Choosing Wisely Update

Rosalio J. Lopez MD MBA

HASC Most Appropriate Care Initiative Meeting

October 30, 2015

• An initiative of the American Board of Internal Medicine (ABIM) Foundation and Several Consumer Groups

• 70 specialty societies

• Robert Wood Forum Foundation

Choosing Wisely – originally presented to PIH Health physician leadership in April 2013

• Inspiring conversations on the wise use of health care resources

• Changing decision-making to provide the best care

• Patient education and shared decision-making

• More medicine is not always better

• Promoting good stewardship

Choosing Wisely Goals

Why?

Resources are limited

Physicians and patients need tools to support the delivery of beneficial healthcare resources National health care expenditure reached $3.1 trillion

in 2014 $800 billion was spent providing care that was wasteful

or harmful National health care expenditures are expected to

reach $4.6 trillion and 19.6% of GDP by 2020

Choosing Wisely (cont.)

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

Some of the Choosing Wisely Consumer Groups (through collaboration with Consumer Reports)

National Hospice and Palliative Care Organization

National Partnership for Women & Families

Pacific Business Group on Health

SEIU Univision (with HolaDoctor) Union Plus The Wikipedia Community

Choosing Wisely (cont.)

Over seventy specialty societies representing more than 1,000,000 physicians developed agreements of “Five things physicians and patients should question”.

They aim to promote conversations between physicians and patients by helping patients choose care that is:

• Supported by evidence

• Not duplicative

• Free from harm

• Truly necessary

An attempt by doctor’s groups to determine their own cuts rather than wait for the government or insurance companies to mandate them

Choosing Wisely (cont.)

Health plans and payers are already measuring compliance with these recommendations: • Currently compliance is highly variable

Choosing Wisely (cont.)

1. Avoid antibiotic prescriptions for acute rhinosinusitis

2. Don’t do imaging for uncomplicated headache

3. Avoid CT scans for acute rhinosinusitis

44% 74% 98%

• As a general rule, PIH Health doesn't give oral antifungals unless culture is positive (and we all take cultures first)

• Melanomas are only referred for node biopsy if > 1mm in depth (unless they are ulcerated or close to 1mm and true depth isn't obtainable- then, depending on patient we will send for node biopsy- but rule is >1mm).

• PIH Health never treats NMSCs on trunk/extrem with Mohs UNLESS they are >2cm or recurrent or have some other large risk factor (high risk pathology, nerve invasion). Of the 2500+ cases done, none have been on trunk and extrem <1cm (unless recurrent!)

• PIH Health doesn't ever treat atopic patients with oral antibiotics unless they have pustules/ or positive culture on exam

• PIH Health gives and uses vaseline for all of our routine surgical wounds- prescribe topical bactroban only in very specialized cases (confirmed infection or patient at very high risk for infection). But, vaseline is what is in clinic and in our handouts- 99% of our patients are treated with that. PIH Health NEVER gives bacitracin or neosporin as it has a high incident of contact allergy.

PIH Health Dermatology

• PHH-Whittier Family Medicine follows guidelines

• PHH-Whittier follows guidelines – Some of the patients

though that we are consulted on with syncope have already had carotid Dopplers done before the neurologist has even seen the patient. With our elderly patient population this in not unreasonable as many have co-existing cerebrovascular disease. It's the younger patients who don't necessarily need CUS with isolated syncope and no neurologic signs.

PIH Health Hospital – Neurology

PIH Health Hospital – Ophthalmology

1. We let our PCP know that no blood testing, x-ray or complex workup needed unless they felt the pt needed them prior to surgery. 2. Very few imaging studies are ordered by ophthalmology 3. Most pink eyes are seen at PCP and UC and Peds office, hardly ever reaches the specialist office. 4. NO intra-vitreal injections are done routinely at the hospital. We also do not perform any in our offices at this point, they mainly occur at retina specialist offices. 5. Our protocol for dry eyes, is lubricant drops, ointment gels, Restasis then punctal plugs.

• PIH Health follows guidelines – These guidelines are evidence-

based and most sleep doctors are very aware of these since they emphasized at the board exam

– Insomnia is a multifaceted disease and best approach is CBT and psych eval with on going sleep evaluation. Sleep study is ONLY indicated when sleep is disturbed by awakenings due to severe apneic episodes. This is very easily obtained in the patient’s history..

– Most MDs are not well trained to obtain a good history of sleep disorders

– Sleep study is indicated only when there is a greater than 10% change in the body weight

PIH Health – Sleep Medicine

• PIH Health neurologists follow these guidelines

– However, since we are consults many patients with stable migraine headaches are imaged before we even see the patient

PIH Health Hospital – Headache

• PIH Health follows guidelines

• We do limit lower extremity activities in the first 24 hours after diagnosis and initiation of treatment, only when the clot is proximal

• Passive modalities are not used except as part of a clinically designed program when required for pain management only to gain more active function in a joint or limb. We have employed this philosophy for many years and in fact have needed to speak about this with some physicians who order or want us to employ massage or passive modalities in cases where it is not clinically warranted.

• All strengthening and therapeutic exercise prescriptions are carried out as an individual treatment program established by a licensed PT after full evaluation of the pts presenting issues thereby resistance etc is all individually prescribed to that pts condition. All care to pts is given by licensed therapists or licensed therapist assistants and we don’t employ unlicensed therapy caregivers which is where you usually see this being an issue

PIH Health Hospital – Physical Therapy

PIH Health Hospital – Physical Therapy (cont.)

• Therapy is held after new dx of DVT. On the in-patient side, we recently went to Medical committee to request an automatic order after 24 hours of anti-coag therapy but were opposed by medical staff. We have a process by which a licensed therapist checks the pt each day they are on hold and requests orders after 24 hours of anti coag therapy. On the OP side, if we suspect DVT, we confer with MD and will resume therapy once anti-coag initiated.

• Use of CPM is a physician behavior and not a therapist driven modality however from being on a project on total joints I know that we have reduced usage significantly.

• Management of wounds at PIH-W is done predominantly by WOC nurses on the IP side, by the wound healing center on the OP side and if we are involved with a wound which is rare, we use wound vacs. I have been requesting our whirlpool area be remodeled for pt use secondary to not using whirlpools for almost a decade or more.

CPM Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Usage 13.3% 13.3% 14.3% 0.0% 2.4% 0.0%

CPM May 2015 Jun 2015 Jul 2015 Aug 2015 Sept 2015 Oct 2015 Usage 0.0% 0.0% 0.0% 0.0% 4.0%

• PIH Health follows guidelines largely except: – Some hematologist have

differences in opinion regarding what the transfusion thresholds should be (7-8 vs 10). Probably same for hospitalist/surgeons etc.

– IVC filters over-utilized at PIH Whittier

• As far as ASCO, largely

following except – There are Stage II breast

cancer patients receiving imaging (ie node positive, triple negative, etc)

PIH Health – Clinical Oncology

PIH Health Hospital – Whittier Pediatric Hospital

• PHH-Whittier follows guidelines:

• Don’t order CXR in children with uncomplicated asthma or bronchiolitis.

– We don’t normally order CXR on kids with either of the dx unless we’re suspicious for pneumonia. However, many of these patients get a CXR routinely in the ED during the triage process.

• Don’t routinely use bronchodilators in children with bronchiolitis

– We don’t order bronchodilators for our bronchiolitic patients unless they have a history of atopy/asthma and showed a positive improvement after a trial was given.

• Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection

– We don’t order steroids for bronchiolitis patients (it’s not an option on our Bronchiolitis order set). The only time we order is if they have underlying asthma.

PIH Health Hospital – Whittier Pediatric Hospital (cont.)

• Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy

– Regular reflux without any symptoms are not treated with acid suppression. The “happy spitters” are typically given reflux precautions and thickened feeds. However, patient with severe GERD and complications (i.e. weight loss, ALTE, etc) are often started on acid suppression. This is consistent with the AAP guidelines.

• Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen

– Continuous pulse oximetry is only placed when a patient is on oxygen. We transition to spot checks once they’re weaned to room

Summary

• PIH Health physicians support the Choosing Wisely campaign

• Since April 2013, the medical staff has made great progress in implementing nearly all the recommendations

• We are continuously reassessing our results and work with patients on shared decision-making to optimize care for every patient

Questions?