2. HOW TO PRACTICE AND TEACH #HIGHVALUECARE Jake Anderson, DO @JakeAndersonDO Mandy Boltz, MSIV @MandyBoltz Steve Brown, MD @SteveBrownMD Lauren Drake, MD @LaurenDrakeMD Megan Hunt, MD @MeganHuntMD University of Arizona College of Medicine – Phoenix Family Medicine Residency @UAMedPhx @UAPhxFamilyMed

3. INTRODUCTION S. Brown

5. SIX AIMS FOR IMPROVING AMERICAN HEALTH CARE: Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity Source: Institute of Medicine. Crossing the Quality Chasm, 2001

7. OVERALL, ABOUT ONE-HALF OF RECOMMENDED CARE IS RECEIVED

8. RAND corporation, 2005

9. ABOUT ONE-THIRD OF COMMON SURGICAL PROCEDURES MAY NOT BENEFIT PATIENTS

12. THE IHI TRIPLE AIM

13. REASONS FOR LOW VALUE CARE IN THE U.S. (PARTIAL LIST) Generalist vs. specialist imbalance

14. REASONS FOR LOW VALUE CARE IN THE U.S. (PARTIAL LIST) Lack of price transparency Practice variation Focus on technology instead of fidelity Misaligned financial incentives System fragmentation Patient expectations Fear of malpractice liability

18. DISCUSSION OF EXAMPLES Megan Hunt, MD

26. WHAT OTHER EXAMPLES CAN YOU THINK OF?

27. HIGH VALUE CARE IN PRACTICE Jacob Anderson, DO

31.  Previous PE or DVT (+1.5)  Heart Rate > 100 beats per minute (+1.5)  Recent surgery or immobilization (+1.5)  Clinically signs of deep venous thrombosis (+3)  Alternative diagnosis less likely than pulmonary embolism (+3)  Hemoptysis (+1)  Cancer (+1) Risk of PE: Low 0-1 points Moderate 2-6 points High ≥7 points

33. #ChoosingWisely -Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. American College of Radiology -Avoid CT pulmonary angiography in emergency department patients with a low-pretest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer. American College of Emergency Physicians

34. SOAP-V: ADDING VALUE TO CARE DELIVERY 1.Have I considered whether the result would change management? 2.Have I incorporated the patient’s goals and values, and considered the potential harm of the intervention compared to alternatives? 3.What is the known and potential cost of the intervention, both immediate and downstream?

35. HIGH VALUE PRESCRIBING Can you guess the cost?

37. HIGH-INTENSITY STATIN THERAPY There are two “High-Intensity Statins” 1. atorvastatin 80mg 2. rosuvastatin 20mg

38. $250.64 $12.88 Rx: Atorvastatin 80mg 1 month supply Rx: Rosuvastatin 20mg 1 month supply

39. NEUROPATHY PAIN

40. $13.42 $362.91 Rx: pregabalin 75mg, PO BID 1 month supply Rx: gabapentin 300mg. PO TID 1 month supply

41. SMOKING CESSATION Both bupropion (Wellbutrin) and varenicline (Chantix) have been FDA approved for smoking cessation.

42. $381.78 $4 Rx: metformin 1 month supply Rx: Januvia 1 month supply

43. SOME WAYS YOU CAN BECOME A HIGH VALUE PRESCRIBER Be aware of the costs (and cost discrepancies)  goodrx.com  healthcarebluebook.com Know the data  Check your favorite resource—dynamed, uptodate, Cochrane Go through the STEPS

44. STEPS: WHAT YOU NEED TO KNOW ABOUT A DRUG Safety Tolerability Efficacy Price Simplicity

45. METFORMIN Safety: Risk of lactic acidosis exceedingly low, incidence of significant LA in 0.03 per 1000 patient-years, and almost exclusively in patients with renal dysfunction. Contraindicated if GFR<45, use with caution if <60. No risk of hypoglycemia Tolerability: 50% of people have diarrhea 26% have nausea and vomiting, significantly less with long acting formulation. No weight gain (unlike most other agents) Efficacy: Lowers A1C by 0.8-1.3%. It is the only medication for diabetes that has been shown to decrease mortality and diabetic complications including cardiovascular and microvascular complications in RTCs Price: 30 day supply $4 Simplicity: Twice a day oral medication

46. CHOOSING WISELY Steve Brown, MD

47. Who is responsible for overuse and waste? Not just waste, but harm

49. PROFESSIONALISM “Elimination of wasteful, non-beneficial interventions is ethically mandated” –H. Brody (2010)

50. The development of

51. “Aims to promote conversations between providers and patients by helping patients choose care that is: supported by evidence, not duplicative, free from harm, and truly necessary.”

53. CRITICAL ELEMENTS OF RECOMMENDATIONS Within specialty’s clinical domain Done frequently in practice and incur real cost (“High impact”) Evidence-based

54. YOUR TASK

56. AMERICAN FAMILY PHYSICIAN Search the lists

57. HOW SHOULD I TALK TO MY PATIENTS ABOUT CHOOSING WISELY? Elicit patient concerns Empathy with legitimation and/or partnership Reassurance using health information Provide clear recommendations Unnecessary testing causing harm Provide written information Treatment plan Confirm agreement www.choosingwisely.org

58. EXAMPLE DISCUSSION Headache

59. SHARED DECISION MAKING Megan Hunt, MD

60. THE FAMOUS QUOTE FROM W.J. MAYO … "The best interest of the patient is the only interest to be considered" 1910 Rush Medical College commencement address by W. J. Mayo, M.D.

61. WHAT HE ACTUALLY SAID … "The best interest of the patient is the only interest to be considered – and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary." 1910 Rush Medical College commencement address by W. J. Mayo, M.D.

62. WHAT DOES SHARED DECISION MAKING REALLY MEAN? Coming from two different backgrounds:  Clinicians know information about the disease, tests and treatments  Patients know information about their body, their circumstances, their goals for life and healthcare But sharing a common goal!

63. WHAT DOES SHARED DECISION MAKING REALLY MEAN? It takes work!  Requires a partnership  Relies on the exchange of information about the available options  Takes time for deliberation while considering the potential consequences of each one  Need compromise, to make a decision by consensus

64. DOES IT MATTER? Since 2000, there have been 86 randomized trials showing knowledge gain by patients, more confidence in decisions, more active patient involvement 2013 Systematic Review: five studies using “enhanced interventions” - including booklet, video, and talks  All screening interventions increased knowledge about the test above “usual knowledge”  Attitudes were not consistently changed - 3 studies found negative attitudes, 1 more positive, unchanged in 2 2014 Systematic Review: 15 studies with decision aids including leaflets, video, and specific screening visits  All showed improved knowledge and informed decision making Biesecker, et. at. “Enhancing Informed Choice to Undergo Health Screening: A Systematic Review”. American Journal of Health Behavior. Van Agt H, Korfage I, Essick-Bot M. Interventions to Enhance Informed Choices Amoung Invitees of Screening Programmesa Systematic Review. European Journal of Public Health

65. SHARED DECISION MAKING IN PRACTICE Smokers in our clinic who met criteria invited for a group visit Used PowerPoint presentation done by a resident  Study involves pre- and post-survey to measure patient knowledge  Also measured satisfaction with the group visits All patients were given the option to ask questions, make an appointment with their PCP, and/or to order or decline the low-dose chest CT scan  Preliminary results showed improved knowledge and satisfaction with the decision tool

66. EASY TO UNDERSTAND VISUAL AIDS

67. WHAT IS A SCREENING TEST? Screening means to look for a disease that is not currently being felt by a person

68. BALANCING HARMS AND BENEFITS

70. A PRACTICAL GUIDE FOR BUSY DOCTORS AND STUDENTS Three step model: 1. Introducing choice 2. Describing options (use available decision support tools!) 3. Helping patients explore preferences and make decisions J Gen Intern Med. 2012 Oct; 27(10): 1361–1367. “Shared Decision Making: A Model for Clinical Practice”.

71. INNOVATIVE CURRICULUM EXAMPLES Mandy Boltz, MSIV

72. HIGH VALUE CARE ELECTIVE (UCSF) Increase students’ ability to start conversations about health care value Weekly 1-hr lectures:  Guidelines  Screening tests  Care coordination  End of life

73. CLASSROOM AND SHADOWING ACTIVITIES Interactive Cost Awareness Exercise (I-CARE)  Medical students, residents, and faculty work through a patient case separately during Morning Report, with the total cost of workup compared at the end -Dr. Robert Fogerty, Yale University Real vs. Ideal Cost Comparison  Medical students participant in an activity where they compare a real patient’s true costs of care to the ideal costs of care -University of Pennsylvania A Day with Billing  Medical students given the opportunity to spend a day with the hospital billing dept. -Tufts University Moriates C, Arora V, Shah N. eds. Understanding Value-Based Healthcare. New York, NY: McGraw-Hill; 2015.

74. ROUNDING WITH VALUE (MARICOPA MEDICAL CENTER) Weekly Cost Discussion  Discuss cost of an intervention given to a current patient on service  Search PubMed, Choosing Wisely Discharge Bill  Ask billing dept. for a breakdown of charges associated with your patient’s hospital stay, and discuss this on rounds  (May be easiest to obtain for Medicare patients) Image: JAMA, June 2014

75. HIGH VALUE IDEA COMPETITION (BANNER UNIVERSITY MEDICAL CENTER–PHOENIX) Residents and fellows submit 500-word proposals Winning ideas from family medicine:  Capping CAP: A 3-step pathway to reduce length of stay in community acquired pneumonia (Jacob Anderson, DO)  An evidence-based approach to reducing the incidence of catheter-associated urinary tract infections (Ryan Evans, MD)

76. STUDENTS: LEAD THE HIGH-VALUE REVOLUTION! 1.Question Cost 2.Choose Wisely! 3.Keep track: IV fluids, foley catheter, empiric antibiotics 4.SOAP-V 5.Code Status and End of Life Care 6.Read 7.Seek feedback on your own cost-effectiveness 8.Be aware of the hidden curriculum 9.Counsel and Educate “Unnecessary care often crowds out necessary care…” – Atul Gawande

77. CHRIS’ BROKEN ARM

78. IT IS ABOUT THE PATIENT IN FRONT OF US! Side Effects May Include: Financial Ruin  Medical bills are the leading cause for personal bankruptcy in the United States  Middle aged, college educated, home owners  >75% were insured! Himmelstein DU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs, no.W5(63), 2005. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122(8):741–6. Adapted from Christopher Moriates, MD. Used with permission.

79. RESOURCES Consumer Reports Best Buy Drugs www.consumerreports.org/cro/health/prescription- drugs/best-buy-drugs/index.htm www.consumerreports.org/cro/health/prescription- drugs/best-buy-drugs/index.htm Teaching Value and Choosing Wisely Challenge www.abimfoundation.org/News/ABIM-Foundation- News/2015/Winners-of-Teaching-Value-Choosing-Wisely- Challenge.aspx Cooke M. Cost Consciousness in Patient Care — What Is Medical Education's Responsibility? N Engl J Med 2010; 362:1253-1255. Moriates C, Arora V, Shah N. Building A Pipeline of Change: Teaching About Cost Awareness and Evidence- Based Medicine. In: Moriates C, Arora V, Shah N. eds. Understanding Value-Based Healthcare. New York, NY: McGraw-Hill; 2015. JAMA Internal Medicine “Less is More” series Choosing Wisely - choosingwisely.orgchoosingwisely.org Healthcare Bluebook - healthcarebluebook.comhealthcarebluebook.com GoodRx - goodrx.comgoodrx.com Teaching Value Project - www.teachingvalue.orgwww.teachingvalue.org ACP High Value Care Curriculum - hvc.acponline.org hvc.acponline.org Costs of Care - www.costsofcare.orgwww.costsofcare.org UCSF Center for Healthcare Value - healthvalue.ucsf.eduhealthvalue.ucsf.edu ABIM Foundation - www.abimfoundation.orgwww.abimfoundation.org RightCare Alliance - rightcarealliance.orgrightcarealliance.org Lown Institute - lowninstitute.orglowninstitute.org American Family Physician STEPS: New Drug Reviews www.aafp.org/afp/viewRelatedDepartmentsByDepartment.ht m?departmentId=4&page=0 www.aafp.org/afp/viewRelatedDepartmentsByDepartment.ht m?departmentId=4&page=0 American College of Radiology Appropriateness Criteria www.acr.org/Quality-Safety/Appropriateness-Criteria www.acr.org/Quality-Safety/Appropriateness-Criteria

80. QUESTIONS AND DISCUSSION

81. #HighValueCare University of Arizona College of Medicine – Phoenix Family Medicine Residency @UAMedPhx @UAPhxFamilyMed The American Family Physician journal has gone audio! The twice-a-month podcasts highlights key points from each AFP issue. Check it out @AFPpodcast or on iTunes