DR. CHRIS WILKES · CHRIS WILKES Dr. T.C.R. WILKES, ASSOCIATE PROF. University of Calgary, Cummings Medical School Division of Paediatrics and Psychiatry, SecJon Chief for SpecialiZed

CHOOSINGWISELYCANADA

DR.CHRISWILKES

Dr.T.C.R.WILKES,ASSOCIATEPROF.UniversityofCalgary,

CummingsMedicalSchoolDivisionofPaediatricsandPsychiatry,

SecJonChiefforSpecialiZedandOutpaJentservicesforCAAMHPP

DISCLOSURE

ConsultanttoBMS/OtsukaPharmaResearchwith

Lundbeckonadolescentdepression

CHOOSINGWISELYCANADA

LearningObjecJves:1.Tolearnaboutthepurposeandhistoryofthe

ChoosingWiselyCAMPAIGN.

2.Tolearnaboutiatrogenicillnessandthatmore

treatmentisnotnecessarilybeVerforpaJents.

3.ToexaminethekeyrecommendaJonsfor

ChildandAdolescentPsychiatry.

ChoosingWisely

•  LedbytheAmericanBoardofInternalMedicineFounda8on,ChoosingWisely(2012)isacampaignthatseekstopromoteconversa8onsbetweencliniciansandpa8ents,byhelpingpa8entschoosecarethatis:• Supportedbyevidence• Notduplica8veofothertestsorproceduresalreadyreceived• Minimizingtheriskofharm• Trulynecessary

•  Itprovidesevidence-based‘lowvalue’listsinover70speciali8esforphysiciansandpa8entstoconsider.

•  Uniquelyprovidescorrespondingpa8entcontentcreatedbyConsumerReports

www.choosingwiselycanada.org

Background

•  The2002publica8onMedicalProfessionalismintheNewMillenniumcalledphysicianstoahighstandardofprofessionalism.

•  Thefundamentalprinciplesofprofessionalismoutlinedinclude:• Pa8entWelfare• Pa8entAutonomy• SocialJus8ce

•  Itisthiscalltoprofessionalismandcommitmenttoimprovingaccesstohighqualityhealthcare,advoca8ngforajustandcost-effec8vedistribu8onoffiniteresourcesthatisthefounda8onforChoosingWisely

American Board of Internal Medicine Foundation, American College of Physicians, European Federation of Internal Medicine. (2002). Professionalism in the New Millennium: A Physician Charter.

HealthCareSpending

•  OveruseofHealthCarecontributestohighcosts.Somees8matesa[ributeupto30%ofUShealthspendingtooveruse.

•  Toreducehealthcostsandimprovepa8entcare,elimina8ngoveruseisamajorhealthcarereform.

•  HealthcareintheUnitedStatesismoreexpensivethaninotherdevelopedcountries,cos8ng$2.7trillionin2011,or17.9percentofthena8onalGDP

Institute of Medicine. (2013). Variation in Health Care: Target Decision Making Not Geography. Korenstein, D., Falk, R., Howell, E. A., Bishop, T., & Keyhani, S. (2012). Less is More - Overuse of Health Care Services in the United States: An

Understudied Problem. Arch Intern Med, 171-178.

IatrogenicDISEASE.

•  Adiseasethatiscausedbymedicaltreatment.Thishiddenepidemicincludes;

•  Thenega8veeffectofdrugs,•  Hospitalacquiredinfec8ons,•  HospitalMedica8onerrors,•  Unnecessarysurgery.•  Thesearees8matedtoresultinthe3rdmostfataldiseaseinthe

USA.•  “Moretreatmentisnotalwaysbe[er”

Seven-NaJonSummaryScoresonHealthSystemPerformance

•  Davis,K.,Schoen,C.,&Stremikis,K.(2010).Mirror,MirrorontheWall.HowthePerformanceoftheU.S.HealthCareSystemComparesInterna<onally.CommonwealthFund.

•  • 

Seven-NaJonSummaryScoresonHealthSystemPerformance–

OverallRankingOverTime

•  Davis,K.,Schoen,C.,&Stremikis,K.(2010).Mirror,MirrorontheWall.HowthePerformanceoftheU.S.HealthCareSystemComparesInterna<onally.CommonwealthFund.

HowMuchDoesHealthCareinCanadaCost?•  TotalHealthExpendituresCanada1975-2013

• 

Canadian Institute Health Information. (2013). National Health Expenditures Trends, 1975-2013. CIHI.

TotalExpendituresonDrugs,perCapita,U.S.Dollars,2011

•  10fig51percapitadrugexpenditure

Canadian Institute Health Information. (2013). National Health Expenditures Trends, 1975-2013. CIHI.

ExpendituresonServicesProvidedbyOfficesof

Physicians,perCapita,U.S.Dollars,2011

TotalHealthExpenditurebyUseofFunds,Canada,2011(BillionsofDollarsandPercentageShare)

TheRoleofPhysicians•  Professionalobliga8ontoprovideappropriatecare•  Con8nuedleadershipinevidence-basedmedicine•  Recogni8onofescala8nghealthcarecosts,andopportunity

forphysicianstoinfluenceforthebe[er.Appealtotheimportanceoftakingproac8vemeasurestoaddresswaste.

•  Asignificantpor8onofhealthcostsarerelatedtophysicianorders.Somees8matesputthisnumberat80%.

•  Commitmenttotransparencyandshareddecisionmaking

Wolfson,D.,Santa,J.,&Slass,L.(2014).EngagingPhysiciansandConsumersinConversa8onsaboutTreatmentOveruseandWaste:AShortHistoryoftheChoosingWiselyCampaign.AcademicMedicine,1-6.

TheNeedforCompellingEvidence

•  Researchevidenceisnottheonlydeterminantofclinicaldecision-making.Variousotherfactorsthatmayexplainthetendencytowardsunnecessarycareand/ordecision-makinginclude:

•  Indica8onCreep•  Cogni8veDissonance

•  theinabilitytoreconcilenewevidencewithhighlyingrainedpriorbeliefsthatbothdetermineandarereinforcedbyrou8nizedprac8ce:onebelievessoonedoes,andasonedoes,soonebelieves.

•  Medical/Legalliabilityconcerns•  SenseofthreatenedProfessionalAutonomy•  VarietyofBiasestowardunnecessarycare

Sco[,I.A.,&Elshaug,A.G.(2013).Foregoinglow-valuecare:howmuchevidenceisneededtochangebeliefs?InternalMedicineJournal,107-109.

BiasesTowardUnnecessaryCare

•  Clinicianregretatnotadministeringatreatmentwhenitmayleadtobenefit(regretofomission)overpoweringregretfortheconsequencesofanunnecessarytreatment(regretofcommission)

•  Pro-interven8onbias,especiallyamongyoungerclinicians,towardschoosingac8onoverinac8onevenifmarginalbenefitsofac8onareverysmall

•  Pro-technologyand‘innova8on’biastowardstooreadilybelievingthatnewertreatmentsandtechnologiesaresuperiortotheirpredecessors

•  Desiretopleasereferringclinicians•  Fearofpa8entapproba8onorli8ga8onfornotdoingthings(defensivemedicine);•  Supply-drivendemand(desireofindustryandproviderstogenerateincomeinpresenceof

excesscapacity)•  Overes8ma8onbybothcliniciansandpa8entsoftreatmentbenefitsandsafety•  Overrelianceonpathophysiologicaloranatomicalreasoning,orsurrogateoutcomesthatdo

notnecessarilytranslateintopa8ent-importantbenefits•  Clinicalprac8ceguidelineslackingasoundevidencebaseorwri[enbyconflictedpanellists•  Fee-for-servicefunding(whichrewardsquan8tynotqualityofservices)

Sco[,I.A.,&Elshaug,A.G.(2013).Foregoinglow-valuecare:howmuchevidenceisneededtochangebeliefs?InternalMedicineJournal,107-109.

RANDModelforCompellingEvidence•  Appropriatenessisdefinedlargelyintermsofnetclinicalbenefittotheaveragepa8entandvariesbyserviceandseqng.ThemostwidelyusedmethodtoassessappropriatenessofhealthcareservicesistheRAND/UCLAModel.

•  Inanefforttoovercomethelimitsofavailableevidence,theRANDmodelincorporatesboththeexis8ngevidenceandtheresultsofclinicalconsensusamongkeyexperts.

•  Thecomposi8onofthepanelma[ers.Thedetermina8onofwhetheraprocedureisappropriate,ornot,willdependinpartonthetypeandmixofcliniciansinvolvedinthedelibera8ons.

Sanmar8n,C.,Murphy,K.,Choptain,N.,Conner-Spady,B.,McLaren,L.,Bohm,E.,etal.(2008).Appropriatenessofhealthcareinterven8ons:Conceptsandscopingofthepublishedliterature.Interna<onalJournalofTechnologyAssessmentinHealthCare,

342-349.

ChoosingWisely-Canada•  April2014-Ini8allaunchofCanadianrecommenda8onsinvolving8specialist

socie8es•  Endorsedby:

• CanadianMedicalAssocia8on• RoyalCollegeofPhysiciansandSurgeonsofCanada• CollegeofFamilyPhysiciansofCanada• CanadianAssocia8onofProfessorsofMedicine

•  June2015–nextrolloutinvolvingseveralmoresocie8esincludingtheCanadianPsychiatricAssocia8on,aswellasconsumergroups

•  Academicenvironmentrarelydiscouragesorderingtestsorproceduresandthiscultureneedstochange

•  Insteadof“moreisbe[er’consider“thinktwice”whenorderingtests,treatmentsandprocedures

Levinson, W., & Huynh, T. (2014). Engaging physicians and patients in conversations about unnecessary tests and procedures: Choosing Wisely Canada. CMAJ, 325-326.

ChoosingWiselyCanada-Psychiatry

•  Don'tuseanJpsychoJcsasfirstchoicetotreatbehaviouralandpsychologicalsymptomsofdemenJa.

•  PeoplewithdemenJaoeenexhibitchallengingbehaviouralsymptomssuchas

aggressionandpsychosis.Insuchinstances,anJpsychoJcmedicinesmaybenecessary,butshouldbeprescribedcauJouslyastheyprovidelimitedbenefitandcancauseseriousharm,includingprematuredeath.UseofthesedrugsshouldbelimitedindemenJatocaseswherenon-pharmacologicmeasureshavefailed,andwherethesymptomseithercausesignificantsuffering,distress,and/orposeanimminentthreattothepaJentorothers.AthoroughassessmentthatincludesidenJfyingandaddressingcausesofbehaviourchangecanmakeuseofthesemedicaJonsunnecessary.Forcontext,thenumberneededtotreatwithanatypicalanJpsychoJcforaclinicallysignificantbenefitrangesfrom5-11,andthenumberneededtoharmformortalityover6-12weeksis100.Datafromepidemiologicalstudiessuggestthattypical(i.e.,firstgeneraJon)anJpsychoJcs(e.g.,haloperidol)areassociatedwithatleastthesameriskofadverseevents.ThisrecommendaJondoesnotapplytothetreatmentofdeliriumormajormentalillnessessuchasmooddisordersorschizophrenia.

ChoosingWiselyCanada-Psychiatry•  Don’tusebenzodiazepinesorotherseda8ve-hypno8csinolder

adultsasfirstchoiceforinsomnia

•  Nonpharmacologicalinterven8onssuchascogni8vebehaviouraltherapyandbriefbehaviouralinterven8onshaveprovenbenefitinthemanagementofinsomniainolderadults.Epidemiologicalstudieshaveshownthattheriskofmotorvehicleaccidents,fallsandhipfracturesleadingtohospitaliza8onanddeathcanmorethandoubleinolderadultstakingbenzodiazepinesandotherseda8ve-hypno8cs.Thenumberneededtotreatwithaseda8ve-hypno8cforimprovedsleepis13,whereasthenumberneededtoharmisonly6.Prescribingordiscon8nuingseda8ve-hypno8csinhospitalcanhavesubstan8alimpactonlong-termuse.Thesepoten8alharmsandotherssuchasimpairedcogni8onneedtoberecognizedwhenconsideringtreatmentstrategiesforinsomnia.Useofbenzodiazepinesshouldbelimitedtoasshortaperiodaspossible,incaseswherenon-pharmacologicaltherapieshavefailed,andthesymptomsofsleepdisturbancecausesignificantsufferingordistress.

ChoosingWiselyCanada-Psychiatry•  Donotuseatypicalan8psycho8csasafirst-lineinterven8onforinsomniainchildrenandyouth.

•  Recentresearchconfirmsadrama8cincreaseintheuseofatypicalan8psycho8cswithsubsequentside-effectsincludingobesity,andasthisisamajorhealthissuealready,itisprudenttopursuenon-pharmacologicalmeasuresfirstsuchasbehaviouralmodifica8onsandensuringgoodsleephygiene(elimina8ngday8menappingandshuqngoffelectronicsanhourbeforebed8me).Iftheseinterven8onsarenotsuccessful,thenconsidershort-termuseofmelatonin.

ChoosingWiselyCanada-Psychiatry•  DonotuseSSRIsasthefirst-lineinterven8onformild

tomoderatelydepressedteens.•  Evidenceclearlyindicatesthatan8depressantmedica8onis

lesseffec8veinchildrenandadolescentsuptotheageof17yearsandfirst-linetreatmentforthisgroupshouldincludecogni8vebehaviouraltherapyorinterpersonalpsychotherapy.A[en8onshouldalwaysbefocusedonchildren’sandteens’environmentalsafetyandadequateparentalsupporttoavoidmissingcasesofneglectorabuse.Followingthis,afirst-lineinterven8onshouldbepsychoeduca8onregardingtheimportanceofregularsleep,dietandexercisetoensurehealthy,age-appropriatedevelopmentalsupport.

ChoosingWiselyCanada-Psychiatry•  Donotuseatypicalan8psycho8csasafirst-lineinterven8on

forADHDcomorbidwithdisrup8vebehaviourdisorders.

•  TreatmentofADHDshouldincludeadequateeduca8onofpa8entsandtheirfamilies,behaviouralinterven8ons,psychologicaltreatmentsandeduca8onalaccommoda8onsfirst.Thens8mulantmedica8onalongwithabehaviouralanalysistoensureappropriatesupportfromtheparentandclassroominterven8on;theuseofalpha2agonists(suchasguanfacine)andatomoxe8neshouldbeconsideredbeforeusingatypicalan8psycho8cs(suchasrisperidone)inkidswithdisrup8vebehaviourdisorders(opposi8onaldefiantdisorder,conductdisorder).


•  Donotusepsychos8mulantsasafirst-lineinterven8oninpreschoolchildrenwithADHD.

•  PreschoolchildrenwithADHDneedtobeassessedforotherneuro-developmentaldisordersandconsidera8ongiventoenvironmentalstressorssuchasneglect,abuseorexposuretodomes8cviolence.Treatmentalsoincludesadequateeduca8onandsupportofparentsfollowedbyadviceonbehaviouralmanagementandcommunityplacement.


•  Donotignoreearlymentalhealthproblemsforyoungchildren(0to5years).

•  Acrucial90%ofbraindevelopmentoccursinthefirstfiveyearsoflife,fosteringadevelopingcapacityfora[achmentandhealthysocialemo8onaldevelopment.Manychildrenwhohaveadiagnosisofmentalhealthdisordersexhibitedsymptomsbeforetheageof6butwereunabletoaccessthesupportsandservicesneededforeffec8veinterven8on.

ChoosingWiselyCanada-Psychiatry•  Donotrou8nelyusean8psycho8cstotreatprimary

insomniainanyagegroup.

•  Second-genera8onan8psycho8cs(SGAPs)seda8veproper8es,suchasolanzapineandque8apine,areosenprescribedoff-labelforcomplaintsofinsomnia.InasurveyofcliniciansprescribingSGAPs,12.1%indicatedprescribingitsolelytoinducesleep.Que8apinewasthemostosenprescribedSGAPfollowedbyrisperidoneandolanzapine.Thesedrugscarrysignificantriskofpoten8alsideeffects.SafetyofSGAPstotreatinsomniahasnotbeensystema8callystudied.Theycancauseweightgainandmetaboliccomplica8onsevenatlowdosesusedtotreatinsomnia.Inpa8entswithdemen8a,theycanalsopoten8allycauseserioussideeffectsofincreasedriskofcerebrovasculareventandincreasedriskofdeath.


•  Donotrou8nelyrequestSTATqualita8vetoxicology(urinedrugscreen)tes8ngonallpsychiatricpa8entspresen8ng

toemergencyrooms.

•  Qualita8veurinetoxicologytes8nghasnotbeenshowntoimprovetherou8nemanagementofpsychiatricpa8entsinemergencyroomsbecauseofthepoten8alforfalseposi8ves,falsenega8ves,trueposi8veswhichareunrelatedorminimallyrelevanttotheclinicalpresenta8on,andfinallythedelayinpsychiatricassessmentandmanagementasaresultoftes8ng.

ChoosingWiselyCanada-Psychiatry•  Donotrou8nelyusean8depressantsasfirstlinetreatmentformild

orsubsyndromaldepressivesymptomsinadults.

•  An8depressantresponseratesarehigherfordepressionofamoderatetoseverenature.Formildandsubsyndromalsymptomsacompleteassessment,ongoingsupportandmonitoring,psychosocialinterven8onsandlifestylemodifica8onsshouldbethefirstlinesoftreatment.Thismayavoidthesideeffectsofmedica8onandestablishe8ologicalfactorsimportanttofutureassessmentandmanagement.An8depressantsareappropriateincasesofpersistentmilddepression,wherethereisapasthistoryofmoreseveredepressionorwhereotherinterven8onshavefailed.

ChoosingWiselyCanada-Psychiatry•  Donotrou8nelyorderbrainneuroimaginginves8ga8onssuchasa

CTscanorMRIforallcasesoffirstepisodepsychosesintheabsenceofsymptoms,later-ageonsetofsymptoms,signsorbasicinves8ga8onssugges8veofotherrelevantintracranialpathology.

•  Wherethereareneurologicalsigns,symptoms,later-ageonsetofsymptoms,orothertestresultssugges8veofintracranialpathologyinaddi8ontoorrelatedtopsycho8csymptomsneuroimagingisindicated.Mul8plestudieshavefoundthatrou8neneuroimaginginfirstepisodepsychosesdoesnotyieldfindingswhichalterclinicalmanagementinameaningfulway.Therisksofradia8onexposure,delayintreatment,andcostsaresignificantfactorswhichalsoargueagainstrou8neneuroimaging.

ChoosingWiselyCanada-Psychiatry•  Donotrou8nelycon8nuetoprescribebenzodiazepines,ini8ated

duringanacutecarehospitaladmissionwithoutacarefulreviewandplanoftaperinganddiscon8nuing,ideallybeforedischarge.

•  Benzodiazepines,whilehelpfulforshort-termreliefofanxietyandinsomnia,areassociatedwithavarietyofside-effectsandlong-termproblemsincludingcogni8veandpsychomotorimpairmentaswellasabuseanddependence.Benzodiazepinesarecommonlyusedinhospitaltotreatanxietyorinsomniainassocia8onwitheitherthepresen8ngcondi8onorthehospitalenvironment.Oncethepresen8ngcondi8onistreatedandthepa8entisdischargedbenzodiazepinesshouldbecarefullyreviewedwiththegoal,whereatallpossible,oftaperinganddiscon8nuingthesemedica8ons.

ChoosingWiselyCanada-Psychiatry•  Don’trou8nelyprescribean8depressantsasfirstlinetreatmentfordepression

comorbidwithanac8vealcoholusedisorderwithoutfirstconsideringthepossibilityaperiodofsobrietyandsubsequentreassessmentforthe

persistenceofdepressivesymptoms.

•  Theconcurrentmanagementofpsychiatricillnessandalcoholusedisordersrequiresevalua8onoftherolealcoholplaysasacausa8vefactorfordepressivesymptoms.Studieshavefoundthatresponseratestoan8depressantsarehigherwhenan8depressantsarereservedforpersistenceofsymptomsaseraperiodofsobrietylas8ngfrom2to4weeks.Responserateswhenprescribedduringaperiodofac8vealcoholmisusearepoorerandosenfailtoseparatefromplacebo.Addi8onallystudieshavedemonstratedremissionfromdepressivesymptomswithsobrietyintheabsenceofan8depressanttreatmentinasignificantpercentageofcases.Managementofcomorbidpsychiatricillnessandsubstanceusedisordersincludingalcoholdependenceinvolvesassessmentandtreatmentdeliveredinconcurrentmanner.Thesequencingofabs8nencefromsubstancemisusebeforeprescribingan8depressantsdoesnotobviatetheneedforaconcurrentapproach.


•  Don'trou8nelyprescribehigh-doseorcombina8onan8psycho8ctreatmentstrategiesinthetreatmentofschizophrenia.

•  High-doseandcombina8onstrategiesinvolvingatypicalan8psycho8cs(AAPs)arefrequentlyusedinclinicalprac8ceforpa8entswithschizophreniawhoareinadequatelycontrolledwithoneormoreAAPsusedatstandarddoses.Arecentmeta-analysisassessedtherela8vesafetyandefficacyofcombina8ontherapyandhigh-doseatypicalan8psycho8ctherapyinpa8entswithschizophreniainadequatelycontrolledonstandard-dosean8psycho8cs,andnoclinicallysignificantimprovementswerefoundfavouringcombina8onorhigh-doseAAPtreatmentstrategieswhencomparedwithstandard-dosemonotherapy.Intermsofsafety,noclinicallysignificantdifferenceswereevidentbetweencombina8onorhigh-dosetherapyincomparisonwithstandard-dosemonotherapy,withtheexcep8onofclozapinecombina8ontherapywherepa8entsexperiencedmoreseriousadverseeventscomparedwithclozapinemonotherapy.However,thesafetyevidencewasconsideredinconclusive,duetothesparsityofdataforkeyharms-relatedoutcomes.Generally,combina8onorhighdosestrategiesshouldbeconsideredaserdemonstra8onofthreefailedtrialsofmonotherapy,includingclozapinewhereappropriate.

MovingChoosingWiselyForward

•  Educa8onandawareness•  Increasednumberofrecommenda8ons•  Increasedandcurrentevidence•  ClinicalPrac8ceGuidelinesbyNa8onalSocie8es•  Formalendorsementbyrelevantbodiesandstakeholders•  AcademicLiterature•  OrderingProtocols

SuccessIndicators?

•  Howdoweknowifitworks?•  WaitandSee•  Research,Evalua8ons,Audits,Cos8ngStudies,Databases•  ImprovedPa8entWellbeing•  ImprovedQualityofCare(Processes)•  ImprovedProfessionalFulfillment

Thankyou

Comments?QuesJons?

Contact:

•  Dr.ChrisWilkes•  [email protected]

REFERENCES

•  h[p://www.theglobeandmail.com/life/health-and-fitness/an8psycho8cs-prescribed-at-high-rate-to-youth-with-adhd-study-shows/ar8cle33666692/

h[p://cpa.sagepub.com/cgi/reprint/0706743716643823v1.pdf?ijkey=hqDZzONDHth7Faz&keytype=finite

Engel,G.L.1980.TheclinicalapplicaJonofthebiopsychosocialmodel.Am.JournalOfPsychiatry,137:535-544.Eisenberg,L.1986,MindlessnessandBrainlessnessinPsychiatry.Brit.JournalofPsychiatry.148:497-508.SeeaVachmentforotherreference.PharmacologicaltreatmentsofChildandAdolescentDisrupJveBehaviourDisorders.CanJPsychiatryfeb2015.Vol60.No2.39-41.

DR. CHRIS WILKES · CHRIS WILKES Dr. T.C.R. WILKES, ASSOCIATE PROF. University of Calgary, Cummings Medical School Division of Paediatrics and Psychiatry, SecJon Chief for SpecialiZed

Documents