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CHOOSINGWISELYCANADA
DR.CHRISWILKES
Dr.T.C.R.WILKES,ASSOCIATEPROF.UniversityofCalgary,
CummingsMedicalSchoolDivisionofPaediatricsandPsychiatry,
SecJonChiefforSpecialiZedandOutpaJentservicesforCAAMHPP
DISCLOSURE
ConsultanttoBMS/OtsukaPharmaResearchwith
Lundbeckonadolescentdepression
CHOOSINGWISELYCANADA
LearningObjecJves:1.Tolearnaboutthepurposeandhistoryofthe
ChoosingWiselyCAMPAIGN.
2.Tolearnaboutiatrogenicillnessandthatmore
treatmentisnotnecessarilybeVerforpaJents.
3.ToexaminethekeyrecommendaJonsfor
ChildandAdolescentPsychiatry.
ChoosingWisely
• LedbytheAmericanBoardofInternalMedicineFounda8on,ChoosingWisely(2012)isacampaignthatseekstopromoteconversa8onsbetweencliniciansandpa8ents,byhelpingpa8entschoosecarethatis:• Supportedbyevidence• Notduplica8veofothertestsorproceduresalreadyreceived• Minimizingtheriskofharm• Trulynecessary
• Itprovidesevidence-based‘lowvalue’listsinover70speciali8esforphysiciansandpa8entstoconsider.
• Uniquelyprovidescorrespondingpa8entcontentcreatedbyConsumerReports
www.choosingwiselycanada.org
Background
• The2002publica8onMedicalProfessionalismintheNewMillenniumcalledphysicianstoahighstandardofprofessionalism.
• Thefundamentalprinciplesofprofessionalismoutlinedinclude:• Pa8entWelfare• Pa8entAutonomy• SocialJus8ce
• Itisthiscalltoprofessionalismandcommitmenttoimprovingaccesstohighqualityhealthcare,advoca8ngforajustandcost-effec8vedistribu8onoffiniteresourcesthatisthefounda8onforChoosingWisely
American Board of Internal Medicine Foundation, American College of Physicians, European Federation of Internal Medicine. (2002). Professionalism in the New Millennium: A Physician Charter.
HealthCareSpending
• OveruseofHealthCarecontributestohighcosts.Somees8matesa[ributeupto30%ofUShealthspendingtooveruse.
• Toreducehealthcostsandimprovepa8entcare,elimina8ngoveruseisamajorhealthcarereform.
• HealthcareintheUnitedStatesismoreexpensivethaninotherdevelopedcountries,cos8ng$2.7trillionin2011,or17.9percentofthena8onalGDP
Institute of Medicine. (2013). Variation in Health Care: Target Decision Making Not Geography. Korenstein, D., Falk, R., Howell, E. A., Bishop, T., & Keyhani, S. (2012). Less is More - Overuse of Health Care Services in the United States: An
Understudied Problem. Arch Intern Med, 171-178.
IatrogenicDISEASE.
• Adiseasethatiscausedbymedicaltreatment.Thishiddenepidemicincludes;
• Thenega8veeffectofdrugs,• Hospitalacquiredinfec8ons,• HospitalMedica8onerrors,• Unnecessarysurgery.• Thesearees8matedtoresultinthe3rdmostfataldiseaseinthe
USA.• “Moretreatmentisnotalwaysbe[er”
Seven-NaJonSummaryScoresonHealthSystemPerformance
• Davis,K.,Schoen,C.,&Stremikis,K.(2010).Mirror,MirrorontheWall.HowthePerformanceoftheU.S.HealthCareSystemComparesInterna<onally.CommonwealthFund.
• •
Seven-NaJonSummaryScoresonHealthSystemPerformance–
OverallRankingOverTime
• Davis,K.,Schoen,C.,&Stremikis,K.(2010).Mirror,MirrorontheWall.HowthePerformanceoftheU.S.HealthCareSystemComparesInterna<onally.CommonwealthFund.
HowMuchDoesHealthCareinCanadaCost?• TotalHealthExpendituresCanada1975-2013
•
Canadian Institute Health Information. (2013). National Health Expenditures Trends, 1975-2013. CIHI.
TotalExpendituresonDrugs,perCapita,U.S.Dollars,2011
• 10fig51percapitadrugexpenditure
Canadian Institute Health Information. (2013). National Health Expenditures Trends, 1975-2013. CIHI.
ExpendituresonServicesProvidedbyOfficesof
Physicians,perCapita,U.S.Dollars,2011
TotalHealthExpenditurebyUseofFunds,Canada,2011(BillionsofDollarsandPercentageShare)
TheRoleofPhysicians• Professionalobliga8ontoprovideappropriatecare• Con8nuedleadershipinevidence-basedmedicine• Recogni8onofescala8nghealthcarecosts,andopportunity
forphysicianstoinfluenceforthebe[er.Appealtotheimportanceoftakingproac8vemeasurestoaddresswaste.
• Asignificantpor8onofhealthcostsarerelatedtophysicianorders.Somees8matesputthisnumberat80%.
• Commitmenttotransparencyandshareddecisionmaking
Wolfson,D.,Santa,J.,&Slass,L.(2014).EngagingPhysiciansandConsumersinConversa8onsaboutTreatmentOveruseandWaste:AShortHistoryoftheChoosingWiselyCampaign.AcademicMedicine,1-6.
TheNeedforCompellingEvidence
• Researchevidenceisnottheonlydeterminantofclinicaldecision-making.Variousotherfactorsthatmayexplainthetendencytowardsunnecessarycareand/ordecision-makinginclude:
• Indica8onCreep• Cogni8veDissonance
• theinabilitytoreconcilenewevidencewithhighlyingrainedpriorbeliefsthatbothdetermineandarereinforcedbyrou8nizedprac8ce:onebelievessoonedoes,andasonedoes,soonebelieves.
• Medical/Legalliabilityconcerns• SenseofthreatenedProfessionalAutonomy• VarietyofBiasestowardunnecessarycare
Sco[,I.A.,&Elshaug,A.G.(2013).Foregoinglow-valuecare:howmuchevidenceisneededtochangebeliefs?InternalMedicineJournal,107-109.
BiasesTowardUnnecessaryCare
• Clinicianregretatnotadministeringatreatmentwhenitmayleadtobenefit(regretofomission)overpoweringregretfortheconsequencesofanunnecessarytreatment(regretofcommission)
• Pro-interven8onbias,especiallyamongyoungerclinicians,towardschoosingac8onoverinac8onevenifmarginalbenefitsofac8onareverysmall
• Pro-technologyand‘innova8on’biastowardstooreadilybelievingthatnewertreatmentsandtechnologiesaresuperiortotheirpredecessors
• Desiretopleasereferringclinicians• Fearofpa8entapproba8onorli8ga8onfornotdoingthings(defensivemedicine);• Supply-drivendemand(desireofindustryandproviderstogenerateincomeinpresenceof
excesscapacity)• Overes8ma8onbybothcliniciansandpa8entsoftreatmentbenefitsandsafety• Overrelianceonpathophysiologicaloranatomicalreasoning,orsurrogateoutcomesthatdo
notnecessarilytranslateintopa8ent-importantbenefits• Clinicalprac8ceguidelineslackingasoundevidencebaseorwri[enbyconflictedpanellists• Fee-for-servicefunding(whichrewardsquan8tynotqualityofservices)
Sco[,I.A.,&Elshaug,A.G.(2013).Foregoinglow-valuecare:howmuchevidenceisneededtochangebeliefs?InternalMedicineJournal,107-109.
RANDModelforCompellingEvidence• Appropriatenessisdefinedlargelyintermsofnetclinicalbenefittotheaveragepa8entandvariesbyserviceandseqng.ThemostwidelyusedmethodtoassessappropriatenessofhealthcareservicesistheRAND/UCLAModel.
• Inanefforttoovercomethelimitsofavailableevidence,theRANDmodelincorporatesboththeexis8ngevidenceandtheresultsofclinicalconsensusamongkeyexperts.
• Thecomposi8onofthepanelma[ers.Thedetermina8onofwhetheraprocedureisappropriate,ornot,willdependinpartonthetypeandmixofcliniciansinvolvedinthedelibera8ons.
Sanmar8n,C.,Murphy,K.,Choptain,N.,Conner-Spady,B.,McLaren,L.,Bohm,E.,etal.(2008).Appropriatenessofhealthcareinterven8ons:Conceptsandscopingofthepublishedliterature.Interna<onalJournalofTechnologyAssessmentinHealthCare,
342-349.
ChoosingWisely-Canada• April2014-Ini8allaunchofCanadianrecommenda8onsinvolving8specialist
socie8es• Endorsedby:
• CanadianMedicalAssocia8on• RoyalCollegeofPhysiciansandSurgeonsofCanada• CollegeofFamilyPhysiciansofCanada• CanadianAssocia8onofProfessorsofMedicine
• June2015–nextrolloutinvolvingseveralmoresocie8esincludingtheCanadianPsychiatricAssocia8on,aswellasconsumergroups
• Academicenvironmentrarelydiscouragesorderingtestsorproceduresandthiscultureneedstochange
• Insteadof“moreisbe[er’consider“thinktwice”whenorderingtests,treatmentsandprocedures
Levinson, W., & Huynh, T. (2014). Engaging physicians and patients in conversations about unnecessary tests and procedures: Choosing Wisely Canada. CMAJ, 325-326.
ChoosingWiselyCanada-Psychiatry
• Don'tuseanJpsychoJcsasfirstchoicetotreatbehaviouralandpsychologicalsymptomsofdemenJa.
• PeoplewithdemenJaoeenexhibitchallengingbehaviouralsymptomssuchas
aggressionandpsychosis.Insuchinstances,anJpsychoJcmedicinesmaybenecessary,butshouldbeprescribedcauJouslyastheyprovidelimitedbenefitandcancauseseriousharm,includingprematuredeath.UseofthesedrugsshouldbelimitedindemenJatocaseswherenon-pharmacologicmeasureshavefailed,andwherethesymptomseithercausesignificantsuffering,distress,and/orposeanimminentthreattothepaJentorothers.AthoroughassessmentthatincludesidenJfyingandaddressingcausesofbehaviourchangecanmakeuseofthesemedicaJonsunnecessary.Forcontext,thenumberneededtotreatwithanatypicalanJpsychoJcforaclinicallysignificantbenefitrangesfrom5-11,andthenumberneededtoharmformortalityover6-12weeksis100.Datafromepidemiologicalstudiessuggestthattypical(i.e.,firstgeneraJon)anJpsychoJcs(e.g.,haloperidol)areassociatedwithatleastthesameriskofadverseevents.ThisrecommendaJondoesnotapplytothetreatmentofdeliriumormajormentalillnessessuchasmooddisordersorschizophrenia.
ChoosingWiselyCanada-Psychiatry• Don’tusebenzodiazepinesorotherseda8ve-hypno8csinolder
adultsasfirstchoiceforinsomnia
• Nonpharmacologicalinterven8onssuchascogni8vebehaviouraltherapyandbriefbehaviouralinterven8onshaveprovenbenefitinthemanagementofinsomniainolderadults.Epidemiologicalstudieshaveshownthattheriskofmotorvehicleaccidents,fallsandhipfracturesleadingtohospitaliza8onanddeathcanmorethandoubleinolderadultstakingbenzodiazepinesandotherseda8ve-hypno8cs.Thenumberneededtotreatwithaseda8ve-hypno8cforimprovedsleepis13,whereasthenumberneededtoharmisonly6.Prescribingordiscon8nuingseda8ve-hypno8csinhospitalcanhavesubstan8alimpactonlong-termuse.Thesepoten8alharmsandotherssuchasimpairedcogni8onneedtoberecognizedwhenconsideringtreatmentstrategiesforinsomnia.Useofbenzodiazepinesshouldbelimitedtoasshortaperiodaspossible,incaseswherenon-pharmacologicaltherapieshavefailed,andthesymptomsofsleepdisturbancecausesignificantsufferingordistress.
ChoosingWiselyCanada-Psychiatry• Donotuseatypicalan8psycho8csasafirst-lineinterven8onforinsomniainchildrenandyouth.
• Recentresearchconfirmsadrama8cincreaseintheuseofatypicalan8psycho8cswithsubsequentside-effectsincludingobesity,andasthisisamajorhealthissuealready,itisprudenttopursuenon-pharmacologicalmeasuresfirstsuchasbehaviouralmodifica8onsandensuringgoodsleephygiene(elimina8ngday8menappingandshuqngoffelectronicsanhourbeforebed8me).Iftheseinterven8onsarenotsuccessful,thenconsidershort-termuseofmelatonin.
ChoosingWiselyCanada-Psychiatry• DonotuseSSRIsasthefirst-lineinterven8onformild
tomoderatelydepressedteens.• Evidenceclearlyindicatesthatan8depressantmedica8onis
lesseffec8veinchildrenandadolescentsuptotheageof17yearsandfirst-linetreatmentforthisgroupshouldincludecogni8vebehaviouraltherapyorinterpersonalpsychotherapy.A[en8onshouldalwaysbefocusedonchildren’sandteens’environmentalsafetyandadequateparentalsupporttoavoidmissingcasesofneglectorabuse.Followingthis,afirst-lineinterven8onshouldbepsychoeduca8onregardingtheimportanceofregularsleep,dietandexercisetoensurehealthy,age-appropriatedevelopmentalsupport.
ChoosingWiselyCanada-Psychiatry• Donotuseatypicalan8psycho8csasafirst-lineinterven8on
forADHDcomorbidwithdisrup8vebehaviourdisorders.
• TreatmentofADHDshouldincludeadequateeduca8onofpa8entsandtheirfamilies,behaviouralinterven8ons,psychologicaltreatmentsandeduca8onalaccommoda8onsfirst.Thens8mulantmedica8onalongwithabehaviouralanalysistoensureappropriatesupportfromtheparentandclassroominterven8on;theuseofalpha2agonists(suchasguanfacine)andatomoxe8neshouldbeconsideredbeforeusingatypicalan8psycho8cs(suchasrisperidone)inkidswithdisrup8vebehaviourdisorders(opposi8onaldefiantdisorder,conductdisorder).
ChoosingWiselyCanada-Psychiatry
• Donotusepsychos8mulantsasafirst-lineinterven8oninpreschoolchildrenwithADHD.
• PreschoolchildrenwithADHDneedtobeassessedforotherneuro-developmentaldisordersandconsidera8ongiventoenvironmentalstressorssuchasneglect,abuseorexposuretodomes8cviolence.Treatmentalsoincludesadequateeduca8onandsupportofparentsfollowedbyadviceonbehaviouralmanagementandcommunityplacement.
ChoosingWiselyCanada-Psychiatry
• Donotignoreearlymentalhealthproblemsforyoungchildren(0to5years).
• Acrucial90%ofbraindevelopmentoccursinthefirstfiveyearsoflife,fosteringadevelopingcapacityfora[achmentandhealthysocialemo8onaldevelopment.Manychildrenwhohaveadiagnosisofmentalhealthdisordersexhibitedsymptomsbeforetheageof6butwereunabletoaccessthesupportsandservicesneededforeffec8veinterven8on.
ChoosingWiselyCanada-Psychiatry• Donotrou8nelyusean8psycho8cstotreatprimary
insomniainanyagegroup.
• Second-genera8onan8psycho8cs(SGAPs)seda8veproper8es,suchasolanzapineandque8apine,areosenprescribedoff-labelforcomplaintsofinsomnia.InasurveyofcliniciansprescribingSGAPs,12.1%indicatedprescribingitsolelytoinducesleep.Que8apinewasthemostosenprescribedSGAPfollowedbyrisperidoneandolanzapine.Thesedrugscarrysignificantriskofpoten8alsideeffects.SafetyofSGAPstotreatinsomniahasnotbeensystema8callystudied.Theycancauseweightgainandmetaboliccomplica8onsevenatlowdosesusedtotreatinsomnia.Inpa8entswithdemen8a,theycanalsopoten8allycauseserioussideeffectsofincreasedriskofcerebrovasculareventandincreasedriskofdeath.
ChoosingWiselyCanada-Psychiatry
• Donotrou8nelyrequestSTATqualita8vetoxicology(urinedrugscreen)tes8ngonallpsychiatricpa8entspresen8ng
toemergencyrooms.
• Qualita8veurinetoxicologytes8nghasnotbeenshowntoimprovetherou8nemanagementofpsychiatricpa8entsinemergencyroomsbecauseofthepoten8alforfalseposi8ves,falsenega8ves,trueposi8veswhichareunrelatedorminimallyrelevanttotheclinicalpresenta8on,andfinallythedelayinpsychiatricassessmentandmanagementasaresultoftes8ng.
ChoosingWiselyCanada-Psychiatry• Donotrou8nelyusean8depressantsasfirstlinetreatmentformild
orsubsyndromaldepressivesymptomsinadults.
• An8depressantresponseratesarehigherfordepressionofamoderatetoseverenature.Formildandsubsyndromalsymptomsacompleteassessment,ongoingsupportandmonitoring,psychosocialinterven8onsandlifestylemodifica8onsshouldbethefirstlinesoftreatment.Thismayavoidthesideeffectsofmedica8onandestablishe8ologicalfactorsimportanttofutureassessmentandmanagement.An8depressantsareappropriateincasesofpersistentmilddepression,wherethereisapasthistoryofmoreseveredepressionorwhereotherinterven8onshavefailed.
ChoosingWiselyCanada-Psychiatry• Donotrou8nelyorderbrainneuroimaginginves8ga8onssuchasa
CTscanorMRIforallcasesoffirstepisodepsychosesintheabsenceofsymptoms,later-ageonsetofsymptoms,signsorbasicinves8ga8onssugges8veofotherrelevantintracranialpathology.
• Wherethereareneurologicalsigns,symptoms,later-ageonsetofsymptoms,orothertestresultssugges8veofintracranialpathologyinaddi8ontoorrelatedtopsycho8csymptomsneuroimagingisindicated.Mul8plestudieshavefoundthatrou8neneuroimaginginfirstepisodepsychosesdoesnotyieldfindingswhichalterclinicalmanagementinameaningfulway.Therisksofradia8onexposure,delayintreatment,andcostsaresignificantfactorswhichalsoargueagainstrou8neneuroimaging.
ChoosingWiselyCanada-Psychiatry• Donotrou8nelycon8nuetoprescribebenzodiazepines,ini8ated
duringanacutecarehospitaladmissionwithoutacarefulreviewandplanoftaperinganddiscon8nuing,ideallybeforedischarge.
• Benzodiazepines,whilehelpfulforshort-termreliefofanxietyandinsomnia,areassociatedwithavarietyofside-effectsandlong-termproblemsincludingcogni8veandpsychomotorimpairmentaswellasabuseanddependence.Benzodiazepinesarecommonlyusedinhospitaltotreatanxietyorinsomniainassocia8onwitheitherthepresen8ngcondi8onorthehospitalenvironment.Oncethepresen8ngcondi8onistreatedandthepa8entisdischargedbenzodiazepinesshouldbecarefullyreviewedwiththegoal,whereatallpossible,oftaperinganddiscon8nuingthesemedica8ons.
ChoosingWiselyCanada-Psychiatry• Don’trou8nelyprescribean8depressantsasfirstlinetreatmentfordepression
comorbidwithanac8vealcoholusedisorderwithoutfirstconsideringthepossibilityaperiodofsobrietyandsubsequentreassessmentforthe
persistenceofdepressivesymptoms.
• Theconcurrentmanagementofpsychiatricillnessandalcoholusedisordersrequiresevalua8onoftherolealcoholplaysasacausa8vefactorfordepressivesymptoms.Studieshavefoundthatresponseratestoan8depressantsarehigherwhenan8depressantsarereservedforpersistenceofsymptomsaseraperiodofsobrietylas8ngfrom2to4weeks.Responserateswhenprescribedduringaperiodofac8vealcoholmisusearepoorerandosenfailtoseparatefromplacebo.Addi8onallystudieshavedemonstratedremissionfromdepressivesymptomswithsobrietyintheabsenceofan8depressanttreatmentinasignificantpercentageofcases.Managementofcomorbidpsychiatricillnessandsubstanceusedisordersincludingalcoholdependenceinvolvesassessmentandtreatmentdeliveredinconcurrentmanner.Thesequencingofabs8nencefromsubstancemisusebeforeprescribingan8depressantsdoesnotobviatetheneedforaconcurrentapproach.
ChoosingWiselyCanada-Psychiatry
• Don'trou8nelyprescribehigh-doseorcombina8onan8psycho8ctreatmentstrategiesinthetreatmentofschizophrenia.
• High-doseandcombina8onstrategiesinvolvingatypicalan8psycho8cs(AAPs)arefrequentlyusedinclinicalprac8ceforpa8entswithschizophreniawhoareinadequatelycontrolledwithoneormoreAAPsusedatstandarddoses.Arecentmeta-analysisassessedtherela8vesafetyandefficacyofcombina8ontherapyandhigh-doseatypicalan8psycho8ctherapyinpa8entswithschizophreniainadequatelycontrolledonstandard-dosean8psycho8cs,andnoclinicallysignificantimprovementswerefoundfavouringcombina8onorhigh-doseAAPtreatmentstrategieswhencomparedwithstandard-dosemonotherapy.Intermsofsafety,noclinicallysignificantdifferenceswereevidentbetweencombina8onorhigh-dosetherapyincomparisonwithstandard-dosemonotherapy,withtheexcep8onofclozapinecombina8ontherapywherepa8entsexperiencedmoreseriousadverseeventscomparedwithclozapinemonotherapy.However,thesafetyevidencewasconsideredinconclusive,duetothesparsityofdataforkeyharms-relatedoutcomes.Generally,combina8onorhighdosestrategiesshouldbeconsideredaserdemonstra8onofthreefailedtrialsofmonotherapy,includingclozapinewhereappropriate.
MovingChoosingWiselyForward
• Educa8onandawareness• Increasednumberofrecommenda8ons• Increasedandcurrentevidence• ClinicalPrac8ceGuidelinesbyNa8onalSocie8es• Formalendorsementbyrelevantbodiesandstakeholders• AcademicLiterature• OrderingProtocols
SuccessIndicators?
• Howdoweknowifitworks?• WaitandSee• Research,Evalua8ons,Audits,Cos8ngStudies,Databases• ImprovedPa8entWellbeing• ImprovedQualityofCare(Processes)• ImprovedProfessionalFulfillment
REFERENCES
• h[p://www.theglobeandmail.com/life/health-and-fitness/an8psycho8cs-prescribed-at-high-rate-to-youth-with-adhd-study-shows/ar8cle33666692/
h[p://cpa.sagepub.com/cgi/reprint/0706743716643823v1.pdf?ijkey=hqDZzONDHth7Faz&keytype=finite
Engel,G.L.1980.TheclinicalapplicaJonofthebiopsychosocialmodel.Am.JournalOfPsychiatry,137:535-544.Eisenberg,L.1986,MindlessnessandBrainlessnessinPsychiatry.Brit.JournalofPsychiatry.148:497-508.SeeaVachmentforotherreference.PharmacologicaltreatmentsofChildandAdolescentDisrupJveBehaviourDisorders.CanJPsychiatryfeb2015.Vol60.No2.39-41.
