ChoosingwiselyWorkshop1– ESIM2017RigaYoungInternists– Mikko Parry,HelsinkiFinland

Whatdoyoumean– Choosingwisely?

Initiallyaniniative ofAbimNowspreadingalltheworld…even reaching remote locationssuch asFinland

Aim:toreduce costs andharm andrationally focus limited resources

Fromguidelinesto“avoidlines”

Shortstatementsofwhatnottodowithashortmotivationandreferencestohighqualitypapers

Understandableforbothprofessionalsaswellaspatients

Examples…

Keypoints

InvolvethepatientinmakingdecisionabouttheirhealthProvidingpatientswiththenecessarybackgroundinformationaidscommunication

AvoidUnnecessaryscreeningUselessorevenharmfultreatments

Isthisarealproblem?

Isthisarealproblem?

Doesyourpatientbelievewhatyousay?

Youarethetrainedprofessional!

Motivateanddiscussyourdecicions withyourpatient!

Donotmakedecisionsthatyoucan’tstandbehind!

Whydon’twechoosewisely?

Whatfactorsaffectyourdecisions?

TimeofdaySituationathomeStressPatientrelatedfactors

Isthepatientannoying?Howarethesymptomspresented?

Haveyouhadasimilarcasewithadismaloutcome?Unrealisitic expectations

Humanbehaviour isirrational

KnowthelimitationsofyourthinkingWetendtooverestimatethepossibilityoftheunlikelybutpotentiallyseriouseventsThewaydataispresentedaffectsthewayitisinterpreted

Wetendtooversimplifycomplexproblemsandrushintoconclusions

Howcanyouimproveyourthinkingandhabits?

Educateyourself,yourstaffandyourpatientsPeercomparisondiminishedunnecessaryantibioticprescriptionsforflufrom19.9%to3.7%

Inthefuturecomputerbasedthinkingaids?

Brainstorm…

Whatdoyoucurrentlyknowaboutthetopic?

Whatwouldyouliketoknowbetter?

Howcouldyouusetheseconceptsinyourdailyprofession?

HowcouldyouinvolveyourpatientsindecidingontheirtreatmentMakingtogether,thepatientstillis99.95%ofthetimealonewithhisdiseaseandinchargeofthetreatment

Groupwork

Familiarizeyourselveswiththecase

ApplytheconceptsofchoosingwiselyTrytojustifythedecisionsmade.

Wouldyoudosomethingdifferently?Why?

Presentthecasetotheothergroupsfordiscussion5+5min/case

Case1– Atrialfibrillation

JonathanSmithis64yearsold.Hehasbeenpreviouslywellanddoesn’ttakeanymedicationonregularbasis.Hehasbeenactivelypracticingendurancesports,suchasfinishing20fulllengthmarathonsinthepastyears.Henowpresentstotheemergencyroomwithnewlyonsetatrialfibrillationwithaventricularrateof110-127.HisBPis160/90mmHg.Hehasminorchestdiscomfort,nodyspnea.Hislaboratorytestsareasfollows:

JasminAnoschkin

Hb 142g/l (134-167g/l)Na 140mmol/l (137-145mmol/l)K 3.6mmol/l (3.3-4.9mmol/l)Creatinine 87mmol/l (60-100umol/l)Troponin T 27ng/l (<15ng/l)NT-BNP 500ng/l (<194ng/l)

Questionsfordiscussion:HowshouldwetreatMrSmith?

WhatkindofadviceshouldwegivehimforthenextoccasionofAF?Thinkabouthowtoimprovetheoverallworkflowwithsuchpatients

DoesthepatienthaveNSTEMI?ShouldweroutinelyassesstroponinorBNPlevelsofpatientswithnewlyonsetAF?

KeypointsCase1– AF

History:onsetofAF?48hoursLess48:?rateorrhythmECHO?Anticoagulation:CHADVASc 1

?comorbiditiesthatwearenotawareofNoheartdefectfleicaide

Advice:anythingthatinducedAF?ethanolabuse,hyperthyroidismNoindicationfortroponinorBNP

Case2– UTIandantibiotics

MrsTheresaSmithis84yearsold.Shelivesathomewithregularvisitsofhomecarenurses3timesaday.Shehasamedicalhistoryofarterialhypertension,hypercholesterolemia,hypothyroidism,osteoarthritisandosteoporosis.She’sonaregularmedicationincludinglosartan100mgx1,Bisoprolol 2.5mgx1,Furosemide20mgx2,Atorvastatin20mgx1,Thyroidhormonereplacement0.1mgx1,Acetosalicylic acid100mgx1,Zopiclone 7.5mgx1,Paracetamol1000mgx2-3andAlendronate70mgaweek.

Nowshecametohospitalinthenightafteralertinghernursesbecauseshefelloutofbedandcouldn’tgetup.Shewasexaminedinbed.ShewasfoundtobeafebrilewithaBPof160/90,pulseregular82,notendernessorpalpablemassesintheabdomen.Asmallbruiseonherleftthigh.Asystolicmurmurovertheaorticarchandaudibleoverhercarotidsalreadymentionedin2014duringaregularfollowup.Otherwisenothingremarkable.

Laboratorytests:Hb 117g/l (117-155g/l)CRP 8mg/l (<10mg/l)WBC 8x109/l (3.4-8.2x109/l)Na 132mmol/l (137-145mmol/l)K 3.2mmol/l (3.3-4.9mmol/l)U-dipstickLeuc+,Urinaryanalysispositiveforg- coliformbacteria

Questionsfordiscussion:Shouldweroutinelyscreenforurinaryinfectionin

thissortofpatients?Shouldshebetreatedurinaryinfection?

Whataretherisksandbenefits?Doessheneedanechocardiogram?

Howcouldweimprovetheworkflowoftakingcareoftheincreasingnumberofelderlypeoplestilllivingintheirhomesandinfrequentneedofmedicalconsultation?

JasminAnoschkin

KeypointsCase2– UTI

DonotroutinelyscreenasymptomaticpatientsNoECHOnecessaryiftheresultdoesn’taffecttreatmentAvoidoverdiagnostics infrailelderly

Case3– DVTandPE

MrJamesSmith(62yo)fromNewHampshirewasluckyenoughtowin30000€onEuroJackpot.Hedecidedtofulfilhislong-timedreamoftravelingaroundtheworld.This,however,iswhereherunoutofluckandhadtobetakenintohospitalinHelsinkionhiswaybackfromJapanbecauseofshortnessofbreathandaswollenthigh.

Uponpresentation,hehadarespiratoryrateof34/minwithanoxygensaturationof88%breathingambientair.OnECGhehadsinustachycardia of100bpm,invertedT-wavesontheprecordialleadsV1-V3,nowideningoftheQRScomplex.HisBPwas140/70mmHg.Bedsideechocardiographyshowedamildlydilatedrightventriclewithatricuspidvalvegradientof60mmHg.Noevidentthrombuscouldbevisualizedintheheartchambers.ThediagnosisofPEwassupportedbyanelevatedd-dimerof13.4mg/l(<0.5mg/l)andconfirmedbysubsequentCT-angiographyofthepulmonaryvasculature.

Questionsfordiscussion:Shouldhereceivethrombolysis?Wasthed-dimertestnecessaryinthediagnostics?

Whatquestiondoesthetestanswer?Isitsensitive?Isitspecific?Whenshouldweuseit?

JasminAnoschkin

KeypointsCase3– DVTandPE

NoindicationforthrombolysisHighriskpatientD-dimernotnecessaryinhighriskcases->CTneededirrespectiveofresultAnticoagulation6monthsRepeatECHOpriortodiscontinuation

Case4– VictimOfMedicalImagingTechnology

MrsEmilySmithis57yearsoldandhasbeentakingRamipril5mgx1formildlyelevatedbloodpressuretogetherwithoestrogenreplacementtherapyformenopausalsymptoms.MrsSmith’sbrothershadnotbeentoowelllatelyandhadtoreceivemedicalattentionduetoatrialfibrillationandpulmonaryembolism.ThismadeMrsSmithquiteanxiousandsoonafterhearingaboutherbrother’shospitalizationinFinland,shestartedhavingpalpitations,shortnessofbreathespeciallyintheeveningswhenlyingdown,withnocorrelationtoexercise.ShepresentedtotheemergencywitharestingBPof150/80,p67BPM,nosignsofischemiaonECG.Spo297%breathingambientair.

Herbloodtestswereasfollows:Hb 137g/l (117-155g/l)WBC8.2x109/l (3.4-8.2x109/l)Na140mmol/l (137-145mmol/l)K4.2mmol/l (3.3-4.9mmol/l)Creatinine87umol/l (50-90umol/l)D-dimer0.9 (<0.5mg/l)

BecauseofthemildlyelevatedD-dimerapulmonaryCTangiographywasperformed.Inthestudy,pulmonaryembolismwasruledout.Anexpansionof2.2x1.4cmwashowevernotedinherrightadrenalgland.Theapplicationofcontrastmediumfortheangiographypreventeddiagnosingthisexpansionbenignbasedonthefirststudy.

Questionsfordiscussion:Whathappensnext?Howcouldwehavepreventedthisscenario?

Shouldwehavepreventedthisscenario?

JasminAnoschkin

KeypointsCase4– VOMIT

Nosuspicionofpulmonaryembolism;noD-dimerorCTscan

Incidentaloma:ActiveorinactiveMalignantorBenign

->Assesshormonelevels,doafocusednativeCT

Case5– Screeningforcancer

MrJohnSmithisnow82yearsold.HehadaPSAscreen12yearsagoafterreadingaboutayoungmaninexcruciatingagonymetastasisedcancerinthenewspaper.HisGPfirstexaminedtheprostateclinicallywithoutanythingsuspicious.HisPSAwasmildlyelevated(8ug/l,ref.<6.5ug/l),15%unbound.Thus,hewasreferredtoseeaurologist.Transrectal biopsyoftheprostatewasperformedwithanormalhistologyasresult.LateragoodfriendofhiswasdiagnosedwithprostatecancerandMrSmiththoughtthatitwouldbewisehe’dhaveanothercheck.HisPSAcontinuedrisingandhadnowreachedalevelof9ug/lwithafreefractiondecreasedto9%.AfterdiscussingwithhisGP,theydecidedtogoforanotherbiopsy.Thistimediagnosedtobelocal,notgrowingthroughtheprostaticcapsule.TheGleasonscorewas6.

AfterdiscussingtheprognosisofthislowriskcancerMrSmithdecidednottohaveanytreatmentforthediseaseatthisstage.ThistimehoweverMrSmithbecamefebrileaweekafterthebiopsyandtestedpositiveforenterococcusfaecalis inbloodcultures.Heneededtreatmentwithbroad-spectrumantibioticsforseveralweeksandunderwentmanyrule-outstudiessuchasTEEtoscreenforbacterialendocarditis.

Questionsfordiscussion:Shouldweroutinelyscreenforcancer?Whatcriteriacanyounameforagoodscreeningtest?

JasminAnoschkin

KeypointsCase5– Cancerscreening

PSAscreeninghasnotshowntodecreasemortality

Sensitivityvs.specificityvs.priceYouneedtobeabletoimproveoutcomebyearlydetection

Summingitup

Alwaysthink,thinkandthink• Doesthismakesense?• WhyamIdoingthis?

Atthecenterstandsthepatient!

Don’tunderestimateyourpowerinaffectingyourclinic• Youarethefutureboss!