Finite Resources and Health Care:
Choosing Wisely
Royal College of Physicians and Surgeons of Canada
December 2, 2013
Wendy Levinson, MD
Objectives
1. To present the case for managing finite resources
2. To demonstrate why and how physicians should
lead the management of finite resources
3. To consider the implications for medical education
Total health expenditures as a percentage of gross
domestic product (1970-2011)
Germany
U.K.
Canada
Japan
U.S.
1970
1980
1990
2000
2008
2011
OECD, 2013
Berwick D. JAMA. 2012.
Studies of overuse
Service
Condition(s)
No. of Studies
Range of Overuse
Rates, %
(2000–2009)
Coronary angiography
MI, CAD
17
8.0 – 21.8
Coronary
revascularization
CAD
16
1.4 – 14.0
Upper endoscopy
Bleeding (upper),
PUD
7
19.0 – 23.0
Bronchiolitis, asthma
5
32.0 – 72.0
Colon CA
4
23.0 – 60.8
Antibiotics
URI, acute bronchitis
59
2.0 – 89.0
Bronchodilators
Obstructive diseases
6
30.0 – 81.0
Radiographs in acute
respiratory illnesses
Colonoscopy
Korenstein D. Arch Intern Med. 2012.
Physicians determine care
1. Which patients are seen and how frequently
2. Which patients are hospitalized
3. Which tests, procedures and surgical
operations are administered
4. Which technologies are used
5. Which medications are prescribed
Emanuel EJ. JAMA. 2013.
I’ve always
done this
Patients
want it
New tests
are good
$$
Fear of
litigation
Easier to
order than
discuss
Referring
doctor wants
it
Better to get a
test than “do
nothing”
“We – physicians – are the only people
that can get health care costs under
control”.
- Zeke Emanuel
“Somebody has to do something, and it's
just incredibly pathetic that it has to be
us”.
- Jerry Garcia
A campaign to help physicians and patients
engage in conversations about the overuse of
tests and procedures and support physician
efforts to help patients make smart and
effective care choices.
First 9 – now 60 societies
www.consumerhealthchoices.org
Physician
Consumer
Media
Societies develop
lists
Consumer groups
to adapt Consumer
Report materials
Coordinated
release of lists
Disseminate to
physician leaders
Disseminate
Medical
Schools
Curriculum
development
(undergrad,
postgrad, faculty)
Medical societies – April 2014 launch
•
•
•
•
•
•
•
•
Canadian Cardiovascular Society
Canadian Association of Radiologists
CMA GP and Family Practice
Canadian Orthopaedics Association
Canadian Society for Internal Medicine
Canadian Rheumatology Association
Canadian Geriatrics Society
Canadian Association of General Surgeons
Implications for medical education
www.teachingvalue.org
How we
are taught
Patients
want it
New tests
are good
Preemptive
ordering
Lack of
feedback
Demonstrate
thoroughness
Better to get
a test than
“do nothing”
Residents are interested in improving
efficiency
•
Treatment of asymptomatic bacteriuria and use
of urine cultures
•
Rbc and serum folate levels for folate deficiency
•
EPO Hg > 125
Stuebing EA. Arch Surg. 2011.
Training environment and conservative
management
100
90
80
Mean
Conservative
Management
Score
(percentile)
70
60
54%
45%
50
40
30
20
10
0
Lowest (1)
2
3
4
Highest (5)
Quintile of intensity (visits/last 6 months of life) , HRR
p=0.002
Discussion
1.
Developing curriculum for students, residents, and
faculty
2.
Opportunity to set standards for training
(website)
www.choosingwiselycanada.org
(Twitter)
ChooseWiselyCA
https://twitter.com/ChooseWiselyCA