Choosing Wisely: More Medicine Doesn’t Mean Better Medicine Dominic Lorusso – Director, Consumer Reports Health October 2014 www.consumerhealthchoices.org 2 2 What is 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. www.consumerhealthchoices.org 3 What is • A successful communication campaign – Stimulating culture change • More is not better – Create conversations about overuse • Doctor and patient • Practitioner and practitioner – Nurses, dentists and physical therapists coming – Strategies to consider www.consumerhealthchoices.org 4 More than 60 specialty societies American Academy of Family Physicians American Academy of Pediatrics American College of Cardiology American College of Emergency Physicians American College of Physicians American College of Radiology American College of Surgeons American Geriatrics Society American Psychiatric Association Society of General Internal Medicine Society of Hospital Medicine … etc. www.consumerhealthchoices.org 5 Topic Themes • Preoperative evaluations – Chest Xray – Heart imaging • Common treatments – Antibiotics – Opioids – Heartburn meds – Anti-inflammatories • Routine FU/Monitoring • “Disease” approach – Cancer – Chronic kidney failure/dialysis – Heart disease – Maternity • Screening tests – EKG – Exercise test – Pap smear – Bone density – Heart imaging – Colon cancer • Diagnostic testing – Low back pain – Headache – Allergy – Fainting www.consumerhealthchoices.org 6 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: www.consumerhealthchoices.org. www.consumerhealthchoices.org 7 The Choosing Wisely Campaign and Consumer Reports Consumer Reports leads consumer communication efforts for this campaign. • Since early 2012, new societies began joining the campaign, bringing the total to more than 60, and with each one supplying a “list of 5,” there are over 300 topics to cover • We have been focusing on the two-page pieces, however, as new information comes in, we are anticipating additional formats. • These could include: • Tri-Folds • Posters • Combination Reports • Wallet Cards www.consumerhealthchoices.org 8 8 Free consumer brochures • • • • • • • 90+ campaign topics Specialty society endorsed All in English and Spanish Supports conversation Suited for easy printing Suited for email, linking Suited for clinic display www.consumerhealthchoices.org 9 Typical Choosing Wisely brochure www.consumerhealthchoices.org 10 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? 5 QUESTIONS to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure 1 Do I really need this test or procedure? Medical tests help you and your doctor or other health care provider decide how to treat a problem. And medical procedures help to actually treat it. 2 What are the risks? Will there be side effects? What are the chances of getting results that aren’t accurate? Could that lead to more testing or another procedure? 3 Are there simpler, safer options? Sometimes all you need to do is make lifestyle changes, such as eating healthier foods or exercising more. 4 What happens if I don’t do anything? Ask if your condition might get worse — or better — if you don’t have the test or procedure right away. Posters and wallet cards available for free download. Can be branded. 5 How much does it cost? Ask if there are less-expensive tests, treatments or procedures, what your insurance may cover, and about generic drugs instead of brand-name drugs. Use the 5 questions to talk to your doctor about which tests, treatments, and procedures you need — and which you don’t need. Some medical tests, treatments, and procedures provide little benefit. And in some cases, they may even cause harm. Talk to your doctor to make sure you end up with the right amount of care — not too much and not too little. ✓ FOR MORE INFORMATION Use your smartphone to access all of the lists of tests and procedures for you and your physicians to question as part of the Choosing Wisely® campaign. www.consumerhealthchoices.org 1 http://consumerhealthchoices.org/campaigns/choosing-wisely/ 5 Questions to Ask your Doctor – Video Accompaniment • Three different formats: – Public Service Announcement (PSA) format, cartoon, lyrical – “Grass Roots” interview – “Talking” doctor video • Some available in English and Spanish. • PSA has appeared in several local and regional TV stations around the country, including local PBS and Univision. www.consumerhealthchoices.org 1 Other Choosing Wisely posters • “5 question” format • Questions about antibiotics 5 WAYS To Be Smart About Ovarian Cancer 1 Take steps to prevent ovarian cancer. Keep a healthy weight and get regular exercise. Eat a lot of fruits and vegetables. Eat foods with omega-3 fats, such as salmon and sardines. Ask your doctor about taking oral contraceptives and getting enough vitamin D. • Questions about pre-op tests 2 Know your risks. Your risk is higher if you have a family history of breast, uterine, ovarian or colon cancer, or you have the BRCA1 or BRCA2 gene mutation, or Lynch syndrome. • Questions about new drugs 3 Know the symptoms of ovarian cancer. The symptoms of ovarian cancer are listed below. See your doctor if the symptom lasts for two weeks or more. • Questions about EKGs • Questions about ovarian cancer 4 Know when to get tested. Testing might make sense if you have symptoms, or high risks, or your doctor sees something in an exam. Discuss the tests with your doctor. A blood test called CA-125 measures a protein found in ovarian cancer cells. An ultrasound test uses sound waves to look for cancer. 5 Know when NOT to get tested. Avoid the tests if you don’t have symptoms and your risk is low. The tests are not very accurate in women with no symptoms. The tests can cause false alarms, leading to unnecessary follow-up tests and procedures. See your doctor if the symptom is new and lasts for a couple of weeks. Symptoms to watch for: ■ Pressure or pain in the abdomen, pelvis, or both ■ Bloating or swelling in the abdomen ■ Difficulty eating or feeling full quickly ■ Nausea, indigestion, gas, constipation, or diarrhea ■ Feeing tired all the time ■ Shortness of breath ■ A need to urinate more often ■ Unusual vaginal bleeding, such as heavy periods or bleeding after menopause www.consumerhealthchoices.org 1 ConsumerHealthChoices.org • Home page, Consumer Health Choices. • Library of free materials for Health Impact efforts. www.consumerhealthchoices.org 14 Choosing Wisely videos • Por>olio of videos • Hosted at Vimeo (also at YouTube) • 14 Choosing Wisely videos • 18 Best Buy Drugs videos • 19 Spanish-‐version videos • Link, embed or download www.consumerhealthchoices.org 15 In Depth: Safe Pregnancy We have hubs for these topics: • Safe Pregnancy • Antibiotics • Pre-op Tests • Screening Tests • …more to come www.consumerhealthchoices.org 1 Consumer Partners Founding(Partners:!Original!partners!from!birth!of!campaign Distributors :!Organizations!that!license!our!content!and!support!our!campaigns National(Partners:!!Must!have!national!consumer!reach Grantees:((((((Received!funding!for!Choosing!Wisely!from!the!ABIM!Foundation( Regional(Partners:!Must!have!regional!consumer!reach www.consumerhealthchoices.org 17 ConsumerHealthChoices.org/RIBGH • Home page, Rhode Island Business Group on Health -‐ Consumer Health Choices. • Co-‐branded, managed micro-‐ site. www.consumerhealthchoices.org 18 Consumer Response • Findings from a December 2012 Consumer Reports survey of 2,669 consumers who received Choosing Wisely information: • 72% agreed that it had changed their opinion of the topic, taught them new information, or prompted them to ask more questions of their health provider. • 81% of consumers reporting interest in a Choosing Wisely topic said they were likely to have a conversation with their physician about what they had read. • In the case of one topic (back pain), 85% intended to have a conversation with their doctor. • More recent survey indicated that the best message for the campaign is about Patient / Doctor communication. www.consumerhealthchoices.org 19 Choosing Wisely: Has it been a success? What have others done? www.consumerhealthchoices.org 20 What do Physicians Think of Overuse? • • • • 72%: Say docs do it at least once a week 73%: Say somewhat or very serious problem 66%: Feel responsibility for avoiding overuse 58%: Say docs in best position to address problem Source: Unnecessary Tests and Procedures In the Health Care System. Conducted for The ABIM FoundaXon by PerryUndem Research/CommunicaXon. (2014). Early Measures of Success • More than 420,400 physicians reached through specialty society communications after first set of lists. Hundreds of thousands more with second release. • 163 journal articles. 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 and third releases. • More than 100+ million reached annually through Consumer Reports partnerships with consumer/employer groups for the last 2 years www.consumerhealthchoices.org 22 Clinical Decision Support: Cedars-‐Sinai • Cedars-‐Sinai has incorporated 120+ CW recommendaXons into its EPIC system • Physicians receive alert when they order test, procedure or medicaXon quesXoned by CW • Alert provides informaXon on the CW rec • Response from physicians has been posiXve, despite “alert faXgue” – Cedars leader credits this to respect for specialty socieXes www.consumerhealthchoices.org 23 alerts integrated into workflow physician starts order in EMR likely Choosing Wisely: Don’t use benzodiazepines or other seda<ve-‐hypno<cs in older adults as first choice for insomnia, agita<on or delirium. unnecessary (American Geriatrics Society)1, 2, 3 Hyperlink: Choosing Wisely – American Geriatrics Society stanson likely appropriate Reasons for override: sleep disorder end of life care non-‐drug opXons failed peri-‐procedural anesthesia withdrawal / DT order placed order cancelled physician cancels or places the order Note: CDS alert displays using Epic’s na>ve best prac>ce alerts; Epic does not allow use of actual screenshots Impact Analysis Antipsychotics Pre IntervenXon Post Intervention Jan 1 – Sep 9 Sep 10 – Nov 25 mean orders mean orders % change p-‐value 203 166 -18.2% <0.001 133 116 -12.5% <0.001 4.13 3.58 -13.3% <0.04 322 286 -13.7% <0.001 Patients ≥ 70 Benzo-‐SedaXves PaXents ≥ 65 Butalbital Adults Vitamin-‐D levels Rates per 10,000 encounters Maine Quality Counts An independent Health care collaboraXve • Maine Quality Counts (MQC) will work with four pilot sites to idenXfy a set of specific measures to implement and to monitor progress, idenXfy lessons learned, best pracXces, and barriers. – Penobscot Bay Medical Center (25,000 paXents): inpaXent, pre-‐operaXve and ED order sets reviewed and tailored based on the CW guidelines. PaXent materials made available at doctors’ offices and through PaXent Resource Center. – Penobscot Community Health Center (14,950 paXents): integrate CW into Nurse PracXXoner Residency Program. Training on overuse conversaXons provided to medical assistants and health counselors. – Winthrop Family PracXce (6,700 paXents): educaXonal presentaXons at all clinical team meeXngs, staff training on CW and handouts in waiXng rooms and exam rooms for pts. – Oxford Hills Family PracXce (2,700 paXents:) provider educaXon campaign , consumer engagement iniXaXve using paXent educaXon materials and the hospital website. • A pre and post web based survey will be conducted by GfK to assess astudes and awareness of Choosing Wisely in both the physician and paXent populaXons. www.consumerhealthchoices.org 26 Iowa Health Care CollaboraXve • IHC has formed a Task Force Steering Commitee and Work Group of physician champions across the state. One of their tasks is to develop an “Iowa 5” set of recommendaXons unique to the state’s communiXes. • IHC will work with Wellmark to track claims data across the state to measure the effect of implemenXng the campaign across these focus areas, and promote resources to improve. www.consumerhealthchoices.org 27 PaXent Support: Anne Arundel Medical Center • Anne Arundel Medical Center has embedded Consumer Reports’ translaXons into its EMR system so that physicians can provide them to paXents to enhance their understanding and ability to make decisions about their care • AAMC has also included numerous arXcles about CW in its newsleter and “enews” for staff, as well as on its website and other communicaXons geared to the public, including video loop. www.consumerhealthchoices.org 28 Hospital Medicine: UCSF • UCSF had exisXng focus on overuse, and leaders there thought their use of procedures highlighted by CW would already be low • Discovered that their uXlizaXon was lower than their peers for only one of five SHM adult medicine recs • Now implemenXng a quality improvement plan focused on other four recs from SHM, covering medicaXons for stress ulcer prophylaxis, blood transfusions, conXnuous telemetry monitoring outside of the ICU, and certain lab tests • Effort is led by commitee of physicians and finance administrators who are focused on increasing physician awareness of the costs of treatments they commonly order www.consumerhealthchoices.org 29 System as Employer: Mercy • Mercy, an integrated Catholic health system with 32 hospitals, has aggressively promoted CW to its own employees • Each month, one recommendaXon is highlighted through employee communicaXons, and Mercy developed an internal website that directs employees to the CW site and to Consumer Reports • Used flagship site (Springfield, MO) to implement on physician side – medical directors reviewed 45 iniXal recs and narrowed to 27 where Mercy was performing the procedures • Medical directors and other leaders addressed large secXons about the recommendaXons, received litle pushback • Mercy now has 14 measures to review whether the recommendaXons are having an impact – also sharing comparaXve data with its physicians on uXlizaXon of procedures covered by CW (e.g., imaging for headache) www.consumerhealthchoices.org 30 Other examples: Doctors Talk to Doctors • Awareness of Choosing Wisely increasing in physician communities—partner with the doctors who get it – WESTMED (NY) – developed a campaign based on Choosing Wisely / Consumer Reports coverage of antibiotics. Placed posters in exam rooms, distributed pamphlets to consumers. – Crystal Run Healthcare (NY) – developed aggressive campaign on 3 topics, antibiotics, EKG’s, and Imaging for back pain. Saw a drop of up to 10 - 15% usage in just 2 months of study. – Washington (state) Health Alliance - identifed 11 Choosing Wisely topic areas to focus on. Developed a toolkit for others to use and a plan for integrating Choosing Wisely approaches into medical practices across the state. – Many others …… www.consumerhealthchoices.org 31 Choosing Wisely: How to get started? www.consumerhealthchoices.org 32 What to do? • Continue culture change efforts – Educate all about these tests • Benefit/Risk, downstream implications – Take on inappropriate demand strategies • Online promotion, health fairs, “wellness” screening – Stop incentives that rely on creating inappropriate demand www.consumerhealthchoices.org 33 Employers have a role to play Three-fourths of employees use their employer as a primary resource for medical and health information (PBGH, 2010) Implementation support: 1) Employers can use web-based materials, the Employer Toolkit, to create a Choosing Wisely campaign for their workers. www.consumerhealthchoices.org 34 Making it easy for employers: Choosing Wisely Toolkit Employer Materials (Creating strategy; planning campaign) Employee Materials (Ready for use by employers) Consumer Reports tip sheets (New set of Choosing Wisely Tips!) All Consumer Reports resources (Over 150 articles and tip sheets) www.consumerhealthchoices.org 35 Employer Toolkit www.nbch.org/Choosing-Wisely-Employer-Toolkit www.consumerhealthchoices.org 36 Employer materials About Choosing Wisely and the Employer Toolkit Quick start guide Index of Choosing Wisely Employer Toolkit and Consumer Reports resources Sample timeline and editorial calendar Tip sheets for using new channels and communications methods and integrating the toolkit with wellness, enrollment and other campaigns www.consumerhealthchoices.org 37 Questions? Website: ConsumerHealthChoices.org Facebook: https://www.facebook.com/ConsumerHealthChoices Vimeo: http://vimeopro.com/consumerhealthchoices/portfolio Twitter: @ConsumerDavid Email addresses: Dom Lorusso: [email protected] www.consumerhealthchoices.org 38 Video Links Public Service Announcement http://vimeopro.com/consumerhealthchoices/portfolio/ video/89757078 “Grass Roots” interview http://vimeopro.com/consumerhealthchoices/portfolio/ video/99658899 “Talking” doctor video http://vimeopro.com/consumerhealthchoices/portfolio/ video/89756088 Choosing Wisely video https://www.youtube.com/watch?v=FqQ-JuRDkl8 www.consumerhealthchoices.org 39
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