Choosing Wisely What is it and why should I know?

May 25, 2014 (10:30 – 11:30 a.m.)

Tristan Boyd and Shirley Chow

•  To discuss low-value testing, resource stewardship and barriers in providing high-quality care.

•  To present the process for implementing and sustaining change using the CRA Choosing Wisely campaign as a framework.

•  To review the the top 5 CRA Choosing Wisely recommendations and their evidence.

Learning Objectives

•  None.

Disclosures

1. Why do we overuse healthcare resources unnecessarily? -  Clinical vignettes with discussion.

2. What is Choosing Wisely? -  Framing the challenges: low-value testing + resource stewardship.

-  Background on Choosing Wisely Canada.

3. Canadian Rheumatology Association Top 5 items.

4. What can we do to advance resource stewardship? -  Discussion on quality improvement strategies to bridge the gap

between education and implementation.

Outline for the next hour…

Is there high suspicion of SLE in this patient?

Was ANA a low-value test to perform in this patient?

How might this positive test lead to further unnecessary testing and harm to patient?

37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:80 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, and inflammatory markers. Comorbidities include hypertension, rosacea, fibromyalgia, and depression. Current medications: hydrochlorothiazide, duloxetine, and topical metronidazole.

Scenario 1

Does knowing HLA-B27 status change diagnosis or influence management in this patient?

If HLA-B27 was positive, would you order an x-ray or MRI to look for evidence of sacroiliitis? Would you consider starting biologic therapy?

If patient had more clear-cut inflammatory back pain (≥3 months, AM stiffness >60 min., response to NSAIDs) PLUS enthesitis and history of uveitis, would HLA-B27 be helpful?

24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm).

Scenario 2

Should this patient be prescribed bisphosphonate therapy?

What are the risks/benefits?

When should her bone mineral density be repeated?

58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (T-scores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28.

Scenario 3

What are barriers that prevent appropriate use of finite health resources?

What are the enablers that promote inappropriate use of finite healthcare resources?

What barriers and/or enablers pose the greatest threat to the appropriate use of finite health care resources?

Discussion

•  Habit/pre-printed order forms •  Pre-emptive ordering

•  Reassurance •  Thoroughness

•  Referring doctor requesting test

•  Patient requesting test •  Fear of litigation

Why do we use health care resources unnecessarily ?

Berwick D. JAMA. 2012.

30% of what is spent in health care does NOT add value!

•  A national campaign encouraging physicians and patients to engage in conversations about the overuse of tests, treatments and medical procedures.

•  Help physicians and patients make informed and

effective choices.

•  Limit exposure to unnecessary or potentially harmful tests, treatments and procedures while ensuring patients get the care they need.

What is Choosing Wisely Canada ?

What is Choosing Wisely ?

•  Modeled after the Choosing Wisely campaign in U.S. •  Over 60 US and 30 Canadian societies have joined thus far

(at different stages of list development).

•  Focus is on tests, treatments and procedures for which there is concrete evidence of no benefit to patients.

Physician List Development

13

Process must be publicly available

Must be evidence to support list

items

List items must be frequent

List items must be within

society’s purview

Societies free to

determine process

•  The number of available tests, treatments and procedures in modern medicine is large and growing.

•  Just because something is available doesn’t mean we should use it.

•  Unnecessary tests, treatments and procedures do not add value to patient care.

•  Potentially hazardous to the health of patients.

Dispel notion that “More Care is Better Care”

Top 5 list.

NOT a list of rules!

Based on best available evidence.

How the List was Created Choosing Wisely

Committee Formed

Item identification: Delphi Survey

CRA Membership Survey (172)

Methodology Subcommittee Review

and Item Selection

Literature and Guideline Review

Review and revision

CRA Board and Patient Consumers Review

Wave 1 launch

July 2013

Aug/ Sept 2013

Sept/ Oct 2013

Oct 2013

Oct/Nov 2013

Nov/Dec 2013

Dec 2013

Spring 2014

16 members Round 1 n=64 items Round 2 n=24 items Round 3 n=13 items n=13 items n=5 items

Website launched

Information disseminated

Multidisciplinary Working Group Pooneh Akhavan, MD FRCPC Claire Bombardier, MD FRCPC Vivian Bykerk, MD FRCPC Glen Hazlewood, MD FRCPC James Pencharz, MD CCFP Janet Pope, MD FRCPC John Thomson, MD FRCPC Carter Thorne, MD FRCPC

Lyddiatt

Pooneh Akhavan, MD FRCPC Mary Bell, MD FRCPC Shirley Chow, MD FRCPC Gregory Choy, MD FRCPC Natasha Gakhal, MD FRCPC

Bindee Kuriya, MD FRCPC Dharini Mahendira, MD FRCPC Zarnaz Bagheri, MD FRCPC Damian Frackowick, MD FRCPC Dawn Richards

Proton Rahman, MD FRCPC Jennifer Burt

Martin Cohen, MD FRCPC Edith Villeneuve, MD FRCPC

Robert Ferrari, MD FRCPC Sylvie Ouellette, MD FRCPC Chris Debow

§  Rheumatologist (16) §  Rheumatology trainee (5) §  Allied health provider (1) §  Patient Consumer (3) §  Coordinator (1)

Peter Tugwell, MD FRCPC Anne Lyddiatt

Carter Thorne, MD FRCPC Christine Charnock

Ann Marie Colwill, MD FRCPC

Glen Hazlewood, MD FRCPC Nadia Luca, MD FRCPC

Michelle Jung, MD FRCPC Tristan Boyd, MD FRCPC

What were our Top 5 topics?

Guidelines:

•  American College of Pathologists

•  British Columbia Ministry of Health

•  American College of Rheumatology

•  Italian Society of Laboratory Medicine Guidelines

1. Don’t order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus (SLE) or another connective tissue disease (CTD).

Recommendation 1

Is there high suspicion of SLE in this patient?

Was ANA a low-value test to perform in this patient?

How might this positive test lead to further unnecessary testing and harm to patient?

37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:80 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, and inflammatory markers. Comorbidities include hypertension, rosacea, fibromyalgia, and depression. Current medications: hydrochlorothiazide, duloxetine, and topical metronidazole.

Scenario 1

ANA testing should not be used to screen subjects without specific symptoms (e.g., photosensitivity, malar rash, symmetrical polyarthritis, etc.) or without a clinical evaluation that may lead to a presumptive diagnosis of SLE or other CTD.

ANA reactivity is present in many non-rheumatic conditions and even in “healthy” control subjects (up to 20%).

In patients with low-test probability, positive ANA results can be misleading and may precipitate further unnecessary testing, erroneous diagnosis or even inappropriate therapy.

37 year-old woman referred by GP for assessment of possible lupus with positive ANA at 1:160 (homogenous pattern). Symptoms include facial rash, fatigue and arthralgias. Normal CBC, BUN/Cr, inflammatory markers. Comorbidities: hypertension, rosacea, fibromyalgia, and depression. Medications include hydrochlorothiazide, duloxetine, and topical metronidazole.

Scenario 1 – Discussion

Pre-test and Post-test Probability

Changes to Referral Patterns

Guidelines:

•  Assessment of SpondyloArthritis International Society (ASAS) Guidelines

•  3e Initiative in Rheumatology

2. Don’t order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms.

Recommendation 2

Does knowing HLA-B27 status change diagnosis or influence management in this patient?

If HLA-B27 was positive, would you order an x-ray or MRI to look for evidence of sacroiliitis? Would you consider starting biologic therapy?

If patient had more clear-cut inflammatory back pain (≥3 months, AM stiffness >60 min., response to NSAIDs) PLUS enthesitis and history of uveitis, would HLA-B27 be helpful?

24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm).

Scenario 2

HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without further spondyloarthropathy (SpA) signs or symptoms.

If HLA-B27 is used, at least 2 SpA signs or symptoms, or the presence of positive imaging findings, need to be present to classify a patient as having axial SpA.

There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

24 year-old man referred to rheumatologist with low back pain (symptom duration 3 weeks, no AM stiffness, no response to NSAIDs). Review of systems negative for uveitis, enthesitis, dactylitis, psoriasis, or inflammatory bowel disease. No known family history. Exam reveals no abnormalities and normal spinal measurements (OTW = 0 cm, CWE 5.8 cm, Schöber test = 5.4 cm).

Scenario 2 – Discussion

Guidelines:

•  2010 Clinical Practice Guidelines for the diagnosis and management of osteoporosis in Canada

•  2013 international society for clinical densitometry position development conference on bone densitometry

•  U.S. Preventive Services Task Force recommendation statement

3. Don’t repeat dual energy X-ray absorptiometry (DEXA) scans more often than every 2 years.

Recommendation 3

Guidelines:

•  2010 Clinical Practice Guidelines for the diagnosis and management of osteoporosis in Canada

•  FRAX® – WHO Fracture Risk Assessment Tool

•  Cochrane Database Systematic Reviews

4. Don’t prescribe bisphosphonates for patients at low risk of fracture.

Recommendation 4

Should this patient be prescribed bisphosphonate therapy?

What are the risks/benefits?

When should her bone mineral density be repeated?

58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (T-scores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28.

Scenario 3

There is no convincing evidence that anti-osteoporotic therapy in patients with osteopenia alone reduces the risk of fracture.

Given the lack of proven efficacy, widespread use of bisphosphonates in patients at low risk of fracture is not currently recommended.

The use of repeat DEXA scans at intervals of every 2 years is appropriate in most clinical settings, and is supported by several current osteoporosis guidelines.

58 year-old woman with past medical history of hypertension and hyperlipidemia undergoes BMD-DEXA which reveals osteopenia (T-scores -1.7 lumbar spine and -1.8 in femoral neck). Started on Vitamin D (advised re: dietary calcium). Current medications include ramipril and atorvastatin. No history of alcohol or tobacco use. No history of glucocorticoid use and no fracture. BMI 28.

Scenario 3 – Discussion

The diagnosis of peripheral and axial inflammatory arthritis can usually be made on the basis of an appropriate history, physical exam and basic investigations.

Whole body bone scans, such as the Tc-99m MDP scintigraphy, lack specificity to diagnose inflammatory polyarthritis and spondyloarthritis and have limited clinical utility.

The equivalent of radiation exposure of a total whole body bone scan is reported as over 40 routine chest X-rays, thus posing risk.

5. Don’t perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adults.

Recommendation 5

No definitive data to show that these tests are currently “overused”.

No data to show cost-effectiveness from altered practice.

Level of evidence for some of recommendations is variable.

Some Limitations

How are we getting our message across?

Bridging the gap…

Print Resources

Patient Materials

Specialty societies & Consumer

Reports Health developed

materials that are:

Plain language

Easily accessible

Canadian-specific Educational

Evidence-based

www.ChoosingWiselyCanada.org

http://www.choosingwiselycanada.org/resources/campaign-videos/2014/04/01/x-ray-or-mri-lets-think-again/

Implementing and Sustaining Change

www.ChoosingWiselyCanada.org Twitter followers @ChooseWiselyCA

What can we all do in the next year to advance resource stewardship?

Discussion: Implementing and Sustaining Change

•  Rheumatology professionals can and should be able to identify low-value testing, resources stewardship and barriers in providing high-quality care.

•  Rheumatologists and healthcare providers can provide leadership in implementing and sustaining change using the CRA Choosing Wisely campaign as a framework.

43

Conclusions

Acknowledgements

Dr. Mary Bell Jennifer Burt Christine Charnock Dr. Shirley Chow Dr. Gregory Choy Dr. Martin Cohen Dr. Robert Ferrari Dr. Natasha Gakhal Dr. Nadia Luca Dr. Dharini Mahendira Dr. Sylvie Ouellette Dr. Proton Rahman Dawn Richards Dr. Carter Thorne Dr. Edith Villeneuve Dr. Diane Wilson

Dr. Pooneh Akhavan Dr. Robert Ferrari Dr. Glen Hazelwood Dr. Bindee Kuriya Dr. Peter Tugwell Zarnaz Bagheri Ann-Marie Colwill Damian Frackowick Michelle Jung Tristan Boyd

Methodology Working Group

Fellows

Dr. Jinoos Yazdany Dr. Wendy Levinson Karen McDonald Tai Huynh Virginia Hopkins Sharon Brinkos Tamara Rader Ekaterina Petkova Laura Corbett Corinne Holobowich Kellee Kaulback

Special Thanks to

Thank you! Questions? Comments?

Shirley.Chow@sunnybrook.ca