1. Introduction to High Value Care in Endocrinology Evan Klass, MD October 29, 2015

2. WHY? Unsustainable growth in health care costs – $253B in 1980 to $2.6T in 2010 Estimated 30% ($750B) spent on unnecessary care – Avoidable costs that would not reduce quality Failure to rein in waste may result in poorly focused, across-the-board cuts – Desperate circumstances lead to desperate measures!

3. choosingwisely.org 2014 physician attitude study 73% of physicians recognize unnecessary testing as a problem 66% feel responsibility to make sure patients avoid unnecessary tests 72% say the average physician orders an unnecessary test at least once a week 70% say that after discussion with a patient the patient often avoids the test

4. choosingwisely.org Partners Consumer Reports American College of Physicians American Academy of Family Physicians American Academy of Nursing Endocrine Society And many other professional and consumer groups

5. High Value Care Weinberger proposes HCV as a seventh “clinical competency” Laine suggests- “slow down and consider if the test is a duplication, if it will change management of the patient, and recognize the potential for risk or downstream effects of false-positives (including incidentals)” So it’s not a guideline but a way of thinking!

6. Choosing Wisely/Endocrine Society Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia – Get the most bang for the buck Once or twice a week testing Vary testing times Intensify testing during illness or when adjusting meds.

7. Choosing Wisely/Endocrine Society Don’t routinely measure 1,25- dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function – Levels do not reflect whole body vitamin D stores – Levels tend to go up (not down) in vitamin D deficiency – Unregulated 1,25 dihydroxy D is rare- sarcoidosis, other granulomatous diseases

8. Choosing Wisely/Endocrine Society Don’t routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland – The probability of identifying and unrelated nodule and diverting attention from the functional disorder is great – A sonogram will not confirm the etiologic diagnosis- nuclear scanning is preferred

9. Choosing Wisely/Endocrine Society Don’t order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients – T4 is converted to T3 intracellularly – Intracellular T3 in the pituitary determines TSH secretion, hence a normal TSH indicates adequate thyroxine dosing – T4 levels in those on thyroxine may be a bit higher and T3 a bit lower than those with normal thyroid function

10. Choosing Wisely/Endocrine Society Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency – Are there clinical sx? Loss of libido, erectile dysfunction, and poor AM erection – Is there reliable biochemical support? Total T< 300 Free T does not improve sensitivity or specificity

11. Pertinent Data Sets Getting the most out of consultations Allow effective triage Reduce waste