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Advancing the Choosing Wisely® Campaign Objectives • Why Choosing Wisely? • Genesis and overview Of Choosing Wisely • SHM Adult Recommendations • Other Recommendations and Discussion Commonwealth Fund, via Ezra Klein, et. al., Washington Post, Wonkblog http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/ Sources of waste Berwick D. JAMA. 2012;307(14):1513-1516. Overview http://www.choosingwisely.org • A unique partnership with 35 medical societies • Main objective - to foster communications between doctors and patients about commonly performed tests and procedures that may fail to provide value or enhance patient outcomes • Consumer Reports as additional partner • Specific • Evidence-based • Recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation. http://www.choosingwisely.org/ “Five Things Patients and Physicians Should Question” • Participating societies developed top 5 recommendations for consideration • Lists include evidence-based recommendations to assist with making decisions about selecting the right care at the most appropriate time • SHM developed a list of five adult and five pediatric recommendations The campaign aims to educate patients and physicians and provoke dialogue about improved resource utilization to achieve more optimal outcomes. http://www.spotlight-on-science.com/2010/10/breast-cancer-awareness-month.html How can the Choosing Wisely® campaign impact patient care? Overutilization of healthcare resources has significant implications for health care costs, patient care and outcomes as well as system sustainability In 2010, $2.6 trillion dollars were spent on healthcare, an increase of $1.3 trillion between 2000 and 2010 ten times the $256 billion spent in 1980 As much as 30% of health care spending may be wasted A larger healthcare expenditure does not necessarily translate into better patient outcomes http://www.kaiseredu.org/issue-modules/us-health-care-costs/background-brief.aspx http://choosingwisely.org/ http://www.choosingwisely.org/doctor-patient-lists/society-of-hospital-medicine-adult-hospital-medicine/ • Urinary tract infections (UTI) ~ 30% of all healthcare-associated infections - Usually related to urinary catheters - Catheter-associated UTI (CA-UTI) affects 900,000 patients per year (U.S.) • Increased morbidity, mortality, hospital cost and length of stay • Anemia • Morbidity • Increased cost Pediatrics SHM Recommendations 1. 2. 3. 4. 5. Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. Don’t routinely use bronchodilators in children with bronchiolitis. Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection. Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy. Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. More Recommendations American Society of Nephrology • Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia. • Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians American Academy of Hospice and Palliative Medicine • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. More Recommendations American Academy of Neurology • Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms American Academy of Ophthalmology • Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications. American College of Cardiology • Don’t perform stress cardiac imaging or advanced noninvasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. More Recommendations American College of Physicians • In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). • In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. American College of Rheumatology • Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease. More Recommendations American Geriatrics Society • Don’t use benzodiazepines or other sedativehypnotics in older adults as first choice for insomnia, agitation or delirium. The Society of Thoracic Surgeons • Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery. More Recommendations American Academy of Family Physicians • Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age. • Don't routinely prescribe antibiotics for acute mild-tomoderate sinusitis unless symptoms last for seven or more days OR symptoms worsen after initial clinical improvement. • Don't do imaging for low back pain within the first six weeks, unless red flags are present. More Recommendations American Academy of Family Physicians • Don't perform Pap smears on women under the age of 21 or women who have had a hysterectomy for noncancer disease. • 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 order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. SHM HQPS Choosing Wisely Subcommittee members Center for Hospital Innovation and Improvement, SHM Discussion John B. Bulger, DO, MBA [email protected]