Choosing  Wisely    in  Medical  Toxicology  

Anne-­‐Michelle  Ruha,  MD  American  College  of  Medical  Toxicology  

Annual  Scien=fic  Mee=ng  March  2015  

Objec=ves  of  this  Talk  

•  Review  the  Choosing  Wisely®  Campaign  and  how  ACMT  and  AACT  have  par=cipated    

•  Iden=fy  areas  where  medical  toxicologists  can  posi=vely  influence  evalua=ve,  diagnos=c,  and  management  approach  to  toxicological  concerns  by  the  medical  community  and  the  public  

www.choosingwisely.org  

Goals  of  the  Campaign  

•  Encourage  physicians  and  pa=ents  to  have  conversa=ons  about  what  care  is  truly  necessary  and  appropriate  

•  Reduce  wasteful  care  

Wolfson  D,  Santa  J,  Slass  L.  Acad  Med  2014;89:990-­‐995  

Choosing  Wisely  ‘Lists’  

•  Medical  socie=es  create  5-­‐item  lists  of  tests  or  procedures  that  physicians  and  pa=ents  should  ques=on    – ‘things  to  ques=on’  are  within  the  society’s  clinical  domain  

– Done  frequently  in  prac=ce  and  incur  real  costs  – Evidence-­‐based  recommenda=ons  

April  2012  –  9  socie=es  released  lists  

Campaign  Gains  Momentum  

•  February  2013  –  17  addi=onal  socie=es  released  lists  in  ‘phase  2’  of  the  campaign  

Where  do  ACMT  /  AACT  fit  in?  •  The  Choosing  Wisely  Campaign  is  about  encouraging  physician/pa=ent  conversa=ons  regarding  what  care  is  really  necessary    

•  ACMT/AACT  wish  to  improve  the  approach  to  and  care  of  pa=ents  and  the  public  with  poisoning  concerns  

•  How  do  ACMT/AACT  par8cipate  in  order  to  expand  our  outreach  to  the  medical  community  and  the  public?  

ACMT/AACT  List  #1  

•  The  ACMT  BOD  established  a  Work  Group  in  March  2013  to  create  a  list  of  5  tests  or  procedures  that  should  be  recommended  against  

•  Deadline  for  list  submission  was  May,  giving  us  a  very  short  =me  to  develop  the  list  

Other  Socie=es  

Crea=ng  List  2  

•  What  toxicology  tests  and  procedures  (or  treatments)  exist?  

– from  the  perspec=ve  of  a  medical  toxicologist?  

– from  ‘other’  medical  and  non-­‐medical  perspec=ves?    

lidle  tox  world:  common  ‘toxicology’  tests  and  procedures/treatments  

•  Drug  levels:  asa,  dig,  TCA,  apap,  lithium,  etc…  •  Tests  for  metals,  cholinesterase  levels….  

•  Radiology:  xrays,  CTs  (not  much  tox-­‐specific)  

•  Procedures:  (not  much  tox-­‐specific)  

•  An=dote  administra=on:  methylene  blue,  hydroxocobalamin,  bicarb,  etc…  

•  Other  treatments:  chela=on,  hyperbaric  oxygen,  etc…  

Broader  view:  common  ‘toxicology’  tests  and  procedures/treatments  

•  (Unvalidated)  tes=ng  for  ‘mold  toxicity’  •  (Unvalidated)  tes=ng  for  chemical  and  environmental  insensi=vi=es  

•  Generalized  hair,  nail,  urine,  blood  tes=ng  for  a  wide  range  of  ‘toxins’  

•  ‘Detoxifica=on’  therapies  •  Herbal  remedies  

Addressing  ‘alterna=ve’  prac=ce?  

•  What  is  the  point  in  crea=ng  list  ‘items’  that  address  non-­‐mainstream  prac=ces?    

o  Many  ‘MDs’  who  are  hugely  influen=al  promote  non-­‐scien=fic  toxicology  tests  and  treatments    o  Creates  confusion  for  pa=ents  o  Busy  physicians  also  confused  –  don’t  

have  =me  to  research  each  tox  concern  

ACMT/AACT  List  Development  

•  Work  Group  created  a  preliminary  list  of  items  which  was  sent  to  the  membership  for  feedback  and  sugges=ons  

•  Leaders  within  the  field  were  also  directly  contacted  for  their  input  

•  September  2013  –  ACMT  and  AACT  released  a  list,  joining  30  other  medical  socie=es  at  the  =me  

List  #1  

Statement  to  provide  the  evidence  and  thinking  behind  the  recommenda=on,  and  to  specify  when  the  interven=on  is  appropriate.  Any  condi=ons  or  s=pula=ons  that  the  physician  might  need  to  consider  can  be  addressed  here.    

What’s  become  of  List  #1?    

ABIMF  partners  with  Consumer  Reports  to  communicate  recommenda=ons  to  the  public  

•  To  date,  over  70  medical  socie=es  have  joined  the  Campaign,  including  ACMT  and  AACT  

ACMT/AACT  Work  Group  

•  Opportunity  for  greater  outreach  

•  Developed  a  2nd  preliminary  list  of  items  for  considera=on    

•  Sent  these  via  survey  to  the  memberships  for  feedback  and  sugges=ons  for  addi=onal  items  

Med  Tox  Community  –  Specific  Items  

•  Tend  to  be  controversial  among  our  members  – Examples:  

• Don’t  order  rou=ne  salicylate  screening  in  overdose  pa=ents  • Don’t  order  rou=ne  urine  drug  screens  in  overdose  pa=ents  • Don’t  order  rou=ne  head  CTs  in  pa=ents  with  clear  history  or  evidence  of  drug  overdose  

An  Item  We  Agreed  On  -­‐  Twice  

•  Do  not  discourage  vaccina=on  based  on  concern  that  the  mercury  or  other  vaccine  components  cause  au=sm  spectrum  disorders  – Our  members  really  liked  this  item  –  both  in  2013  and  2014  

– We  submided  it  twice  

– Did  not  fit  the  goal  of  the  Campaign,  which  is  to  do  LESS,  not  more  

Final  List  2  

Final  List  2  

– Detoxifica=on  hugely  popular,  without  evidence  to  support  the  prac=ce  

– Promoted  widely  on  the  internet,  including  by  physicians  – Primary  target  more  likely  to  be  pa=ents  

Final  List  2  

– Physicians  diagnosing  and  tes=ng  for  these  condi=ons  con=nues  

– Evidence  does  not          support  

Final  List  2  

– Physicians  may  order  upon  pa=ent  request  – Promoted  on  the  internet  

hdp://www.greatplainslaboratory.com/home/eng/metals_hair.asp  

Final  List  2  

– S=ll  performed,  without      confirming  ICP  

– Good  evidence            against  this  prac=ce  

Press  Release  

If  you  are  not  loving  an  item,  remember…  

•  The  aim  of  the  Choosing  Wisely®  campaign  is  to  promote  conversa8ons  between  physicians  and  pa=ents  by  helping  pa=ents  choose  care  that  is  supported  by  evidence,  free  from  harm,  and  truly  necessary.    

•  The  recommenda=ons  should  be  used  as  principles  to  determine  an  appropriate  treatment  plan  tailored  for  pa=ent-­‐centered  care.    

Summary  

•  ACMT  and  AACT  are  proud  to  have  joined  this  important  na=onal  ini=a=ve  by  the  ABIM  Founda=on.    

•  Promo=ng  educa=on  and  beder  understanding  of  the  risks  and  benefits  of  tests  and  treatments  is  one  of  our  goals  as  a  professional,  evidence-­‐based  community  of  toxicologists.    

Thank  You  

•  Jeff  Brent    •  Patrick  Daubert  •  Tony  Pizon  •  Silas  Smith  

•  Suzanne  White