From Overtreatment to  Patient-Centered Care
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  • 1. From Overtreatment to Patient-Centered Care National Academy for State Health Policy New Orleans, LA October 5, 2010 Rosemary Gibson, M.Sc. Author, The Treatment Trap and Wall of Silence
  • 2. Overview of Presentation
    • Define overtreatment: what it is, the impact on patients, and how to begin to address it
    • Discuss how reducing overtreatment can improve patient outcomes and reduce health care costs.
    • Identify action steps for states to begin to address overtreatment
  • 3. Three Overarching Quality Challenges
    • Underuse
    • Misuse
    • Overuse
    • Source: Institute of Medicine, National Roundtable on Quality, 1998
  • 4. Underuse Defined
    • Underuse : the failure to provide a health care service when it would have produced a favorable outcome for a patient.
    • Example: missing a childhood immunization for measles or polio is an example of underuse.
    • Health care reform will reduce underuse of essential services
    • Source: Institute of Medicine, National Roundtable on Quality, 1998
  • 5. Misuse Defined
    • Misuse : when an appropriate service has been provided but a preventable complication has occurred.
    • Example: a patient who suffers a rash after receiving penicillin for strep throat despite having a known allergy to that antibiotic is an example of misuse.
    • Source: Institute of Medicine, National Roundtable on Quality, 1998
  • 6. The Impact of Misuse
    • In 1999, the Institute of Medicine report, To Err is Human, estimated 44,000 – 98,000 deaths from preventable harm each year
    • The CDC estimates 99,000 deaths from hospital-acquired infections each year
  • 7.  
  • 8.  
  • 9.  
  • 10.  
  • 11. Overuse Defined
    • Overuse: when the potential for harm of a health care service exceeds the possible benefit.
    • Source: Institute of Medicine, National Roundtable on Quality, 1998
  • 12.
    • “ I was troubled to read that the President's physical examination included an electron beam computed tomographic (CT) scan for coronary calcium. This screening test likely exposed Mr. Obama to significant radiation unnecessarily, increasing his risk of future cancer…
    • … A single electron beam CT scan is estimated to result in a lifetime excess cancer risk of 9 additional cancers per 100 000 persons for men.
    • Dr. Rita Redberg, Editor
    • Archives of Internal Medicine
    • March 8, 2010
    • http://archinte.ama- assn.org/ cgi/content/full/2010.81?home
  • 13. Commonwealth Fund Survey
    • 32% of people surveyed for a Commonwealth Fund report said they have had medical care they thought was unnecessary
    • Source: Sabrina How, et al, “Public View on U.S. Health System Organization: A Call for New Directions,” The Commonwealth Fund, Data Brief, August 2008 p. 4.
  • 14. Two Questions For You
    • Have you or someone you know had medical care that you/they thought was unnecessary?
    • Have you or someone you know declined treatment recom-mendations because they were too invasive, and found a medically appropriate, less intensive alternative?
  • 15.
    • “ I’ve been getting an EKG at my annual physical exam since I was 27. I’m 41 now. I don’t know why. I have no heart disease. My husband gets one, too.”
  • 16.
    • “ My knees were hurting and I went to a well-known orthopedic surgeon. He said he could do surgery. He didn’t talk about me or my situation. I left and found a personal trainer who helped me strengthen my muscles. I’m much better now.”
  • 17.
    • “ My 83-year old mother-in-law was having problems with her shoulder. She went to a doctor who said he could operate. I went with her to get a second opinion. With physical therapy and time for healing, she was fine.”
  • 18.
    • Share your story:
    • A partnership with Consumers Union
    • Safe Patient Project
    • www.treatmenttrap.org
  • 19.
    • For the first time, a subset of the population is saying “no” to medical care, not cavalierly but in an informed and thoughtful way.
  • 20.
    • Where to begin to curb overuse?
  • 21. National Priorities Partnership: A Roadmap to Begin
    • Overuse is one of the six priorities of the National Priorities Partnership which was convened by the National Quality Forum
    • Source: National Priorities and Goals, National Priorities Partnership, November 2008. www.nationalprioritiespartnership.org.
  • 22. National Priorities Partnership: Areas to Reduce Overuse
    • Medication use especially antibiotics and multiple drugs prescribed for a patient
    • Lab tests
    • C-sections
    • Diagnostic imaging, CT scans, x-rays
  • 23. National Priorities Partnership: Areas to Reduce Overuse
    • Non-palliative services at the end of life
    • Unnecessary doctor office visits
    • Preventable ED visits/hospitalizations
    • Potentially harmful preventive services
  • 24. National Priorities Partnership: Procedures That Are Overused
    • Procedures that are overused include:
    • * heart bypass surgery
    • * hysterectomy
    • * spine surgery
    • * prostatectomy
  • 25. National Priorities Partnership: Procedures That Are Overused
    • What are examples of the literature on which the identification of overused tests, surgeries and other services is based?
  • 26. Research on Heart Bypass Surgery
    • An expert panel of physicians convened by Rand and the Harvard School of Public Health reviewed the angiograms of patients who were recommended for heart bypass surgery.
    • One-third of the patients who were recommended for heart bypass surgery did not need it.
    • Source: Leape, Lucian, et al., “Effect of Variability in the Interpretation of Coronary Angiograms on the Appropriateness of use of coronary Revascularization Procedures, American Heart Journal, vol 139, no 1, part 1, January 2000, 111.
  • 27. Overuse of Ear Tube Surgery in Children
    • Nearly 70% of ear tube surgeries studied at a five hospital cohort were found to have been performed on children whose condition did not meet criteria for surgery set by the American Academy of Pediatrics.
    • Source: Salomeh Keyhani, et al., “Overuse of Tympanostomy Tubes in New York Metropolitan Area: Evidence from Five Hospital Cohort,” British Medical Journal, vol 337, 2008 1607. See also Salomeh, Keyhani, et al, “Clinical Characteristics of New York City children Who Received Tympanostomy Tubes, in 2002,” Pediatrics, vol 121, no 1, 24-33.
  • 28. Outcomes from Back Surgery Among Workers’ Compensation Patients
    • 725 patients with low back pain had pain mgmt and physical therapy
    • Return-to-work status at 2 years: 67%
    • Days off of work: 316
    • Source: Nguyen, T. et al, “Long-Term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects, Spine , August 2010.
    • 725 patients with low back pain who had spine surgery
    • Return to work status at 2 years: 26%
    • Days off of work: 1140
    • 27% re-operation rate
  • 29. New Study Findings on End-of-Life Care
    • New England Journal of Medicine published a landmark study of patients with metastatic lung cancer
    • Patients who received early palliative care and less aggressive treatment lived 2.7 months longer than patients who received usual oncology care.
    • Source: Temel JS et al., “Early palliative care for patients with metastatic non-small-cell lung cancer, NEJM, 2010: 363:733-742. http://www.nejm.org/doi/full/10/1056/NEJMoa1000678 .
  • 30. Recent Events in Raising Awareness About Overuse
    • The Archives of Internal Medicine published by the AMA has started a series, “Less is More” that reports evidence of overtreatment.
    • They will start a series on patient experience of overtreatment.
    • The American Board of Internal Medicine Foundation has a Task Force on Stewardship of Resources
  • 31. Recent Events cont’d
    • The Radiological Society of N. America has called for a national plan to reduce diagnostic imaging.
    • Source: http://radiology.rsna.org/content/early/2010/08/05/radiol.10100063.abstract
  • 32. National Cancer Institute Study of CT scans
    • 70 million CT scans performed in 2007 will cause 29,000 cancers in Americans and 15,000 deaths.
    • Two thirds of the projected cancers will occur in women.
    • Source: Archives of Internal Medicine, 2009
  • 33. Recent Events cont’d
    • Hospital Compare is now reporting 4 measures of appropriate use of diagnostic imaging
    • 2 measures address overuse of abdominal and chest CT scans
  • 34. Recent Events
    • “ Top 5” Project underway by the National Physician Alliance
    • It asks the question of primary care physicians: what are the top 5 things we should stop doing in primary care?
    • Plan is to spread to other medical specialties
  • 35. Factors Contributing to Overtreatment
    • Uncertainty
    • Belief
    • Enthusiasm
    • Fear/Liability
    • Peers
    • Knowledge
    • Financial incentive
    • Patient expectation
  • 36. What A Health Care Insider Says About Overuse
    • “ Health insurance used to be about giving patients access to providers. Now it’s about giving providers access to patients.”
    • Dean of a Midwest nursing school.
  • 37.
    • One way to communicate to patients and the public about overuse:
  • 38. What is Overuse?
  • 39. Green Light
    • Treatment you absolutely want to get
  • 40. Yellow Light
    • Mammograms for women in their 40s
    • Should I or shouldn’t I?
    • Reasonable people will weigh the risks and benefits differently based on medical history, tolerance for risk, etc.
  • 41. Red Light
    • Treatment you don’t want to get because the possibility of harm exceeds the potential benefit.
  • 42. Strategies for Change
    • A problem cannot be fixed unless we talk about it: ask yourself, friends and colleagues these two questions:
    • Have you had medical care you thought was unnecessary?
    • Have you declined recommendations and found a less intensive, medically appropriate alternative?
  • 43. Public Reporting of Outpatient Imaging
    • Can states begin to report CMS measures that are publicly reported for Medicare beneficiaries on outpatient diagnostic imaging?
    • An example of one measure is: outpatient CT scans of the abdomen -- use of contrast material
    • The ratio of CT abdomen studies that are performed both with/without contrast out of all CT abdomen studies performed (those with contrast, those without contrast, and those with both).
  • 44. Establish a Registry for Selected Surgeries
    • Can states begin a voluntary registry that tracks the outcomes of selected procedures?
    • Benefits: offers the opportunity for learning what works in an environment transparent to other clinicians
    • Areas to focus: back, knee and hip surgery
  • 45.  
  • 46.
    • Contact:
    • [email_address]
    • www.treatmenttrap.org