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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 h c a r e I m p r o ve m e n t
O r l a n d o , F L
Vi ka s S a i ni , M .D.
Pres iden t , Lown Ins t i tu te
REMOVING WASTE FROM
HEALTH CARE: LESSONS FROM
CHOOSING WISELY AND THE
RIGHT CARE ALLIANCE
� Origins in the Avoiding Avoidable Care conference 2012
� A newly established initiative of the Lown Institute
� Attempting to build a social movement within the medical
community and beyond for change in health care delivery
THE RIGHT CARE ALLIANCE
Overuse is a pervasive cultural phenomenon.
Avoiding overuse and underuse is an ethical obligation.
Delivering the right care will result in the right amount of spending.
GETTING TO THE RIGHT CARE:
A POINT OF VIEW
� Overuse is a target rich environment for Quality Improvement
� Choosing Wisely lists are clear, more or less uncontested, measurable, and subject to QI efforts
� Not a traditional error of the quality and safety movement
� Harms are colored by a presumption of benefit , casting any adverse event as a downstream target for improvement
GETTING TO THE RIGHT CARE: NOT SO
EASY
� Placement of a PA catheter was not in and of itself a medical
error
� Indeed, it was an unofficial standard of care for over a decade
� One could systematically try to reduce the complication rate,
the infection rate, etc. of PA catheters placed…….
THE CASE OF PULMONARY ARTERY CATHETERS
KAPLAN-MEIER SURVIVAL CURVES TO ONE YEAR
PA CATHETERS VS STANDARD CARE
Sandham, J. et al. N Engl J Med 2003;348:5-14
� We will miss the question: is this even needed?
� That question is an upstream target for improvement
THE RISK OF NOT FOCUSING ON OVERUSE
� Some core propositions:
� Unnecessary care increases risk of harm without net benefit
� Can violate patient preferences and cause “wrong patient error”
� For any test or treatment there is a population distribution of benefit and harm
� There is also a population distribution of risk tolerance and treatment preferences
� The right care is always to be found in this 2-D matrix.
OVERUSE IS A QUALITY AND SAFETY ISSUE
� Appropriateness of clinical decision-making
is or should be a quality metric
� Degree of patient-centered decision-making
is or should be a quality metric
OVERUSE AS A QUALITY AND SAFETY ISSUE
69 yo male lawyer told he needed CABG surgery
History of CHF, Afib, PAD
� 3 nuclear scans, 3 echos, 2 cardiac caths over 1 year
� No angina, good exercise tolerance, doesn’t want surgery
� AUC criteria of the American College of Cardiology:
Appropriate for Surgery
Lown opinion: defer surgery
A SECOND OPINION
� Deferring surgery: Attending to the patient’s preference, but
within the doctor’s comfort zone of “OK and safe to do this”
� Regardless of the doctor’s comfort zone, if the patient makes
an informed decision and decides against a procedure, isn’t
that always the “right” decision?
GETTING TO THE RIGHT CARE: 2ND OPINION
CASE
WHAT’S THE RIGHT RATE?
� RCTs of Shared Decision Aids consistently show 20% drop in demand for procedures such as PCI or knee surgery
� 400,000 elective PCIs; 1-2% serious adverse events
� With SDM, 80,000 fewer PCIs; 800-1,600 harmed inappropriately?
� 1,015,000 hip knee arthroplasties; with SDM, 253,750 fewer; 17,500 harmed?
WRONG PATIENT ERROR*
*J. Wennberg and A. Mulley
Morgan, M.W., et al., J Gen Intern Med, 2000. 15(10): p. 685-93.
Arterburn, D., et al., Health Affairs, 2012. 31(9): p. 2094-104.
Feldman, D.N., et al., Am J Cardiol, 2006. 98(10): p. 1334-9; Boden, W.E., et al., N Engl J Med, 2007. 356(15): p. 1503-
16.
Cushner, F., et al., Am J Orthop, 2010. 39(9 Suppl): p. 22-8.
� Paulo Borem, Unimed, Brazil
� Nadia Chambers, NHS, UK
ACHIEVING RIGHT CARE AROUND THE WORLD
Promoting Healthier Moms and Babies by achieving
40% of Natural Child Birth among Unimed Jaboticabal’s
clients by August 2013
A Project Pilot to drive
the change for 20 million
clients
Quality Innovation Center UnimedPaulo Borem, MDIHI Improvement Advisor
A Success
Story of
Mobilisation
THE NHS’ RIGHT CARE CALL TO ACTION:
WHAT HAVE THEY ACHIEVED AND HOW?
Articulated an unacceptable situation
Agreed on a shared goal
Mobilised a constituency
Organised and Strategised
Measured Improvement
� Developed systems that did not previously exist
� Audit demonstrated low diagnosis rates (30-40%)
� 72,000 people with a diagnosis of dementia on antipsychotics
� 80% had a clinical review
� National audit showed a 52% decrease in prescribing
� The Right Care Call to Action cited as making a significant contribution to achieving this.
DEMENTIA CARE – THE RIGHT PRESCRIPTION
OUTCOMES 2011-12
�Reduce underuse, overuse, and misuse
�A renewed sense of purpose and
professionalism
�An alliance with the public
�Working together to change culture
GOALS OF THE RIGHT CARE ALLIANCE
� Annual meetings
� Building a multispecialty, multi-professional network for taking action
� Medical Education Initiatives
� Designing a public engagement process
� Developing a research agenda
ACTIVITIES OF THE RIGHT CARE ALLIANCE
� Choosing Wisely
� American Medical Students Association
� National Physicians Alliance
� Emerging International Contacts
COLLABORATIONS
� www.rightcaredeclaration.
org
AN ORGANIZING TOOL
� The lists we have are the tip of an iceberg of culture and a way of thought of “more is better”
� Long journey, many complexities
� Much required innovations of measurement, of intervention, and of assessment
� Primary responsibility lies with healthcare professions
A VAST LANDSCAPE OF CHALLENGES
“Customer expectations? Nonsense. All customer
expectations are only what you have led him to
expect. He knows nothing else.”
Last published interview of W. Edwards Deming, January 17,
1994; Industry Week magazine
PATIENT ROLE, PROVIDER ROLE
