Choosing Wisely Richard Honsinger, MACP Past Governor, ACP Council of Subspecialty Societies President, Joint Council of Allergy, Asthma and Immunology.

Choosing Wisely

Richard Honsinger, MACPPast Governor, ACP

Council of Subspecialty SocietiesPresident, Joint Council of Allergy, Asthma and

Immunology

American Board of Internal Medicine

• National Physicians Alliance

• ABIM Foundation• Consumer Reports• Robert Wood Johnson

Christine Cassel, MACP President ACP, ABIM, NQF

Consumer Reports Foundation

As part of Choosing Wisely®, each participating specialty society has identified its own list of five common tests or procedures whose use in their profession should be discussed or questioned. The societies were given the following parameters to develop the lists:

Each item should be within the specialty’s purview and control;

Procedures should be used frequently and/or carry a significant cost;

There needs to be evidence to support each recommendation.

Consumer Reports then is creating consumer education materials for each item, intended for patients and their families.

• 30% of Health Care is Unnecessary!

• Five Billion Dollar Savings – Arch IM 2012

Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care Just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibility

Charter Commitments

• Endorsed by 104 societies

Five Things Physicians and Patients Should Question

• Supported by Evidence • Not Duplicative of Other Tests or

Procedures• Free from Harm• Truly Necessary

2012 – Nine Societies• AAAAI (Allergy/Imm)• AAFP• ACP• ACC (Cardiology)• ACR (Radiology• AGA (Gastroenterology)• ASN (Nephrology• ASNC (Nuclear Cardiol)• ASCO (Clinical Oncology

• Patient Centered Performance Management – JAMA 310:137 July 10, 2013

• Choosing Wisely – low value services– Volpp JAMA 308:1635 (2012)

Medical Professionalism in the New Millennium

A Physician Charter Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine*

Annals of Internal Medicine Volume 136 • Number 3 243-6, 5 February 2001

The Lancet, Volume 359, Issue 9305, Pages 520 - 522, 9 February 2002

Allergy Number One

• Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

• Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment. Appropriate diagnosis and treatment is both cost eective and essential for optimal patient care.

Allergy Number Two• Don’t order sinus computed tomography (CT) or

indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

• Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2 percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinusitis.

Allergy Number Three• Don’t routinely do diagnostic testing in patients

with chronic urticaria.

• In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost eective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.

Allergy Number Four• Don’t recommend replacement immunoglobulin

therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.

• Immunoglobulin (gammaglobulin) replacement is expensive and does not improve outcomes unless there is impairment of antigen-specific IgG antibody responses to vaccine immunizations or natural infections. Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/ dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin.

Allergy Number Five

• Don’t diagnose or manage asthma without spirometry.

• Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.

How This List Was Created• The American Academy of Allergy, Asthma & Immunology (AAAAI) Executive

Committee created a task force to lead work on Choosing Wisely consisting of board members, the AAAAI President and Secretary/Treasurer and AAAAI participants in the Joint Task Force on Practice Parameters. Through multiple society publications and notifications, AAAAI members were invited to offer feedback and recommend elements to be included in the list. A targeted email was also sent to an extended group of AAAAI leadership inviting them to participate.

• The work group reviewed the submissions to ensure the best science in the specialty was included. Based on this additional members were recruited for their expertise. Suggested elements were considered for appropriateness, relevance to the core of the specialty, potential overuse of resources and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. Finally, the work group chose its top five recommendations which were then approved by the Executive Committee.

References at www.choosingwisely.org

Videos on consumerreports.org

Sinusitis

AAFP chose from the National Physicians Alliance 2002 Publication “Less is

More” and Field Tested. Board approved.

• 1 Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

• 2 Antibiotics for sinusitis• 3 Don’t DEXA screen for osteoporosis in women younger

than 65 or men younger than 70 with no risk factors. • 4 Don’t order annual electrocardiograms (EKGs) or any

other cardiac screening for low-risk patients without symptoms.

• 5 Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

Am College of Cardiology Each Clinical Council submitted items, a steering committee narrowed

down to 5 for Exec Committee approval

• 1 Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

• 2 in asymptomatic patients. • 3 as a pre-operative assessment in patients scheduled to undergo low-risk

non-cardiac surgery • 4 Don’t perform echocardiography as routine follow-up for mild,

asymptomatic native valve disease in adult patients with no change in signs or symptoms.

• Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction.

ACP 11 man workgroup put together multiple scenarios. Sent to 1% of ACP

members to pick 5 best

• 1 Stress ECG• 2 Low Back Pain Imaging• 3 In the evaluation of simple syncope and a normal

neurological examination, don’t obtain brain imaging studies (CT or MRI).

• 4 In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

• 5 Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

Am College of Radiology7 commission chairs passed on to Board of Chancellors

• 1 Don’t do imaging for uncomplicated headache. • 2 Don’t image for suspected pulmonary embolism (PE)

without moderate or high pre-test probability of PE. • 3 Avoid Routine Admission or Pre-op Chest Xrays • 4 Don’t do computed tomography (CT) for the evaluation of

suspected appendicitis in children until after ultrasound has been considered as an option.

• 5 Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

AGA• 1 For pharmacological treatment of patients with gastroesophageal reflux

disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.2 Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.3 Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.

• 4 For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.

• 5 For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.

Am Society of Nephrology• Don’t perform routine cancer screening for dialysis patients

with limited life expectancies without signs or symptoms.• Don’t administer erythropoiesis-stimulating agents (ESAs) to

chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.

• Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

• Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.

• Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.

Am Soc Nuclear Cardiology• 1 Don’t perform stress cardiac imaging or coronary

angiography in patients without cardiac symptoms unless high-risk markers are present.

• 2 Don’t perform cardiac imaging for patients who are at low risk.

• 3 Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.

• 4 Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.

• 5 Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.

Am Soc Clinical Oncology1. Don’t use cancer-directed therapy for solid tumor patients with the

following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment.

2. Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.

3. Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

4. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.

5. Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.

Delphi Method

• The method entails a group of experts who anonymously reply to questionnaires and subsequently receive feedback in the form of a statistical representation of the "group response," after which the process repeats itself. The goal is to reduce the range of responses and arrive at something closer to expert consensus.

• Questionnaires to team of experts. Review and discuss the results and then question again until consensus.

Am College of RheumatologyDelphi Method and then submitted to 90% of members

1. Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

2. Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.

3. Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

4. Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs).

5. Don’t routinely repeat DXA scans more often than once every two years.

Society of General Internal Medicine

1. Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.

2. Don’t perform routine general health checks for asymptomatic adults.

3. Don’t perform routine pre-operative testing before low-risk surgical procedures.

4. Don’t recommend cancer screening in adults with life expectancy of less than 10 years.

5. Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience

Society of Hospital Medicine

• PPI• Foley Cath• BOTH CAUSE MORE INFECTIONS

Organizations publishing 5 Choosing Wisely Recommendations

• Allergy• Clinical Toxicology• Derm• FP• Hospice• Neurology• Ophthalmology• Orthopedic Surgery• ENT• Pediatrics• Blood Banks• Endocrine• Neuro Surgery• Pediatric

Ophthalmology• Cardiology

Chest PhysiciansEmergency PhysiciansMedical ToxicologyOb-GynOccupational MedACPRadiologyRheumatologySurgeryGastroenterologyHeadacheLong Term CarePsychiatryAnesthesiaClinical OncologyClinical Pathology

Colon Rectal SurgeryEchocardiographyHematologyNephrologyNuclear CardiologyRadiation OncologyAm Thoracic SocUrologyHeart Rhythm SocSpine SocCritical CareGyn OncologyHosp MedicineMaternal-Fetal MedThoracic SurgeryVascular Medicine

More than 80 societies

Date of download: 8/18/2013Copyright © 2012 American Medical

Association. All rights reserved.

From: “Top 5” Lists Top $5 Billion

Arch Intern Med. 2011;171(20):1858-1859. doi:10.1001/archinternmed.2011.501

Potential Savings-$5 Billion• Cost of unnecessary services was a function of

both the frequency and the reimbursement rates for each service.

• The practice activity associated with the highest cost was the prescribing of brand instead of generic statins, resulting in excess expenditures of $5.8 billion per year (95% CI, $4.3-$7.3 billion).

• Bone density testing in women younger than 65 years was the least prevalent activity but accounted for $527 million (95% CI, $474-$1054 million) in costs.

WHAT NEXT?

The Patient-Centered Medical Home Neighbor: The Interface of the Patient-CenteredMedical Home with Specialty/Subspecialty Practices

Referral Guidelines

• High Value Care Coordination – ACP workgroup – Designing Referral Templates

• NCQA– Patient Centered Medical Home– Specialty Recognition

Referral Template• Specialty Out-Patient Referral Request Checklist• (This information, which is recommended to be included with all referrals, can be communicated through any of• several means including a paper-based referral form, detailed clinical note from last appointment or a template• within the Electronic Medical Record)• 1. Patient demographics and scheduling information• a. Patient name, demographics, and contact information (including surrogate if appropriate)• b. Special considerations such as vision loss, hearing loss, language preference, cognitive• deficits, cultural factors, preference regarding who to include in treatment planning• c. Insurance company name/type of coverage• d. Referring provider name and contact information (including method for direct contact for• urgent issues)• e. Indicate that patient (or surrogate) understands and agrees with the purpose of the• referral, the type of referral (e.g. consultation or co-management) and the expected• process and division of responsibilities (e.g. patient to contact specialty practice or• specialty practice to call the patient; need for additional testing prior to visit)• f. If a face-to-face appointment is requested, indicate whether: (Choose one)• _______ the patient will call to schedule an appointment• _______ the specialty practice should contact the patient• 2. Referral information• a. What is the specific clinical question?• b. Urgency: (Choose one)• _______Urgent: (local definition; often 1-2 days) Recommend direct communication• between referring and referral practice; Minimally provide written justification for• urgency• _______Subacute (local definition; often 1-2 weeks)• _______Routine• c. Pending subspecialist/specialist evaluation, the anticipated referral-type is: (Choose one)• ______ Previsit Advice *• ______ Non Face-to-Face (information-only) consultation **• ______ Consultation (Evaluate and Advise, with the goal to managing the problem• remaining with the referring clinician)• ______ Procedural Consultation• ______ Co-Management with Shared Care (Referring clinician (e.g. PCP)• maintains first call for the referral disorder) ***• ______ Co-Management with Principal Care (Referred to subspecialist/specialist• assumes first call for the referral disorder) ****• ______ Please assume Full Responsibility for Complete Transfer of all Patient Care• d. A brief summary of case details pertinent to the referral, include related co-morbidities• e. Pertinent data set: Clinical information directly relevant to the specific referral question.• May include:• Office notes• Care summaries• Lab and imaging results• 76• Clinical information (e.g. specific lab tests) requested by the referred to• specialty/subspecialty practice prior to a consultation regarding the specific• condition• 3. Patient’s Core (general) data set:• a. Active problem list• b. Past medical and surgical history• c. Medication list; medical allergies• d. Preventive care (e.g., vaccines and diagnostic tests)• e. Family history• f. Habits/social history• g. List of providers (care team)• h. Advance directive;• i. Overall current care plan and goals of care• 4. Care Coordination• a. Referring practice requests notification from the specialty practice of the following:• (circle any applicable)• Receipt of the referral• Date of scheduled appointment• Decision to defer appointment and reason why• Patient cancellation or no-show for the appointment• b. Referrals made from one non-primary care specialty to another (e.g. secondary referrals)• are advised to include the notification of the patient’s primary care clinician.

Specialty Templates

Nephrology• NEPHROLOGY REFERRAL FORM• (If not noted elsewhere) Patient’s age_____ sex ______ race _____• Why did you refer the patient to us?• ____ concern about the severity of kidney disease• ____ concern about the rapidity of progression of kidney disease• ____ concern about the severity and rapidity of kidney disease• ____ other reason:___________________________________________• What is the most recent serum creatinine? _____ What was it a year ago? _____• Does the patient have proteinuria/albuminuria?____ If so, how much?_____• Does the patient have diabetes? _________• Does the patient have hematuria? _________• What is the recent average office blood pressure? ________________• (If not noted elsewhere) Current medication list:__________________________• If available, it would be helpful to include recent and past:• Blood chemistry results, including BUN and creatinine levels• Kidney imaging study results• Urinalysis and urine chemistry (i.e. urine protein, creatinine) results• Serological or autoimmunity tests (HIV, Hepatitis B and C, ANA, complements, etc.)• Office blood pressure measurements• SOME WEB RESOURCES FOR PHYSICIANS AND PATIENTS• http://nkdep.nih.gov/index.shtml• http://kdigo.org/home/guidelines/• http://www.kidney.org/index.cfm• https://www.aakp.org/education/resourcelibrary/ckd-resources.html

Endocrinology• yperthyroidism—Pertinent Data Set• 2d. A brief summary of case details pertinent to the referral, include related co-morbidities.• Please indicate in the summary if the patient has any of the following signs, symptoms or• conditions as that may impact the urgency of the referral:• Persistent tachycardia• Significant change in Weight• New onset Atrial Fibrillation• Cardiovascular Disease• New onset or Exacerbation of Congestive Heart Failure• Myopathy (difficulty getting up from sitting position or ambulating)• Ophthalmopathy with vision changes• Thyroid pain• Amiodarone therapy• IV contrast (? Time frame)• Tests to Prepare for Consult• TSH• Free T4• Not necessary for referral but Include if Already Performed• CBC• Liver Function Test• Any additional thyroid function tests• Chemistry Panel• Thyroid Antibodies• Thyroid Imaging (Ultrasound, Thyroid Nuclear Medicine Scan)• Avoid if possible• Radiocontrast Studies (due to iodine load which can exacerbate some forms of• hyperthyroidism and interfere with imaging and therapy; if study needed/needs to be

• • Suspected neurological symptom: Spells• Core Data Elements:• A brief summary of the case details pertinent to the referral, including family

history. Please indicate in the summary if the patient has any of the following:– Prolonged altered consciousness – Abnormal movements with episodes– Inability to stand at all due to orthostasis– Chest pain or palpitations– Any reported focal signs during the episode

• Prior to the consult:– Check orthostatic vital signs if fainted with standing– Consider cardiac causes: Check EKG and review history. If cardiac mechanism suggested,

consider Holter Monitor or refer to cardiology.• Not necessary for referral but include if already performed:

– Imaging and EEG (often of little value). – Do not check Ultrasound of carotids for syncope (choosing wisely campaign point).

What Next?

• Providers• Patients• Hospitals and Clinics• Payers