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Healthcare Transformation Learning Sessions February 26th Webinar, 1:00 - 2:00 PM Learning Topic: Choosing Wisely - How can physicians and patients have the important conversations necessary to ensure the right care is delivered at the right time? Agenda •

Lessons Learned from Choosing Wisely John Santa, MD, MPH, Medical Director, Consumer Reports

Value of Participating in the Choosing Wisely Initiative Sarah Durfee, RN, Clinical Programs Officer, Ohio Public Employees Retirement System

What assistance is available to advance Choosing Wisely in Greater Columbus? Jeff Biehl, Healthcare Collaborative of Greater Columbus

Lead Support

Major Support

Additional Support 100% Access HealthColumbus Board & Staff

Individual & Corporate Donations

Innovation and Transformation Lessons Learned from Choosing Wisely

John Santa MD MPH Medical Director, Consumer Reports Health February 26, 2014

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,

• 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

• An innovative and transformational communication campaign about standards of care – Focused on professionalism

• Stimulating culture change of clinical practice – More is not better

• Thinking about innovative and transformative strategies

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.

ACP Foundation/ABIM Foundation/EFIM Physician Charter 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 Fundamental Principles • Maintaining trust by managing conflicts of interest •Primacy of patient welfare • Professional responsibilities •Patient autonomy •Social justice

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 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 OtolaryngologyHead and Neck Surgery • American Academy of Pediatrics • American College of Obstetricians and Gynecologists • American College of Rheumatology

• • • • •

American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology

• • • • •

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

• • • •

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

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

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

• • • • • •

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

What’s Next? • 25+ 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 patientfocused materials

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)

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) – Heartburn meds – Anti-inflammatories Routine FU/Monitoring (12) “Disease” approach – Cancer (21) – Chronic kidney failure/dialysis (4) – Heart disease (21) – Maternity (4)

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

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

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

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.

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 prostatespecific 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

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

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:

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

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)

Consumer Reports Heart Disease Survey Issues discussed with doctor prior to getting a heart-specific screening test High cholesterol and/or High Blood 'Healthy' Issues discussed with Doctor Prior to Getting Screening Test Pressure The type of heart problem the test was screening for 31% 17% What you would need to do if the test showed something abnormal 18 11 The accuracy of the test 16 9 What types of treatments would be available if the test indicated a problem 15 6 Cost and insurance coverage 10 6 How much discomfort you should expect 8 5 Potential complications from the test 7 4 Whether or not medical studies have shown the test saves lives 4 1 51 69 None of the above Base: 2309 521

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

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?

Time to Pivot?? • “Culture” prepared. Leadership opportunity? • 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) Post intervention testing in low risk patients who do well (12 topics) Drugs---especially antibiotics (12 topics) and those advertised Imaging---especially those involving radiation (19 topics) Safety—especially elective delivery, inappropriate induction

• From one on one conversations to a “practice dialogue” • From large professional societies to communities • From victims of “demand driven healthcare” to engaged patients

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

What to do? • Change the Standard of Care • Physician to Physician interactions – Patient Physician Communication strategies – “Hard Stops” -- induction of labor – Formation of Optimal Cardiovascular Utilization Strategies (FOCUS) ACC – Image Gently/Image Wisely

• Right Size care strategies – Insist that demand strategies be evidence based not revenue based – Address disparities aggressively – Integrate into routine care – Change incentives

Interactions That Enhance Outcomes • Four common components: – Provide clear information – Develop mutually agreed upon goals – Have patients take an active role in their care – Physician provides positive affect, empathy and support.

• Meta-analysis of studies of physicianpatient interactions that lead to enhanced outcomes (Stewart,1999; Stewart, 2000)

Provide empathy/partnership • Physicians that use empathic statements have improved patient satisfaction even if patients’ requests are not granted. (Eisenthal & Lazare, Froehlich & Welch) • Best option “I understand your worries and I am ready to address them”

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

John Santa campaigns/choosing-wisely/

Value of Participating in the Choosing Wisely Initiative Sarah Durfee, RN, Clinical Programs Officer, Ohio Public Employees Retirement System

Collaborative Activity Update January 2014

What assistance is available to advance Choosing Wisely in Greater Columbus? A number of no-cost resources are available for our partners in Greater Columbus that wish to incorporate Choosing Wisely into their own communication campaigns.  Customized, co-branded microsites offering tools for consumers that will be maintained and regularly updated by Consumer Reports Health.  Co-branded poster for use in wellness communications. This poster offers five questions that patients should ask their doctor about any medical test or procedure.  Communication tools such as campaign messages, talking points, digital communication tips, and social media resources. If your organization is interested in exploring any of these resources, please contact John Leite (

February 26 Learning Session Presentation  
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