Workshop Choosing Wisely

Learning outcomes Understanding stewardship of NHS resources How to rationalise investigations Communication with patients and the concept of shared decision making Introduction to the Choosing Wisely campaign

When making a decision about choosing an investigation, what factors do you consider? Can I deal with this result?, Do I know what this result means?, Is there a cheaper alternative? Will I be able to adequately store/ send on the specimen correctly?

Case 80 year old male with severe COPD on long term oxygen therapy was admitted to hospital with an infective exacerbation of COPD. His admission chest X-ray showed a mass in the RUZ and abnormal R hilum. What would be your next steps? Book CT CAP and EBUS Treat IE COPD and discharge with f/u with GP Ensure adjusted calcium and LFTs are normal and book f/u CXR in 6/52 Liaise with respiratory about EBUS or CT guided lymph node biopsy Discuss with patient all the above options and be guided by their decision

http://buzz. bournemouth. ac http://buzz.bournemouth.ac.uk/2017/01/the-18-countries-that-have-implemented-choosing-wisely/ [Accessed 09/07/2018]

Choosing Wisely UK Aim to reduce unnecessary interventions Promote shared-decision making conversations between doctors and patients, to choose care that is supported by evidence not duplicative free from harm truly necessary consistent with patients’ values

What is shared decision making? Shared decision making (SDM) ensures that individuals are supported to make decisions that are right for them.  It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment.

4 questions patients should feel free to ask their clinicians The choosing Wisely Campaign has developed posters that can be displayed in waiting rooms to promote this approach

A case to reflect on……. 35 yr old female Presented with fatigue & muscle aches to GP +ve ANA GP now concerned about lupus Referred to rheumatology Patient Googled lupus Lots of additional vague symptoms which they associate with lupus Seen in rheumatology clinic - very anxious History and examination consistent with fibromyalgia

Implications Patient Anxiety Time spent at appointments, having additional tests Correct diagnosis + treatment delayed Difficulty accepting that lupus is not the cause Possible request for second opinions

Implications NHS Venepuncture Transporting sample to laboratory Lab cost Administrative time checking result and writing referral OPA +/- further opinions Clinician frustration

The scale of the problem 1/20 people have +ve ANA 3/20 people have musculoskeletal pain 1/2000 have SLE For every patient with SLE there are 15 people with +ve ANA and pain St George’s Population ~ 1.3 million ~ 600 patients with SLE > 600 ANAs every week

ANA + ENAs Antibodies do not equate to a diagnosis of a CTD Avoid testing in widespread pain or fatigue alone Only request tests if the implications are fully understood Antibody picture unlikely to change https://www.hindawi.com/journals/jir/2012/494356/fig1/

ANA + ENAs Clinician: Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly. No patient recommendation as felt to be too technical, but highest on working group’s recommendation

Over to you! In groups please identify your top 3 key points which relate to your practice as a foundation doctor You can use the ChoosingWisely UK website or Canadian or US websites You will present these back to the rest of the group You have 15mins!

Choosing wisely topics Rheumatology Radiology Pathology Emergency Medicine Gastroenterology General medicine- physicians

Time to present your findings

Canadian Federation of medical students Don’t suggest ordering the most invasive test or treatment before considering other less invasive options. Don’t suggest a test, treatment, or procedure that will not change the patient’s clinical course. Don’t miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary

Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe are unnecessary. Don’t suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience. Don’t suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want

How do we put this into action? Have you experienced people ordering unnecessary tests? QIP projects Plan, Do, Study,  Act. Audits

Questions and summary Thank you