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Choosing Wisely: How California Pathologists Can Influence Appropriate Testing
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This symposium is made possible by the Choosing Wisely campaign with support from
This symposium is being recorded for future ASCP promotional and educational use.
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How to Vote via Texting with Poll Everywhere (Audience Response System)
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Choosing Wisely: How California Pathologists Can Influence Appropriate Testing Dr. E. Blair Holladay, Executive Vice President The American Society for Clinical Pathology CSP Annual Meeting – December 2013
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This symposium is made possible by the Choosing Wisely campaign with support from
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We must continue to push the envelope as we think and work “Beyond the Lab.”
• Our health care system is moving to a new model that maximizes efficiency, with changes to delivery and reimbursement approaches.
• Doing the right thing for patients will always be what is most important, requiring the right diagnostic insights
• That depends on our laboratories and laboratorians
• We must lead when it comes to diagnostic services • Advance patient-centered care • Improve overall healthcare quality • Reduce unnecessary utilization
• And we will be regarded (and rewarded) as much for
what we don’t do as what we do actually do
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Effective and timely use of laboratory diagnostic services will be a cornerstone of ACO success • Optimizes quality
• More rapid diagnosis and treatment • Patient centered management • Allows for effective treatments
• Reduces Costs
• Reduced unnecessary (and potentially dangerous) interventions
• Shortened times to treatment
There’s a big opportunity for effective use of laboratory services in new delivery models.
IN PARTNERSHIP WITH +
The Choosing Wisely campaign is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.
When Less is More: The Choosing Wisely Campaign
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• Discuss why Choosing Wisely is a unique opportunity for pathology leadership to impact positive clinical outcomes and cost reduction
• Identify techniques for influencing clinical best practices in test ordering
• Identifying methods for overcoming communication, organizational, and systems barriers to implementing Choosing Wisely Best Practices
Today, we want to engage in a dialogue between pathologists and others.
In partnership with + What do consumers think of Laboratory Services? Beccah Rothschild, MPA Consumer Reports
How can Pathologists better influence tests ordering? Richard Kravitz, MD, MSPH Professor of Medicine, UC Davis Haya Rubin, MD, PhD Internal Medicine Practice
Discussion
Laboratory Leadership and Choosing Wisely George Lundberg, MD Medscape General Medicine
Wrap Up Eric R. Parks, PhD ASCP Staff
We’ve invited a group of influential leaders to help stimulate the discussion.
Beccah
Rothschild, MPA
Richard Kravitz,
MD, MSPH
George
Lundberg, MD
Haya Rubin,
MD, PhD
In partnership with +
ABIM Foundation
American Academy of Allergy, Asthma & Immunology
American Academy of Clinical Toxicology
American Academy of Dermatology
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology–Head and Neck Surgery
American Academy of Pediatrics
American Association of Blood Banks
American Association of Clinical Endocrinologists
American Association of Neurological Surgeons
American Association for Pediatric Ophthalmology and Strabismus
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Medical Toxicology
American College of Obstetricians and Gynecologists
American College of Occupational and Environmental Medicine
American College of Physicians
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Geriatrics Society
American Headache Society
AMDA—Dedicated to Long Term Care Medicine
American Psychiatric Association
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society for Clinical Pathology
American Society of Colon and Rectal Surgeons
American Society of Echocardiography
American Society of Hematology
American Society of Nephrology
American Society of Nuclear Cardiology
American Society of Plastic Surgeons
American Society for Radiation Oncology
American Society for Reproductive Medicine
American Thoracic Society
American Urological Association
Commission on Cancer
Consumer Reports Health
The Endocrine Society
Heart Rhythm Society
National Physicians Alliance
North American Spine Society
Robert Wood Johnson Foundation
Society for Cardiovascular Angiography and Interventions
Society of Cardiovascular Computed Tomography
Society for Cardiovascular Magnetic Resonance
Society of Critical Care Medicine
Society of General Internal Medicine
Society of Gynecologic Oncology
Society of Hospital Medicine
Society for Maternal-Fetal Medicine
Society of Nuclear Medicine and Molecular Imaging
Society of Thoracic Surgeons
Society for Vascular Medicine
There are many organizations on board.
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• Institute of Medicine Report: 30% of U.S. health care is duplicative or unnecessary.
• Paul O’Neill recognized this when he was CEO of Alcoa.
• Inefficiency threatens our nation’s ability to deliver the highest care possible to all patients.
Inefficiency in U.S. Health Care
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• Pathologists, lab professionals and our laboratories need to play a leadership role in addressing these challenges.
• This is why ASCP joined the Choosing Wisely campaign in 2012 and announced its first five tests in February 2013.
ASCP + Choosing Wisely
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• Our laboratories constantly contribute to improving patient care and reducing the high cost of health care.
• In hospitals, pathologists and lab professionals serve on many committees and task forces.
• Unnecessary testing = inappropriate treatment decisions and consumption of finite resources.
Pathologists as Leaders
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“The US Spends More On Care But People Don’t Live Longer”
U.S. Health Care Spending is Out of Control
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Choosing Wisely:
• To reduce cost that provides no benefit
• To help mitigate tough decisions about how care is delivered in the future
Choosing Wisely is one initiative that seeks to reverse the trend.
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Take Charge of Reducing Costs
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Most doctors have no idea what these tests cost, so they have no way of knowing they are contributing to the astronomical cost of health care. Dr. Leonard Feldman Johns Hopkins University School of Medicine
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• Center appropriate test utilization on good patient care and include both the cancellation of inappropriate tests and the addition of appropriate tests for the best patient outcomes.
• Five tests that ASCP recommends for Choosing Wisely are an important dimension of appropriate test utilization in the lab.
• Patients should learn firsthand about these tests, so they can make informed choices.
Many Dimensions to Appropriate Test Utilization
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• The ASCP Institute Advisory Committee spearheaded the selection of ASCP’s 5 tests for Choosing Wisely.
• A review panel examined hundreds of options based on both the practice of pathology and evidence available through literature.
Choosing Wisely Experts
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• We only were allowed to have five!
• Common situations • Tests with merit in some circumstances but are not
appropriate in others • Tests with no clinical utility • Tests that have been generally replaced by better tests • New and emerging diagnostics
• Envision this as the beginning
The five initial tests were selected to be illustrative of common situations we confront.
Do not perform population-based screening for 25-OH-Vitamin D deficiency. 1
Do not perform low-risk HPV testing. 2
Avoid routine preoperative testing for low-risk surgeries without a clinical indication. 3
Only order Methylated Septin 9 (SEPT9) on patients for whom conventional diagnostics are not possible. 4
Do not use bleeding time to guide patient care. 5
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• Many of the organizations shown earlier have developed recommendations that involve laboratory testing
• Laboratory testing is so critical to the practice of medicine
• That’s why other organizations talk about testing appropriateness
Although there is only one primary lab organization involved…
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American Academy of Allergy, Asthma, and Immunology (AAAAI) • Don’t perform unproven diagnostic tests, such as IgG
testing or an indiscriminate battery of IgE tests, in the evaluation of allergy
• Don’t routinely do diagnostic testing in patients with chronic urticaria
Endocrine Society and AACE • Don’t routinely measure 1,25-dihydroxyvitamin D
unless the patient has hypercalcemia or decreased kidney function
• Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency
There are lots of examples in other organizations’ recommendations.
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American Academy of Family Physicians • Don’t perform Pap smears on women younger than 21 or
who have had a hysterectomy for non-cancer disease • Don’t screen women younger than 30 years of age for
cervical cancer with HPV testing, alone or in combination with cytology
• Don’t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer
• Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam
American Academy of Ophthalmology • Don’t perform preoperative medical tests for eye surgery
unless there are specific medical indications
And some of them are consistent with ASCP.
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American Academy of Clinical Toxicology • Don’t order heavy metal screening tests to assess non-
specific symptoms in the absence of excessive exposure to metals
American Congress of Obstetrics and Gynecology • Don’t perform routine annual cervical cytology screening
(Pap tests) in women 30–65 years of age • Don’t screen for ovarian cancer in asymptomatic women
at average risk American College of Rheumatology • Don’t test ANA sub-serologies without a positive ANA and
clinical suspicion of immune-mediated disease • Don’t test for Lyme disease as a cause of musculoskeletal
symptoms w/o an exposure history & exam findings
Many address women’s health issues.
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American College of Surgeons • Avoid colorectal cancer screening tests on asymptomatic
patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia
American Gastroenterological Association • Do not repeat colorectal cancer screening (by any
method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals
American Society of Clinical Oncology (ASCO) • 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
Many focus on avoiding tests where the likelihood of a false positive is high.
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Commission on Cancer • Don’t perform surgery to remove a breast lump for
suspicious findings unless needle biopsy cannot be done
Society of General Internal Medicine • Don’t perform routine general health checks for
asymptomatic adults • Don’t perform routine pre-operative testing before
low-risk surgical procedures • Don’t recommend cancer screening in adults with life
expectancy of less than 10 years Society of Hospital Medicine • Don’t perform repetitive CBC and chemistry testing in
the face of clinical and lab stability
And the benefit is low…
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You can review the entire list at choosingwisely.org
www.choosingwisely.org
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• 5,000 new genomic lab tests available in next 5 to 10 years
• Patients may want all tests available but not understand the consequences or costs of inappropriate testing
• Laboratorians must lead balanced discussions and recommend appropriate tests for individual patients
Genomic Testing: New Challenges
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• Diagnostic tests = crucial link to patient quality and safety
• Assure there is a valid medical reason to order a particular test and know how the test result contributes to guiding patient management
• Ask why is this test necessary for this patient. Are there better alternatives? Including no test?
Diagnostic Tests & Patients
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• Educate clinicians and patients about when patients need these 5 tests and when they do not.
• Examine local utilization and determine other Choosing Wisely priorities based on local practice.
• Build on our discussion this afternoon
Next Steps for Choosing Wisely
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• Lab tests are usually so reliable, but they have limitations.
• We can improve the diagnostic value of lab tests while preventing the misuse of resources.
Become Consultants
Choosing Wisely: What Do Consumers Think About Laboratory Purchases?
Beccah Rothschild, MPA Senior Outreach Leader Consumer Reports www.consumerhealthchoices.org CSP Annual Meeting – December 2013
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This symposium is made possible by the Choosing Wisely campaign with support from
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Clinically Meaningful
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Consumer Reports, in conjunction with the ABIM Foundation, has developed 99 two-page pamphlets for consumers, covering 54 topics. • Of the 99, there are 54 in English and 45 in Spanish. • All are available for your use, including distribution, at:
Choosing Wisely: The Consumer Perspective
http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials
IN PARTNERSHIP WITH +
Lyme Disease Tests (ACR) There are two blood tests for Lyme disease, but usually you don't need them. Medical Tests Before Eye Surgery (AAO) Most people don't need to have their blood tested or their heart checked before they have eye surgery. Painkiller Choices with Kidney or Heart Problems (ASN) If you suffer from high blood pressure, heart failure, or kidney disease, steer clear of some pain relievers. Pap Tests (AAFP) Many teenage girls and some women have the test when they don’t need it. Spirometry for Asthma (AAAAI) Many people who need the test don’t receive it.
Sample of Choosing Wisely Topics for Consumers
Testosterone for Erection Problems (AUA) Unless you have other symptoms of low testosterone, you should think twice about the treatment. Treating Blocked Leg Arteries (SVM) Most people with Peripheral Artery Disease won't benefit from surgery or angioplasty. Treating Heartburn and GERD (AGA) In most cases of heartburn a PPI isn't necessary. Treating Sinusitis (AAAAI and AAFP) Millions of people who don’t need them are prescribed antibiotics each year for sinusitis.
Lab Tests Before Surgery (ASCP) Most healthy people don't need blood or urine tests done before surgery, especially low-risk surgery.
Stress Tests After Procedures (ASNC) Unless you're experiencing symptoms, this test usually isn't helpful in the first few years after heart bypass surgery or a stent procedure. Stress Tests After Procedures (ASNC) Unless you're experiencing symptoms, this test usually isn't helpful in the first few years after heart bypass surgery or a stent procedure. Stress Tests Before Surgery (SVM) If you’re having surgery, you will probably not need a heart stress test beforehand if you are healthy, active, and feeling well, or if you’re having minor surgery. Stress Tests for Chest Pain (ASNC) If you’re at low risk for having a heart problem, even if you have symptoms, you usually don’t need this imaging test.
IN PARTNERSHIP WITH + SOCIETIES WHICH HAVE RELEASED A LIST American Academy of Allergy, Asthma & Immunology American Academy of Family Physicians* American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Otolaryngology– Head and Neck Surgery American Academy of Pediatrics American College of Cardiology American College of Obstetricians and Gynecologists American College of Physicians American College of Radiology American College of Rheumatology American Gastroenterological Association American Geriatrics Society American Society of Clinical Oncology American Society for Clinical Pathology American Society of Echocardiography American Society of Nephrology American Society of Nuclear Cardiology American Urological Association Society of Cardiovascular Computed Tomography Society of Hospital Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Society for Vascular Medicine
Sample of Medical Societies & Associations
SOCIETIES RELEASING A LIST IN THE FALL 2013
American Psychiatric Association American Society of Anesthesiologists American Society of Clinical Oncology* American Society of Hematology American Society for Radiation Oncology American Thoracic Society Commission on Cancer— a multidisciplinary program of the American College of Surgeons The Endocrine Society Heart Rhythm Society North American Spine Society Society of Cardiovascular Magnetic Resonance Society of Critical Care Medicine Society of General Internal Medicine Society of Gynecologic Oncology
American Academy of Clinical Toxicology American Academy of Dermatology American Academy of Family Physicians** American Academy of Orthopaedic Surgeons American Association for Pediatric Ophthalmology and Strabismus American College of Chest Physicians American College of Emergency Physicians American College of Medical Toxicology American College of Rheumatology* American College of Surgeons American Geriatrics Society* American Headache Society AMDA – Dedicated to Long Term Care Medicine
IN PARTNERSHIP WITH +
To get consumer feedback on the pamphlets, we conducted usability tests to enhance the participatory design methodology of creating them as well as a post-creation evaluation before expanding dissemination. • One word descriptors to describe the content included
informative, excellent, condensed, educational, interesting, and useful.
• One word descriptors to describe the look included clean, organized, slick, specific, discreet, and pleasant.
• The blue boxes on page two were the highlight: Engaging Clear Specific Relevant Actionable Trustworthy
Main Usability Test Findings
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We were interested in learning:
• What are consumers taking away from the materials?
• Are the materials successful in changing consumer behavior?
• Will it prompt a conversation with their health provider?
• Will it prompt the consumer to research further?
• Are the materials trustworthy?
• Are the materials written in an appropriate language?
• Are the results consistent across pamphlet topics?
• Do results differ by analytical subgroups?
Post-Creation Pamphlet Evaluation
IN PARTNERSHIP WITH +
1. Theoretical and realistic interest in seeing the pamphlets differed greatly. • Initial interest in seeing the pamphlets was low (11% - 16%) • After reading the pamphlets, over 50% of the respondents indicated they would
be interested in receiving this type of information in the future • 72% became interested in the pamphlets when the topic is relevant to their life
2. The pamphlets are written in clear & understandable language for consumers.
• 85% felt the materials were clear and uses language they can understand • 75% felt the pamphlets had enough information to help them make a decision • 65% indicated that the materials taught them new information • 43% were persuaded to change their opinions based on what they read
3. Participants are willing to change behavior/take action.
• 64% indicated they are likely to have a conversation with provider • 61% indicated they are likely to research the topic themselves further online • 47% agreed that the materials prompted them to ask their HCP more questions
Main Post-Creation Pamphlet Evaluation Findings
IN PARTNERSHIP WITH +
REGIONAL COLLABORATIVES Better Health Greater Cleveland HealthInsight Utah Institute for Clinical Systems Improvement and the Minnesota Health Action Group Iowa Healthcare Collaborative Maine Quality Counts Massachusetts Health Quality Partners Michigan Health Information Alliance, Inc. Puget Sound Health Alliance Wisconsin Collaborative for Healthcare Quality
The Grantees: Advancing Choosing Wisely in Clinical Practices & Communities
SOCIETIES/STATE MEDICAL ASSOCIATIONS American Academy of Hospice and Palliative Medicine American Academy of Ophthalmology American College of Physicians American Society for Clinical Pathology American Society of Echocardiography American Society of Nuclear Cardiology Minnesota Medical Association Oregon Medical Association Society of Hospital Medicine Tennessee Medical Association Texas Medical Association Washington State Medical Association
IN PARTNERSHIP WITH +
AARP
Alliance Health Networks
Covered California
National Business Group on Health
National Center for Farmworker Health
National Hospice & Palliative Care Organization
National Partnership for Women & Families
Pacific Business Group on Health
SEIU
Union Plus
Wikipedia
Sample of Consumer-Oriented Partners
IN PARTNERSHIP WITH +
99 pamphlets for consumers in English and Spanish: http://consumerhealthchoices.org/campaigns/choosing-wisely/#materials
5 videos http://www.youtube.com/user/consumerhealthchoice
2 Posters http://consumerhealthchoices.org/?s=poster
Customized TV, web-optimized, and radio PSAs (Request one-step access to server site)
Wallet card http://consumerhealthchoices.org/catalog/when-to-say-whoa-wallet-card
Newsletter http://consumerhealthchoices.org/connect/our-email-newsletter
Materials from Consumer Reports
Thank you!
Beccah Rothschild, MPA [email protected] 415.431.6747 x 120
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This symposium is made possible by the Choosing Wisely campaign with support from
Choosing Wisely: How Pathologists Can Help Internists to Choose Wisely
Richard L. Kravitz, MD, MSPH UC Davis School of Medicine CSP Annual Meeting – December 2013
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This symposium is made possible by the Choosing Wisely campaign with support from
IN PARTNERSHIP WITH +
Estimates of Excess Cost Domains in the U.S.
European Journal of Internal Medicine Volume 23, Issue 6 2012 495 - 498 http://dx.doi.org/10.1016/j.ejim.2012.03.006
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Choosing Wisely Guidelines Pertinent to the Clinical Pathology-Internal Medicine Interface
Organization Guideline
AAFP No pap <21y or s/p hysterectomy
ACP D-dimer as initial test for VTE in low risk patients
ACR No ANA subserologies w/o pos ANA and clinical suspicion No Lyme testing w/o exposure hx and findings on exam
ASCO No biomarker or radiographic surveillance for breast Ca Rxd with curative intent No PSA screening if life expectancy <10 years
ASN No cancer screenings in dialysis pts
SHM No blood txs for arbitrary H/H Don’t repeat CBC/chemistries if clinically stable
IN PARTNERSHIP WITH +
• Individual clinical judgment
• Education
• Engagement
Approaches to Choosing Wisely
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• Internists: order whatever they want • Pathologists: fan the flames with “panels” • Both reap financial rewards under FFS medicine
Individual Clinical Judgment
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What is wrong with this picture?
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Education
IN PARTNERSHIP WITH +
• Electronic resources • POC guidelines • Lab test interpretation • Risk calculators
• Direct consultation
Engagement
http://himss.files.cms-plus.com/HIMSSorg/content/files/LVHNBNPCaseStudy.pdf
IN PARTNERSHIP WITH +
Choosing Wisely Guidelines at the IM-CP Interface
Org Guideline Implementation Options
Education Electronic Resources
Direct Consultation
AAFP No pap <21y or s/p hysterectomy ✓ ✓
ACP D-dimer as initial test for VTE in low risk patients
✓ ✓
ACR No ANA subserologies w/o pos ANA and clinical suspicion No Lyme testing w/o exposure hx and findings on exam
✓ ✓
ASCO No biomarker or radiographic surveillance for breast Ca Rxd with curative intent
✓ ✓
ASN No cancer screenings in dialysis pts ✓ ✓
SHM No blood txs for arbitrary H/H Don’t repeat CBC/chemistries if clinically stable
✓
IN PARTNERSHIP WITH +
• 49 yo man with R>L calf soreness after cross-country flight
• No h/o of VTE, thrombophilia, smoking or cancer
• Exam shows trace pitting edema at the ankles, perhaps a bit more prominent on right
• Physician orders venous duplex scan “to be sure”
• Within 30 minutes of placing order in EHR, physician receives call from “combined diagnostic consultation service,” a joint service of pathology and radiology
Case Example
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A Futuristic Dialog
Thanks for sending in a request for Duplex scanning. I took the liberty of computing a Wells score, and it looks like this patient is at very low risk of DVT. Is there something I missed?
PATHOLOGIST
Not really. I doubt there’s much going on, but the patient is anxious and we need some reassurance.
INTERNIST
Did you know that in low risk patients, a negative d-dimer practically rules out VTE?
I vaguely remember something along those lines.
If you want, I can change your order to a d-dimer and have the lab tech call you directly when the result is back—it usually takes about 4 hours.
Did you say you’re from Pathology?
IN PARTNERSHIP WITH +
• Collaborate with internists (and radiologists) on: • Educational programs • POC guidelines, test interpretation, and risk calculators
• Establish and evaluate diagnostic consult services
How can pathologists help internists to choose wisely?
Thank you! Richard L. Kravitz, MD, MSPH UC Davis School of Medicine
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This symposium is made possible by the Choosing Wisely campaign with support from
Choosing Wisely: How California Pathologists Can Influence Laboratory Test Ordering Haya R. Rubin MD PhD My Advice Doctor Johns Hopkins University CSP Annual Meeting – December 2013
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This symposium is made possible by the Choosing Wisely campaign with support from
IN PARTNERSHIP WITH +
• Beyond insurance policy
• “Educated” consumers are driving demand for laboratory test services outside insurance plans
• Genomic testing, 23 and me etc. • Trace elements • Salivary hormone levels • Lyme disease panels
• Consumers pay large out of pocket
amounts for designer tests
Consumer-Driven Demand
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Pathologists as Educators
– Opportunity to educate patients about test utility, predictive value
• Consumers do not want to waste money • Financial incentives prevent those who sell tests from
educating people about the tests’ true utility and predictive value
• Market for information about what is useful, as for all consumer products
• Consumer Reports for lab tests, • Decision software to guide cost-benefit concerns
In partnership with +
• Websites and blogs for consumers in health forums discussing pros and cons of testing
• Info materials for PCPs to provide their patients
• Employer materials for employees about over-used preventive tests
• Take the high road: algorithms for appropriate use into test ordering pages in direct to consumer marketing.
• Also of course in physician-directed ordering as discussed
Forums for Education
Thank you! Haya R. Rubin MD PhD My Advice Doctor Johns Hopkins University
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This symposium is made possible by the Choosing Wisely campaign with support from
Choosing Wisely: Laboratory Leadership and Choosing Wisely
George Lundberg, MD President & CEO of the Lundberg Institute CSP Annual Meeting – December 2013
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This symposium is made possible by the Choosing Wisely campaign with support from
Questions? Concerns? Insights? The expert panel is here to talk with you.
Beccah
Rothschild, MPA
Richard Kravitz,
MD, MSPH
George
Lundberg, MD
Haya Rubin,
MD, PhD
Dr. E. Blair Holladay
ASCP
Thank you for participating in the Choosing Wisely symposium. Now what’s next?
+
This symposium is made possible by the Choosing Wisely campaign with support from
This symposium is being recorded for future ASCP promotional and educational use.
http://www.ascp.org/Functional-Nav/The-Choosing-Wisely-
Campaign/Tool-Kit
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How to Vote via Texting with Poll Everywhere (Audience Response System)
Web Based Replies: www.pollev.com
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