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

2. 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

3. 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

4. What needs to change?

5. 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

6. 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

7. 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

8. 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

10. 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

11. 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

12. Dr M Hamilton-Kirkwood, Consultant Public Health Medicine

13. 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 = = 68%
? Harm , capacity release
Dr M Hamilton-Kirkwood, Consultant Public Health Medicine, AMD ABUHB

14. Dr M Hamilton-Kirkwood, Consultant Public Health Medicine

15. 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

16. 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

17. 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

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

19. 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

20. 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