Copello Fellowship Orientation How the NPA Good Stewardship Project Led to the Choosing Wisely Campaign The Mouse That Roared!

Transcription

1 Copello Fellowship Orientation How the NPA Good Stewardship Project Led to the Choosing Wisely Campaign The Mouse That Roared! NPA Good Stewardship Project Director Stephen R. Smith, MD, MPH Professor Emeritus of Family Medicine Warren Alpert Medical School of Brown University

2 Disclosure I have no relationships of any kind with any company whose products or services are in any way related to the practice of medicine, medical education or research.

3 The Physician Charter the wise and cost-effective management of limited clinical resources

4 Stewardship Protecting resources for future generations

5 Health Care Costs

6 What Physicians Can Do

7 Physician s Role o o Overuse o Too soon o Too often o Too easily Misuse o Not indicated o Not supported by evidence o Not the first choice

8 Physician s Role o o Overuse o Too soon MRI for low back pain o Too often o Too easily Misuse o Not indicated o Not supported by evidence o Not the first choice

9 Physician s Role o o Overuse o Too soon o Too often Yearly Paps, colonoscopy o Too easily Misuse o Not indicated o Not supported by evidence o Not the first choice

10 Physician s Role o o Overuse o Too soon o Too often o Too easily Belly aches to GI Misuse o Not indicated o Not supported by evidence o Not the first choice

11 Physician s Role o o Overuse o Too soon o Too often o Too easily Misuse o Not indicated Antibiotics for colds o Not supported by evidence o Not the first choice

12 Physician s Role o o Overuse o Too soon o Too often o Too easily Misuse o Not indicated o Not supported by evidence o Not the first choice Coronary Calcium Scans for Screening for Heart Disease in Asymptomatic Patients

13 Physician s Role o o Overuse o Too soon o Too often o Too easily Misuse o Not indicated o Not supported by evidence o Not the first choice Xopenex vs albuterol

14 Brody Perspective Piece A Top 5 list (restricted) to the most egregious causes of waste can demonstrate that we are genuinely protecting patients interests and not simply rationing care.

15 NPA Project o 5 Things You Can Do in Your Practice (Family Medicine, Internal Medicine, & Pediatrics) o Commonly ordered or performed o Not recommended or preferred action o Carries some risk of harm o If not done would improve health and reduce costs o Strong evidence supporting

16 Top 5 List Family Medicine 1. Don't do imaging for low back pain within the first six weeks unless red flags are present 2. Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis within the first 7 days 3. Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors 4. Don't order annual EKGs or any other cardiac screening for asymptomatic, low-risk patients 5. Don't perform Pap smears under the age of 21 or in women status post hysterectomy for benign disease

17 Top 5 List Internal Medicine 1. Don't do imaging for low back pain within the first six weeks unless red flags are present 2. Don't obtain blood chemistry panels (e.g. CMP, SMA-7, BMP) or urinalyses for screening in asymptomatic, healthy adults 3. Don't order annual EKGs or any other cardiac screening for asymptomatic, low-risk patients 4. Use only generic statins when initiating lipid-lowering drug therapy 5. Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors

18 Top 5 List Pediatrics 1. Don t obtain imaging for minor head injuries without loss of consciousness or other risk factors 2. Advise parents not to use cough and cold medications 3. Use inhaled corticosteroids to control asthma appropriately 4. Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus 5. Don't refer otitis media with effusion (OME) early in the course of the problem

19 Published Top 5 Lists

20 Good Stewardship Demonstration 3 Practices Yale Primary Care Center Long Beach Memorial Family Medicine Residency Harborview Medical Center Family Medicine Clinic, University of Washington Medical School

21 Phase 2 o Training videos o Clarify patient s true concerns o Provide information o Be courteous and respectful o Provide clear contingency plan o Assure patient agreement with plan YouTube: Good Stewardship

22 Significant Changes Sinusitis (LB, S and combined) 55% vs. 0% inappropriate, p <.0001 DEXA (combined) 33% vs. 10% inappropriate, p <.05 Pap smears (LB only) 3% vs. 0% inappropriate, p <.05

23 Good Stewardship Demonstration Clinical Parameter Pre-training Appropriate (%) Post-training Appropriate (%) DEXA screening Sinusitis treatment EKG screening Pap smear screening Low Back Pain imaging Statin prescribing Routine labs All parameters 93 96

24 Publications Treatment of Mild-to-Moderate Sinusitis in Arch Int Med 2012 followed by others in the Less Is More series in JAMA Int Med Kost A, Genao I, Lee JW, Smith SR. Clinical Decisions Made in Primary Care Before and After Choosing Wisely. J Am Board Fam Med 2015;28:471 4.

25 Choosing Wisely Campaign o ABIM Foundation o 70+ Specialty Societies o 500,000+ physicians o More societies to join soon o Each develops their own Top 5 list Choosingwisely.org

26 Choosing Wisely International

27 Consumer Reports

28 What You Can Do Cost of Care Neel Shah, MD, MPP

29 Other Innovative Programs Brandon Combs, MD and Tanner J. Caverly, MD, MPH Do No Harm project David Bor, MD Avoidable Care Rounds at Cambridge Health System Anthony Accurso, MD, Providers for Responsible Ordering (PRO) ACP High-value care curriculum Right Care Alliance

30 More Innovative Programs Mt. Sinai Toronto developed their own Top 5 list of tests that shouldn t be ordered using an online iterative survey I-CARE developed by Robert Fogerty at Yale engages faculty and residents in a friendly competition to create lower cost care plans Antibiotic time-outs trainee-led structured antibiotic time-outs to improve antibiotic stewardship by Lee et al. Amit Pahwa virtual patient cases for med students at Hopkins Pahwa.developdc.net available through the Teaching Value in Health Care Learning Network

31 Copello Fellows