within the first six weeks unless “red flags” are present Don't obtain blood chemistry panels (e.g. CMP, SMA-7, BMP) or urinalyses for screening in asymptomatic, healthy adults   Don't order annual EKGs or any other cardiac screening for asymptomatic, low-risk patients Use only generic statins when initiating lipid-lowering drug therapy Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors

Top 5 List—Pediatrics Don’t obtain imaging for minor head injuries without loss of consciousness or other risk factors Advise parents not to use cough and cold medications Use inhaled corticosteroids to control asthma appropriately Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus Don't refer otitis media with effusion (OME) early in the course of the problem

Published “Top 5” Lists Published our article in August 2011 in the Archives of Internal Medicine now JAMA Internal Medicine. It grabbed the attention of both the lay media and the professional news outlets. Stories appeared in magazines and newspapers ranging from the Wall Street Journal to Vogue. The ABIM Foundation was so pleased with the results that they offered a second round of grants building on our project.

Good Stewardship Demonstration 3 Practices Yale Primary Care Center Long Beach Memorial Family Medicine Residency Harborview Medical Center Family Medicine Clinic, University of Washington Medical School

YouTube: Good Stewardship Phase 2 Training videos Clarify patient’s true concerns Provide information Be courteous and respectful Provide clear contingency plan Assure patient agreement with plan YouTube: Good Stewardship http://www.youtube.com/watch?feature=endscreen&NR=1&v=FbEjy_QVRXA

Significant Changes Sinusitis (LB, S and combined) 55% vs. 0% inappropriate, p <.0001 DEXA (combined) 33% vs. 10% inappropriate, p <.05 Pap smears (LB only) 3% vs. 0% inappropriate, p <.05 Despite the limitations imposed by the small sample size of eligible events, statistically significant changes were observed in 3 clinical parameters: treatment of sinusitis, bone density scanning, and Pap smears. The greatest change was in the treatment of sinusitis where the rate of inappropriate treatment went from more than half of the clinical events to zero. This corresponds to listener responses to an FP Audio presentation on the “Top 5” in family medicine that I did, in which respondents cited the treatment of sinusitis as the clinical practice they were most likely to change after listening to the program. The lead physician in Seattle, however, suspected that some of the change may have been due to doctors writing that symptoms had lasted more than 7 days to their notes in order to make their decision to give antibiotics justified.

Good Stewardship Demonstration Clinical Parameter Pre-training Appropriate (%) Post-training Appropriate (%) DEXA screening 67 90 Sinusitis treatment 45 100 EKG screening 99 Pap smear screening Low Back Pain imaging 88 Statin prescribing 57 Routine labs 94 84 All parameters 93 96 What has been hard to explain is the high level of adherence to the “Top 5” lists even before the training sessions. As this slide shows, levels of adherence were above 90% in 5 of the 8 parameters during the pre-training study period and below 50% in only 1 area—treatment of sinusitis. We hypothesize that this may be due to role modeling by faculty who were already committed to the principles of good stewardship. After all, the faculty had applied to be demonstration sites. The nature of the practice populations may have also contributed with providers being mindful of the limited financial resources of their patients.

Choosing Wisely Campaign ABIM Foundation 70+ Specialty Societies 500,000+ physicians More societies to join soon Each develops their own “Top 5” list Choosingwisely.org

Choosing Wisely International International: spread to Canada, UK, India, Australia, Germany, Italy, Japan, Netherlands, and Switzerland.

Consumer Reports

Recent Article This Perspective piece appeared in the New England Journal of Medicine from authors at Dartmouth’s Institute for Health Policy and Clinical Practice and Harvard praising the potential of Choosing Wisely to change clinical practice, while also admonishing some of the specialty societies of being too timid in their “Top 5” lists, especially the American Academy of Orthopaedic Surgeons and the American College of Cardiology who omitted mention of any procedures in its list. In another article in JAMA Internal Medicine by Rosenberg and colleagues, only 2 of 7 CW recommendations showed improvement in the 18 months after the launch of CW using claims database.

Some Courageous “Top 5” Items Urology: don’t do extensive w/u for overactive bladder ENT: no ear tubes in kids for 1st OME < 3 mos. Neuro: don’t do EMG for neck or back pain after MVA Path: only order TSH initially to evaluate suspicion of thyroid problems Heme: don’t treat ITP in absence of bleeding or very low platelets Sleep: don’t use hypnotics for chronic insomnia Dentists: no need for routine 6-mo. care for everyone Renal: don’t start on dialysis without shared decision-making Rad Onc: don’t initiate non-curative radiation Rx without defining goals Cardio: avoid angiography to assess risk in asymptomatic pts PM&R: don’t repeat epidurals if previous ones didn’t help Examples of just a few recommendations by medical specialty groups that are not in the best financial interest of their members

Challenges to Change Discomfort with diagnostic uncertainty engenders an inappropriate drive to leave no question unanswered. Overconfidence in the effectiveness of medical science results in patients experiencing greater risks and costs in pursuit of even slight clinical benefits or even when there is no benefit at all—the “therapeutic illusion.” Fear of opening “Pandora’s Box” and being too busy to deal with the consequences. Perception of pressure from patients and not knowing how to handle it. Fear of malpractice. Deference to specialists who may have financial conflicts of interest. Lack of knowledge. 62% of GPs expressed concern about being uncertain.

Potential Solutions Administrative controls (ex. Vitamin D testing) Denial of payment without justification More hard evidence Peer comparisons (lower lab testing) Focus on outliers More education (PAs) Ferrari et al. showed that by preventing doctors from ordering vitamin D tests unless they checked off a box indicating that the patient had certain conditions that would put them at high risk of serious vitamin D deficiency reduced the ordering of the test by 92%. 62% of PCPs deferred to GI when shorter-than-recommended intervals for colonoscopy were given. Little evidence that spinal injections work, yet they are frequently done. Gidwani et al. found that while 31% of imaging studies for low back pain were ordered inappropriately, only a relatively small number of providers were responsible for most of the inappropriate orders.

Caveats J. Of Med Educ 1983