1. Choosing Wisely Culture, Strategy and Transformation John Santa MD MPH Medical Director, Consumer Reports Health April 9, 2014

2. Disclosures General internist, most recent practice at the VA in 2008. Employed by Consumers Reports: –Independent of industry, non profit, non partisan, consumer advocacy organization. –Multimedia company, publisher of Consumer Reports, ConsumerReports.org 20 million readers a month, older, affluent, well educated, “savvy buyers” Focused for 78 years on providing an alternative perspective to advertising and promotion All Choosing Wisely content available free at www.ConsumerHealthChoices.org

3. Comments on Vermont Choosing Wisely physician partners –ACP, AAFP, AAP, ASCO, ACOG Choosing Wisely consumer partners –AARP –Employers –Unions Culture of innovation –Health reform –Overuse

4. A successful communication campaign –Focused on professionalism Stimulating culture change –More is not better Create conversations about overuse –Communicating what not to do

5. Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

7. A Commitment to Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities Fundamental Principles Primacy of patient welfare Patient autonomy Social justice ACP Foundation/ABIM Foundation/EFIM Physician Charter

8. Medicine's Ethical Responsibility for Health Care Reform — The Top Five List “A Top 5 list also has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost- cutting purposes.” Howard Brody, MD, PhD New England Journal of Medicine

9. The “Top 5 Lists” Funded by an ABIM Foundation grant, the National Physicians Alliance conceived and piloted the concept through its Good Stewardship Working Group Developed lists of top five activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved Published in Archives of Internal Medicine Subsequent research published in Archives found a cost savings of more than $5 billion could be realized if the recommendations were put in to practice.

10. Components of the Campaign Messengers and Collaborators  60+ specialty societies and Consumer Reports—and growing Communicate Messages  Specialty societies, Consumer Reports, consumer organizations and ABIM Foundation Activate  Concrete action around unnecessary tests and procedures

11. How the Lists Were Created Societies were free to determine the process for creating their lists with the following requirements: Each item was within the specialty’s purview and control Procedures should be used frequently and/or carry a significant cost Should be generally-accepted evidence to support each recommendation Process should be thoroughly documented and publicly available upon request

12. Choosing Wisely Partners Societies That Announced Lists April 2012 American Academy of Allergy Asthma & Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology Societies That Announced Lists February 2013 American Academy of Family Physicians American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Otolaryngology- Head and Neck Surgery American Academy of Pediatrics American College of Obstetricians and Gynecologists American College of Rheumatology American Geriatrics Society American Society for Clinical Pathology American Society of Echocardiography American Urological Association Society of Cardiovascular Computed Tomography Society of Hospital Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Society of Vascular Medicine

13. Societies Announcing Lists Later in 2013 American Academy of Dermatology American Academy of Family Physicians American Academy of Orthopaedic Surgeons American Association of Clinical Endocrinologists American Association for Pediatric Ophthalmology and Strabismus American College of Chest Physicians American College of Emergency Physicians American College of Rheumatology American College of Surgeons American Headache Society AMDA — Dedicated to Long Term Care Medicine American Society of Clinical Oncology American Society of Hematology American Society for Radiation Oncology American Thoracic Society Heart Rhythm Society North American Spine Society Society of Critical Care Medicine Society of General Internal Medicine Consumer Groups Through Partnership with Consumer Reports AARP Alliance Health Networks Leapfrog Group Midwest Business Group on Health Minnesota Health Action Group National Business Coalition on Health National Business Group on Health National Center for Farmworker Health National Hospice and Palliative Care Organization National Partnership for Women & Families Pacific Business Group on Health SEIU Union Plus Univision (with HolaDoctor) The Wikipedia Community

14. Measures of Success Featured in Medscape's “The Year in Medicine 2012: News That Made a Difference” 14 Medscape articles reaching 87,171 physicians More than 420,400 physicians reached through specialty society communications. Hundreds of thousands more with second release. 55 journal articles reaching nearly 4 million. More on the way. 300 million media impressions from first release – including New York Times, Washington Post, Vogue, ABC, NBC, CBS, PBS. Many millions more from second release. 40+ patient-friendly translations of materials More than 100+ million reached through Consumer Reports partnerships with consumer/employer groups

15. What’s Next? Additional specialties have joined the campaign and will release lists in late 2013 and into 2014 Advancement of campaign in local communities through a grant from the Robert Wood Johnson Foundation Rollout of Consumer Reports patient- focused materials

16. ACP Behavior change in the physician community Establish principles for driving behavior Identify the specific targets for behavior change Spread the word through multiple channels Change the culture of the training environment Collaborate with others on the common goal(s)

17. Robust Topic Themes 135 Choosing Wisely Topics Screening tests (20) –EKG –Exercise test –Pap smear –Bone density –Heart imaging –Colon cancer Diagnostic testing (31) –Low back pain –Headache –Allergy –Fainting Preoperative evaluations (11) –Chest Xray –Heart imaging Common treatments (28) –Antibiotics (8) –Opioids (4) –Heartburn meds –Anti-inflammatories Routine FU/Monitoring (12) “Disease” approach –Cancer (21) –Chronic kidney failure/dialysis (4) –Heart disease (21) –Maternity (4)

18. Cross Cutting Categories Imaging---55 topics –CT scans (19) –MRI/Ultrasound—no radiation (14) Drugs---23 topics –Antibiotics (8) –Antipsychotics/benzos/sedatives –Opioids (4) –Several (5) actively advertised Women---28 topics –Specific to women (14) –More common in women (4) –Important children topics (10)

19. Screening Topics EKG—heart disease Nuclear Stress test—heart disease Stress Echo---heart disease Pap Smear (4 topics)---cervical cancer Bone Density---osteoporosis Colonoscopy---colon Cancer Stress, Advanced Imaging---heart disease Bone Density testing intervals---osteoporosis Carotid Ultrasound---stroke CA125 and vaginal ultrasound---ovarian cancer Vit D levels---osteoporosis HPV testing---HPV in low risk women Methylated Septin---colorectal cancer PET/CT---cancer screening Coronary artery calcium scoring---heart disease Coronary computed tomographic angiography---heart disease

20. Drugs Oral antibiotics—mild moderate sinusitis Immunoglobulin therapy---recurrent infections PPIs---GERD NSAIDS---HBP,CKD,CHF Oral antibiotics---external ear infection Oral antibiotics---viral infections Tight glycemic control---elderly Oral antibiotics---bactreria in urine, no symptoms Benzos/sedativehypnotics---older adults Antipsychotics---older adults with agitation Opioids/Butalbital---migraine Interferon/Glatirimir---disabled MS patients Antibiotics---adenoviral conjunctivitis Antibiotics---before intravitreal infections Biologics---RA w/o metotrexate first Testosterone---Erectile dysfunction pts with normal testosterone Antibiotics---men with + PSA Anti nausea gels---hospice patients

21. Opioids American College of Occupational and Environmental Medicine Don’t prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment. The use of both strong and weak opioids has been consistently associated with increased risk of motor vehicle crashes as opioids produce sedation and hinder or impair higher cognitive function. Evidence suggests higher risk with acute opioid use, but risk remains elevated throughout treatment with any opioid and reverses on cessation. American Society of Anesthesiologists – Pain Medicine Don’t prescribe opioid analgesics as first-line therapy to treat chronic non-cancer pain. Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. If drug therapy appears indicated, non-opioid medication (e.g., NSAIDs, anticonvulsants, etc.) should be trialed prior to commencing opioids. Don’t prescribe opioid analgesics as long-term therapy to treat chronic non-cancer pain until the risks are considered and discussed with the patient Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party (eg urine drug testing) and the consequences of non-complianse with the agreement. American Academy of Neurology Don’t use opioid or butalbital treatment for migraine except as a last resort. Opioid and butalbital treatment for migraine should be avoided because more effective, migraine- specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who fail these treatments.

22. New Topics—My Favorites AMDA – Long Term Care Medicine –Don't routinely prescribe lipid lowering medications in individuals with a limited life expectancy. American College of Surgeons –Do not perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy. Commission on Cancer –Do not perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done. AAOS –Do not use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee. Society of General Internal Medicine –Don’t perform routine general health checks for asymptomatic adults.

23. New Topics American Psychiatric Association –Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders. American Society for Radiation Oncology –Don’t initiate management of low risk prostate cancer without discussing active surveillance. –Don’t routinely recommend proton beam therapy for prostate cancer outside a prospective clinical trial or registry. American Academy of Family Physicians –Do not routinely screen for prostate cancer using a prostate- specific antigen (PSA) test or digital rectal exam. –Do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications. American College of Medical Toxicology and the American Academy of Clinical Toxicology –Do not remove mercury-containing dental amalgams

24. Robust Topics Approach to poor prognosis solid cancer treatment Approach to monitoring curative breast cancer patients post treatment Prostate cancer screening and treatment Approach to stenting of “non culprit” lesions Monitoring of patients post heart procedures Overall---tens of millions of decisions, tens of billions of dollars

25. Consumer Reports Consumer Reports is a partner in Choosing Wisely and will support the effort by creating patient-friendly materials based on the society recommendations and engaging a coalition of consumer communication partners to disseminate content and messages about appropriate use to the communities they serve. Tools and resources can be found at: www.consumerhealthchoices.org. www.consumerhealthchoices.org

26. Communicating “What Not to Do” –Go where people are (Wikipedia & Vogue) –Talk about what they are talking about (usually benefits) and connect your dots to theirs (risk, waste) –Use safety if you can –Use empathic stories –Provide structure for decision making (consumers wary of not following doctor advice)

27. Stimulating Culture Change Large scale information campaign focused on doctors and patients and their interaction Use trusted brands---Consumer Reports, Physician specialty societies Organize community consortiums willing to take on overuse Use all appropriate distribution channels including carriers but focus on culture change that prepares for strategies.

28. Sample Content

29. Free for consumers 50 brochure topics All in English and Spanish Two-page PDF format Suited for home printing Suited for email, linking Suited for clinic racks

30. Consumer Reports Heart Disease Survey

31. Consumer Response Findings from a December 2012 Consumer Reports survey of 2,669 consumers who received Choosing Wisely information: 72% agreed that it had changed their opinion of the topic, taught them new information, or prompted them to ask more questions of their health provider. 81% of consumers reporting interest in a Choosing Wisely topic said they were likely to have a conversation with their physician about what they had read. In the case of one topic (back pain), 85% intended to have a conversation with their doctor.

32. 5 Questions to Ask Your Doctor Do I really need this? What are the downsides? Are there simpler, safer options? What happens if I do nothing? How much does it cost?

33. ConsumerHealthChoices.org

34. 34 Partner Highlights www.consumerhealthchoices.org AARP –AARP Bulletin published “7 Medical Tests and Treatments You May Not Really Need” in its May 2012 issue. AARP Bulletin has a circulation of around 28 million readers. –AARP has also covered Choosing Wisely in its radio, television, and online channels in English and Spanish. Business Coalitions and Employer Groups –Consumer Reports has collaborated with a number of coalitions representing organizations that collectively represent tens of millions of employees, patients, and their families. –These include The Leapfrog Group, Midwest Business Group on Health (MBGH), Minnesota Health Action Group, National Business Coalition on Health (NBCH), National Business Group on Health (NBGH), and Pacific Business Group on Health (PBGH). –Each has developed unique channels and tools to explain Choosing Wisely to their members and communicate with employees. –These include popular webinars and member briefings (NBGH) and a new Choosing Wisely® Employer Toolkit (PBGH with NBCH) along with email newsletters, speaker events, member websites, and other outreach.

35. 35 Partner Highlights www.consumerhealthchoices.org The Wikipedia Community –Consumer Reports welcomed Lane Rasberry as Wikipedian in Residence in May 2012 with support from the Wikimedia Foundation. –This opportunity has enabled Consumer Reports to collaborate with the volunteer Wikipedia community and specialty societies to improve health articles on Wikipedia by including relevant information and citations from the Top Five lists of the specialty societies participating in Choosing Wisely. –Since September 2012, there have been an estimated 30 million page views of Wikipedia articles containing information about appropriate use of tests, treatments, and procedures—each referencing Choosing Wisely.

36. ABIMF/Drexel Videos Multiple videos focused on specific overuse situations Adheres to straightforward principles Empathy and alternative plan Available at: http://www.choosingwisely.org/resources/ modules/

37. Choosing Wisely in Local Communities: Washington State Medical Association

38. What to do? Continue culture change efforts –Educate all about these tests Benefit/Risk, downstream implications SAY IT SEVEN TIMES –Take on inappropriate demand strategies Online promotion, health fairs, “wellness” screenings Conversations about advertising and promotion –Stop incentives that rely on creating inappropriate demand

39. Critical Competencies Independence Transparency Good data Robust collaboration Confrontation skills –Advocate for consumers

40. Time for Strategies?? “Culture” prepared. Leadership opportunity? From single topics to broad areas of overuse From one on one conversations to a “practice dialogue.” Doctors talk to doctors Integrate Choosing Wisely into the purchasing process Right size care Influence the Standard of Care

41. From Single Topics to Broad Areas of Overuse –Screening—especially heart disease (18 topics) –Preop testing in low risk folks and low risk surgery (11 topics) –Drugs---especially antibiotics (12 topics) and those advertised –Imaging---especially those involving radiation (19 topics) –Safety—especially elective delivery, inappropriate induction –Cancer –Renal Failure Consumer Reports preparing “roll ups” that cover multiple topics

42. Doctors Talk to Doctors Two doctor approval---”hard stops” –Early elective delivery –Two doctor prescriptions---Opioids?? Testosterone?? In the electronic record –Cedar Sinai As part of other national campaigns –ACC FOCUS--Formation of Optimal Cardiovascular Utilization Strategies –Image Gently/Image Wisely In the practice infrastructure –Henry Ford –Westmed Medical Group (Westchester County NY)

43. Scott Weingarten, MD Senior VP and Chief Clinical Transformation Officer Cedars-Sinai Health System 75% of decision support interventions succeed when the information is provided to clinicians automatically, whereas none succeed when clinicians are required to seek out the advice Alerts > 100 per day

44. Purchasing Process Value Based Benefit Design –Tiered benefit design (like drug benefit) –Start with carrots, work on sticks As part of transparency processes –Provide price and whether potential overuse As part of incentives and disincentives –Remove overused services from production incentives until right sized –Remove upstream screening to reduce downstream overuse

45. Right Size Care –Insist that demand strategies be evidence based not revenue based And include risk –Address disparities aggressively –Integrate into routine care

46. Change the Standard of Care Standard of Care –“the watchfulness, attention, caution and prudence that a reasonable person in the circumstances would exercise” Clinical Practice –“relating to or based on work done with real patients” –“the learned profession that is mastered by graduate training in a medical school and that is devoted to preventing or alleviating or curing diseases and injuries”

47. “When you’re through learning, you’re through.” John Wooden Former UCLA basketball coach

48. John Santa santjo@consumer.org http://consumerhealthchoices.org/ campaigns/choosing-wisely/