REMOVING WASTE FROM HEALTH CARE: LESSONS FROM CHOOSING WISELY AND THE RIGHT CARE ALLIANCE D e c e m b e r 9, 2 0 1 3 I n s t i t u t e f o r H e a l t hc a r e I m p r o v e m e nt O r l a n d o, F L S h a n n o n B r o w n l e e, M S S e n i o r V i c e P r e s i d e n t, L o wn I n s t i t u t e S e n i o r F e l l o w, N e w A m e r i c a F o u n d a t i o n I n s t r u c t o r, D a r t m o u t h I n s t i t u t e f o r H e a l t h P o l i c y a n d C l i n c i a l P r a c t i c e SEQUENCE Introduction to overuse (S. Brownlee) Introduction to Choosing Wisely (D. Wolfson) Introduction to Right Care Alliance (V. Saini) Presenters have nothing to disclose 1
OBJECTIVES What is overuse and what is its scope? How do we know? Evidence for overuse What are the harms? What are its causes? What can we do about it? Introduce Choosing Wisely and Right Care Alliance CATEGORIES OF OVERUSE Ineffective treatment Inappropriately used treatments and tests Non evidence-based treatments or tests Routine but useless tests and procedures Futile rescue care Unwanted elective procedures and tests Unwanted end-of-life care Unnecessary hospitalization and physician visits 2
OVERDIAGNOSIS AND OVERTREATMENT Treatments known to be ineffective Antibiotics for viral infection; Herceptin for HER2neu negative BC Treatment known to cause harm Elective induction Treatments and tests used inappropriately PCI for a patient who has no symptoms of ischemic heart disease; CT scan for a pediatric patient with no evidence of intracranial trauma on a neurological exam OVERDIAGNOSIS AND OVERTREATMENT Non evidence-based treatments or tests Steroids for spinal cord injury; vertebroplasty and kyphoplasty Routine but useless or harmful tests and procedures Routine anticoagulation Futile rescue care CPR or feeding tube for an elderly patient suffering multiple organ failure or advanced dementia 3
UNWANTED CARE Unwanted elective procedures and tests that the patient would have chosen to avoid if he or she had been well informed and the clinician had engaged in shared decision making Unwanted end-of-life care, or end-of-life care that contravenes wishes stated in an advance directive OVERUSE OF HOSPITALIZATION AND PHYSICIAN VISITS Supply-driven Lack of evidence Cultural norms at different institutions 4
WHAT S THE SCOPE OF OVERUSE AND HOW DO WE KNOW? Sources IOM PricewaterhouseCoopers Berwick and Hackbarth Dartmouth Atlas 10-30% of spending is overuse SOURCE: Berwick DM, HackbarthAD. JAMA. 2012 Apr 11;307(14):1513-6. 5
Medicare Spending Source: Dartmouth Atlas 6
Relationship Between Prevalence of Severe Chronic Illness and Medicare Parts A and B Reimbursements per Enrollee Source: 2006 Dartmouth Atlas Note: Each dot represents Medicare spending in a single hospital referral region. 7
Ask your doctor if taking a pill to solve all your problems is right for you. Well Bob, it looks like a paper cut, but just to be sure, I like to do lots of tests. 8
ESTIMATES FOR DEFENSIVE MEDICINE $46 billion (Mello, MM, Chandra, A, Gawande AA, Studdert, DM. Health Aff. 2010 Sep;29(9):1569-77.) $135 243 billion (The Factors Fueling Rising Healthcare Costs 2006, prepared for America s Health Insurance Plans, January 2006 prepared by PWC http://storage.globalcitizen.net/data/topic/knowledge/u ploads/2009022212459760.pdf) No difference in patient outcomes after tort reform (Sloan, FA, Sadle, JH. J. Health Econ. 2009 Mar;28(2):481-91.) WHY DOES IT HAPPEN? Failure to recognize pervasiveness and harms Failure (inability) to share decisions Culture of More is Better Oversupply of resources (e.g. beds and clinicians) Lack of evidence Poor knowledge of evidence Marketing by hospitals, pharma and device makers Indication creep FFS, pressure from hospital Defensive medicine Patient demand 9
HARMS OF OVERUSE Exposure to error, nosocomial infection Excess morbidity and mortality Wrong patient error Unnecessary suffering especially the frail elderly Excess spending Moral distress for clinicians and caregivers HARMS OF OVERUSE Pervasive, systemic, cultural Causes significant harm to patients and to clinicians and caregivers A patient safety issue Drives up costs 10
WHAT NEEDS TO HAPPEN SYSTEM CHANGE (beds we build; clinicians we train) CULTURE CHANGE BEHAVIOR CHANGE (clinicians and patients clinicians first and foremost) WHY WE ARE HERE Pervasiveness, payment and culture will resist change Current notions of professionalism need revitalization Choosing Wisely: more than a list of don ts Right Care Alliance: a vehicle for connecting change agents and uniting multiple facts of change 11
Our goal must be to do much for the patient... and as little as possible to the patient. -- Bernard Lown, MD Cardiologist, inventor of the cardiac defibrillator, Nobel laureate 12