The Do No Harm Project Brandon Combs, MD & Tanner Caverly, MD, MPH Origins –  Harms from overuse occur frequently but clinicians fail to recognize –  Our goals: 1) promote recogni?on of harms from overuse 2) foster local discussions 3) change local culture Which scenario probably represents medical overuse? A.  Pre-­‐opera?ve tes?ng prior to cataract surgery in a pa?ent who feels well B.  Using insulin to decrease A1C from 7.9 to 6.5 in an elderly pa?ent with type 2 diabetes C.  Prescribing TMP/Sulfa for UTI in a pa?ent with a sulfa allergy D.  Avoiding low dose chest CT for lung cancer screening in an otherwise well 65 year old, 50 pk yr smoker E.  A & B F.  A, B, & D G.  These all represent overuse How overuse may manifest •  OvertesBng – when benefit of test is nil and likely outweighed by risks (pap aYer hysterectomy for benign dz) •  Overdiagnosis – diagnosing "pseudo-­‐
disease” (screen detected prostate ca in elderly) •  Overtreatment – trea?ng pseudo-­‐disease harm (bisphosphonate for osteopenia) •  Preference misdiagnosis – trea?ng/tes?ng a pa?ent who if fully informed would decline the service (regret aYer atypical femoral fx) Why does overuse maCer? •  Harm is the only possible outcome e.g. for every 1000 20 year old women who have unnecessary (or necessary) CTPE, about three will develop cancer as a result •  We have an ethical obliga?on to avoid unnecessary harm •  It’s wasteful! Ins?tute of Medicine 2012. “Best Care at Lowest Cost: The Path to Con?nuously Learning Healthcare in America.” Accessed April 30, 2013. hcp://www.iom.edu/bestcare Wait, how much?! 1/3 of the pie WASTED 1/4 of this waste OVERUSE $210 More on why it maCers. Easy to ignore – harms may be downstream or counterintui?ve e.g. harm from prostatectomy 2 yrs a8er PSA detected cancer Labels – pa?ents do worse when told they are sick Lots to diagnose with good prognosis if leY alone e.g. 70% of men > 70 yrs have occult prostate cancer Coley CM, Barry MJ, Fleming C, Mulley AG. Early detec?on of prostate cancer. I. Prior probability and effec?veness of tests. Ann Intern Med 1997;126:394-­‐406 What we are looking for •  Clinical vigneces about 1) overuse resul?ng in harm or harm that was narrowly avoided; or 2) misdiagnosis of pa?ent preferences that subsequently led to overuse and harm, or harm that was narrowly avoided. •  Emphasize importance of doing “as much as possible for the pa?ent and as licle as possible to the pa?ent” Lown, Bernard. Social Responsibility of Physicians (Essay 29). Avoiding Avoidable Care Conference: April 26, 2012 Requirements Authors: 3 or fewer. The first author must be a trainee (professional student, intern, resident, fellow, masters or doctoral student, or post-­‐doctoral student). Format: 600-­‐800 words, including a clinical vignece headed “Story from the Front Lines” (an engaging story with enough clinical informa?on for readers to understand the clinical issues) and a summary of the clinical issues headed “Teachable Moment” (succinct summary of the clinical issues, sta?ng the evidence for overuse and sugges?ng an alterna?ve approach). References: 5 or fewer. Reasons to parBcipate •  $$ prizes for best vigneces on quarterly/annual basis (Colorado ACP). •  Housestaff comple?ng a submission receive a copy of Overdiagnosed, Making People Sick in the Pursuit of Health •  Completed submissions posted online for viewing by your peers. •  Cases are PERFECT for poster presenta?ons, fulfill scholarly requirement. Your peers have presented cases at regional and na?onal conferences. •  GET PUBLISHED – Teachable Moments, JAMA Internal Medicine – So far: Meredith Neiss, Pai Liu, Shelby Badani, Mysha Mason Narra?ves wri/en by trainees describing: (1)unnecessary care resul?ng in harm or harm that was narrowly avoided or (2) the misdiagnosis of pa?ent preferences that subsequently led to unnecessary care and harm or harm that was narrowly avoided. Manuscripts should be 600-­‐800 words, provide a clinical vignece that documents overuse of medical care, and a summary of the evidence that documents the care provided was unnecessary. LogisBcs •  Send a one liner first week [rotaBon] to [email of local champion] •  If case approved, CMR arranges wri?ng day •  Case due end of wri?ng day •  Get an acending involved! •  Revisions completed within 1 month •  Final case published to website, entered into compe??on •  Submit for publica?on in JAMA IM (consent required) THANK YOU! TwiCer: @DoNoHarmProject Website h/p://www.medschool.ucdenver.edu/gim/donoharmproject