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From Overtreatment to From Overtreatment to Patient-Centered CarePatient-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
Overview of Presentation 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
Three Overarching Three Overarching Quality Challenges Quality Challenges
Underuse
Misuse
Overuse Source: Institute of Medicine, National Roundtable on Quality, 1998
Underuse DefinedUnderuse 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
Misuse Defined 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
The Impact of Misuse 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
Overuse Defined 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
“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, EditorDr. Rita Redberg, EditorArchives of Internal Medicine Archives of Internal Medicine March 8, 2010March 8, 2010
http://archinte.ama-http://archinte.ama-assn.org/assn.org/ cgi/content/full/2010.81?home cgi/content/full/2010.81?home
Commonwealth Fund SurveyCommonwealth 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.
Two Questions For YouTwo 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?
“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.”
“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.”
“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.”
Share your story:
A partnership with Consumers Union
Safe Patient Project
www.treatmenttrap.org
For the first time, a subset of the population is saying “no” to medical care, not cavalierly but in an informed and thoughtful way.
Where to begin to curb
overuse?
National Priorities Partnership: National Priorities Partnership: A Roadmap to Begin 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.
National Priorities Partnership:National Priorities Partnership:Areas to Reduce OveruseAreas to Reduce Overuse
Medication use especially antibiotics and multiple drugs prescribed for a patient
Lab tests C-sections Diagnostic imaging, CT scans,
x-rays
National Priorities Partnership:National Priorities Partnership:Areas to Reduce OveruseAreas to Reduce Overuse
Non-palliative services at the end of life
Unnecessary doctor office visits Preventable ED
visits/hospitalizations Potentially harmful preventive
services
National Priorities Partnership:National Priorities Partnership:Procedures That Are Overused Procedures That Are Overused
Procedures that are overused include:
* heart bypass surgery
* hysterectomy
* spine surgery
* prostatectomy
National Priorities Partnership:National Priorities Partnership:Procedures That Are Overused Procedures That Are Overused
What are examples of the literature on which the identification of overused tests, surgeries and other services is based?
Research on Heart Bypass Surgery 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.
Overuse of Ear Tube Overuse of Ear Tube Surgery in Children 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.
Outcomes from Back Surgery Among Workers’ Compensation Patients
725 patients with low back 725 patients with low back pain had pain mgmt and pain had pain mgmt and physical therapyphysical therapy
Return-to-work status at 2 Return-to-work status at 2 years: 67%years: 67%
Days off of work: 316Days off of work: 316
Source: Nguyen, T. et al, “Long-Term Outcomes of Source: Nguyen, T. et al, “Long-Term Outcomes of Lumbar Fusion Among Workers’ Compensation Lumbar Fusion Among Workers’ Compensation Subjects, Subjects, SpineSpine, August 2010. , August 2010.
725 patients with low back 725 patients with low back pain who had spine pain who had spine surgery surgery
Return to work status at 2 Return to work status at 2 years: 26%years: 26%
Days off of work: 1140Days off of work: 1140
27% re-operation rate27% re-operation rate
New Study Findings on New Study Findings on End-of-Life CareEnd-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.
Recent Events in Raising Recent Events in Raising Awareness About Overuse 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
Recent Events cont’dRecent 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
National Cancer Institute National Cancer Institute Study of CT scansStudy 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
Recent Events cont’dRecent 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
Recent Events 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
Factors Contributing Factors Contributing to Overtreatmentto Overtreatment
Uncertainty Belief Enthusiasm Fear/Liability Peers Knowledge Financial incentive Patient expectation
What A Health Care Insider What A Health Care Insider Says About OveruseSays 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.
One way to communicate to patients and the public about overuse:
What is Overuse?What is Overuse?
Green LightGreen Light
Treatment you absolutely want to get
Yellow LightYellow 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.
Red LightRed Light
Treatment you don’t want to get because the possibility of harm exceeds the potential benefit.
Strategies for ChangeStrategies 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?
Public Reporting of Public Reporting of Outpatient ImagingOutpatient 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).
Establish a Registry for Establish a Registry for Selected Surgeries 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
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