from overtreatment to patient-centered care

From Overtreatment to From Overtreatment to Patient-Centered CarePatient-Centered Care

National Academy for State Health Policy New Orleans, LA

October 5, 2010

Rosemary Gibson, M.Sc.Author, The Treatment Trap

and Wall of Silence

Overview of Presentation Overview of Presentation

Define overtreatment: what it is, the impact on patients, and how to begin to address it

Discuss how reducing overtreatment can improve patient outcomes and reduce health care costs.

Identify action steps for states to begin to address overtreatment

Three Overarching Three Overarching Quality Challenges Quality Challenges

Underuse

Misuse

Overuse Source: Institute of Medicine, National Roundtable on Quality, 1998

Underuse DefinedUnderuse Defined

Underuse: the failure to provide a health care service when it would have produced a favorable outcome for a patient.

Example: missing a childhood immunization for measles or polio is an example of underuse.

Health care reform will reduce underuse of essential services

Source: Institute of Medicine, National Roundtable on Quality, 1998

Misuse Defined Misuse Defined

Misuse: when an appropriate service has been provided but a preventable complication has occurred.

Example: a patient who suffers a rash after receiving penicillin for strep throat despite having a known allergy to that antibiotic is an example of misuse.

Source: Institute of Medicine, National Roundtable on Quality, 1998

The Impact of Misuse The Impact of Misuse

In 1999, the Institute of Medicine report, To Err is Human, estimated 44,000 – 98,000 deaths from preventable harm each year

The CDC estimates 99,000 deaths from hospital-acquired infections each year

Overuse Defined Overuse Defined

Overuse: when the potential for harm of a health care service exceeds the possible benefit.

Source: Institute of Medicine, National Roundtable on Quality, 1998

“I was troubled to read that the President's physical examination included an electron beam computed tomographic (CT) scan for coronary calcium. This screening test likely exposed Mr. Obama to significant radiation unnecessarily, increasing his risk of future cancer…

…A single electron beam CT scan is estimated to result in a lifetime excess cancer risk of 9 additional cancers per 100 000 persons for men.

Dr. Rita Redberg, EditorDr. Rita Redberg, EditorArchives of Internal Medicine Archives of Internal Medicine March 8, 2010March 8, 2010

http://archinte.ama-http://archinte.ama-assn.org/assn.org/ cgi/content/full/2010.81?home cgi/content/full/2010.81?home

Commonwealth Fund SurveyCommonwealth Fund Survey

32% of people surveyed for a Commonwealth Fund report said they have had medical care they thought was unnecessary

Source: Sabrina How, et al, “Public View on U.S. Health System Organization: A Call for New Directions,” The Commonwealth Fund, Data Brief, August 2008 p. 4.

Two Questions For YouTwo Questions For You

Have you or someone you know had medical care that you/they thought was unnecessary?

Have you or someone you know declined treatment recom-mendations because they were too invasive, and found a medically appropriate, less intensive alternative?

“I’ve been getting an EKG at my annual physical exam since I was 27. I’m 41 now. I don’t know why. I have no heart disease. My husband gets one, too.”

“My knees were hurting and I went to a well-known orthopedic surgeon. He said he could do surgery. He didn’t talk about me or my situation. I left and found a personal trainer who helped me strengthen my muscles. I’m much better now.”

“My 83-year old mother-in-law was having problems with her shoulder. She went to a doctor who said he could operate. I went with her to get a second opinion. With physical therapy and time for healing, she was fine.”

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Safe Patient Project

www.treatmenttrap.org

For the first time, a subset of the population is saying “no” to medical care, not cavalierly but in an informed and thoughtful way.

Where to begin to curb

overuse?

National Priorities Partnership: National Priorities Partnership: A Roadmap to Begin A Roadmap to Begin

Overuse is one of the six priorities of the National Priorities Partnership which was convened by the National Quality Forum

Source: National Priorities and Goals, National Priorities Partnership, November 2008. www.nationalprioritiespartnership.org.

National Priorities Partnership:National Priorities Partnership:Areas to Reduce OveruseAreas to Reduce Overuse

Medication use especially antibiotics and multiple drugs prescribed for a patient

Lab tests C-sections Diagnostic imaging, CT scans,

x-rays

National Priorities Partnership:National Priorities Partnership:Areas to Reduce OveruseAreas to Reduce Overuse

Non-palliative services at the end of life

Unnecessary doctor office visits Preventable ED

visits/hospitalizations Potentially harmful preventive

services

National Priorities Partnership:National Priorities Partnership:Procedures That Are Overused Procedures That Are Overused

Procedures that are overused include:

* heart bypass surgery

* hysterectomy

* spine surgery

* prostatectomy

National Priorities Partnership:National Priorities Partnership:Procedures That Are Overused Procedures That Are Overused

What are examples of the literature on which the identification of overused tests, surgeries and other services is based?

Research on Heart Bypass Surgery Research on Heart Bypass Surgery

An expert panel of physicians convened by Rand and the Harvard School of Public Health reviewed the angiograms of patients who were recommended for heart bypass surgery.

One-third of the patients who were recommended for heart bypass surgery did not need it.

Source: Leape, Lucian, et al., “Effect of Variability in the Interpretation of Coronary Angiograms on the Appropriateness of use of coronary Revascularization Procedures, American Heart Journal, vol 139, no 1, part 1, January 2000, 111.

Overuse of Ear Tube Overuse of Ear Tube Surgery in Children Surgery in Children

Nearly 70% of ear tube surgeries studied at a five hospital cohort were found to have been performed on children whose condition did not meet criteria for surgery set by the American Academy of Pediatrics.

Source: Salomeh Keyhani, et al., “Overuse of Tympanostomy Tubes in New York Metropolitan Area: Evidence from Five Hospital Cohort,” British Medical Journal, vol 337, 2008 1607. See also Salomeh, Keyhani, et al, “Clinical Characteristics of New York City children Who Received Tympanostomy Tubes, in 2002,” Pediatrics, vol 121, no 1, 24-33.

Outcomes from Back Surgery Among Workers’ Compensation Patients

725 patients with low back 725 patients with low back pain had pain mgmt and pain had pain mgmt and physical therapyphysical therapy

Return-to-work status at 2 Return-to-work status at 2 years: 67%years: 67%

Days off of work: 316Days off of work: 316

Source: Nguyen, T. et al, “Long-Term Outcomes of Source: Nguyen, T. et al, “Long-Term Outcomes of Lumbar Fusion Among Workers’ Compensation Lumbar Fusion Among Workers’ Compensation Subjects, Subjects, SpineSpine, August 2010. , August 2010.

725 patients with low back 725 patients with low back pain who had spine pain who had spine surgery surgery

Return to work status at 2 Return to work status at 2 years: 26%years: 26%

Days off of work: 1140Days off of work: 1140

27% re-operation rate27% re-operation rate

New Study Findings on New Study Findings on End-of-Life CareEnd-of-Life Care

New England Journal of Medicine published a landmark study of patients with metastatic lung cancer

Patients who received early palliative care and less aggressive treatment lived 2.7 months longer than patients who received usual oncology care.

Source: Temel JS et al., “Early palliative care for patients with metastatic non-small-cell lung cancer, NEJM, 2010: 363:733-742.

http://www.nejm.org/doi/full/10/1056/NEJMoa1000678.

Recent Events in Raising Recent Events in Raising Awareness About Overuse Awareness About Overuse

The Archives of Internal Medicine published by the AMA has started a series, “Less is More” that reports evidence of overtreatment.

They will start a series on patient experience of overtreatment.

The American Board of Internal Medicine Foundation has a Task Force on Stewardship of Resources

Recent Events cont’dRecent Events cont’d

The Radiological Society of N. America has called for a national plan to reduce diagnostic imaging.

Source: http://radiology.rsna.org/content/early/2010/08/05/radiol.10100063.abstract

National Cancer Institute National Cancer Institute Study of CT scansStudy of CT scans

70 million CT scans performed in 2007 will cause 29,000 cancers in Americans and 15,000 deaths.

Two thirds of the projected cancers will occur in women.

Source: Archives of Internal Medicine, 2009

Recent Events cont’dRecent Events cont’d

Hospital Compare is now reporting 4 measures of appropriate use of diagnostic imaging

2 measures address overuse of abdominal and chest CT scans

Recent Events Recent Events

“Top 5” Project underway by the National Physician Alliance

It asks the question of primary care physicians: what are the top 5 things we should stop doing in primary care?

Plan is to spread to other medical specialties

Factors Contributing Factors Contributing to Overtreatmentto Overtreatment

Uncertainty Belief Enthusiasm Fear/Liability Peers Knowledge Financial incentive Patient expectation

What A Health Care Insider What A Health Care Insider Says About OveruseSays About Overuse

“Health insurance used to be about giving patients access to providers. Now it’s about giving providers access to patients.”

Dean of a Midwest nursing school.

One way to communicate to patients and the public about overuse:

What is Overuse?What is Overuse?

Green LightGreen Light

Treatment you absolutely want to get

Yellow LightYellow Light

Mammograms for women in their 40s

Should I or shouldn’t I?

Reasonable people will weigh the risks and benefits differently based on medical history, tolerance for risk, etc.

Red LightRed Light

Treatment you don’t want to get because the possibility of harm exceeds the potential benefit.

Strategies for ChangeStrategies for Change

A problem cannot be fixed unless we talk about it: ask yourself, friends and colleagues these two questions:

Have you had medical care you thought was unnecessary?

Have you declined recommendations and found a less intensive, medically appropriate alternative?

Public Reporting of Public Reporting of Outpatient ImagingOutpatient Imaging

Can states begin to report CMS measures that are publicly reported for Medicare beneficiaries on outpatient diagnostic imaging?

An example of one measure is: outpatient CT scans of the abdomen -- use of contrast material

The ratio of CT abdomen studies that are performed both with/without contrast out of all CT abdomen studies performed (those with contrast, those without contrast, and those with both).

Establish a Registry for Establish a Registry for Selected Surgeries Selected Surgeries

Can states begin a voluntary registry that tracks the outcomes of selected procedures?

Benefits: offers the opportunity for learning what works in an environment transparent to other clinicians

Areas to focus: back, knee and hip surgery

Contact:

Rosemarygibson100@gmail.com

www.treatmenttrap.org