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Tue, Aug 8 8:00am · Proposed research agenda--Address disparities for young thyroid cancer patients

In 2013, the television show host from HGTV’s Flip or Flop, Tarek El Moussa, received a concerned email from a fan of the show. The email came from an experienced registered nurse to tell him that while watching the show she noticed a lump in the front of his throat and was extremely concerned the star may have thyroid cancer. She urged the star to see a doctor and get a thyroid biopsy. Thankfully, the star heeded her advice, as she was indeed correct and he was diagnosed with thyroid cancer that had already spread to lymph nodes. Shortly thereafter, the host underwent treatment for thyroid cancer; four years later he is in remission. At the time of diagnosis, he was 31.

According to the American Cancer Society, the most common group diagnosed with thyroid cancer is 45-54 year olds, affecting three times more women than men. Thyroid cancer accounts for 3.4 percent of all cancers and will result in about 2,010 deaths this year, and is the most common cancer in young Americans (age 16-33); the very age group in which El Moussa was at the time of diagnosis.

The high prevalence of thyroid cancer in adolescent and young adults provides the impetus for an understanding of the specific challenges this population experiences in receiving care. Researchers at Mayo Clinic, along with external collaborators, reviewed the epidemiology and challenges of thyroid cancer care among young people, and proposed a research agenda to improve their care in a recent special report in Future Oncology.

J.P. Brito Campana, M.D., M.Sc.

Senior author and endocrinologist, J.P. Brito Campana, M.D., explains, “Adolescent and young adults with thyroid cancer face challenges including overdiagnosis, reduced access to health care and inconsistent care. Successful treatment of these patients results in additional challenges, due to ongoing side effects of treatment, as well as lasting impacts on their quality of life.”

For example, inconsistent care is partially a byproduct of a shortage of pediatric endocrinologists available to care for adolescents or young adults with thyroid cancer; leading to treatment by a physician inexperienced in treating this age group. Care disparities for younger patients also can exist because this age group tends to be more financially unstable, which coupled with complex insurance barriers, can result in fragmented and expensive care. Young adults are more likely to experience bankruptcy than their counterparts without cancer due to the high cost of treatment and survivorship care. Side effects of treatment are also problematic: those that receive radiation treatment are placed at increased risk of secondary cancers such as leukemia and salivary cancer.

Given the prevalence of thyroid cancer in adolescent and young adults, one would assume that the field would be saturated with research focused on understanding this population, but Dr. Brito Campana explains, “Information about thyroid cancer in adolescent and young adults is remarkably sparse. Indeed, a literature search resulted in only 19 papers, which strongly suggests that the burden of thyroid cancer in this population has not been adequately studied.”

Dr. Brito Campana and his colleagues believe these challenges and lack of applicable research should fuel a collaborative research agenda aimed at improving the quality of care for adolescent and young adults with thyroid cancer across the spectrum of diagnosis, treatment and survivorship.

The research team urges their research colleagues to:

  • Study the impact of over and under diagnosis and factors related to increased incidence;
  • Identify socioeconomic factors and disease specific characteristics influencing access to care; and
  • Conduct effectiveness and pharmacovigilance research, promote appropriate referral and treatment, create and support a robust research infrastructure.

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Related Mayo Clinic resources:

Wed, Jun 7 8:00am · Multiple chronic conditions may be worse than previously suspected, especially for stroke patients

Are you tired of hearing about “chronic conditions” that affect every aspect of your health as well as your longevity? These difficult-to-manage diseases—some brought on by natural causes, others influenced by our behavior— interfere with our ability to enjoy life, and so we must address them. For example, coronary artery disease, congestive heart failure, high cholesterol, cancer, diabetes, cardiac arrhythmia, and arthritis are all chronic diseases. They take time, money, appointments, medications, and sometimes medical procedures, to manage; and ultimately require a change in lifestyle and adherence to suggested treatment regimen(s).

M. Yousufuddin, M.D., lead author.

Copious amounts of research have shown how these diseases shorten life expectancy. New research on the topic was recently published by researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.  Led by M. Yousufuddin, M.D., a hospitalist at the Mayo Health System and Hassan Murad, M.D., preventive medicine specialist and health services researcher at Mayo Clinic, the team sought to determine the prevalence of coexisting chronic conditions in hospitalized patients who had suffered a stroke or transient ischemic attack (TIA), and the association of these conditions with 30-day mortality and readmission.

Statistics collected by the American Heart Association show that stroke is a lead cause of hospitalization, long-term disability, and death; and is closely linked with several other diseases and conditions.

The Mayo team looked at patients admitted to the hospital with a stroke or TIA, who had pre-existing heart failure, cardiac arrhythmia, coronary artery disease, cancer, or diabetes. They found that the presence of any one of these contributed to higher odds of death within 30 days. Additionally, patients with cancer, arthritis or coronary artery disease had higher odds of a readmission within 30 days.

M. Hassan Murad, M.D., senior author.

Dr. Murad says, “Our results highlight and justify the public health concern about chronic conditions.”

“In addition to treating the stroke or TIA for which the patient was admitted, health care providers need to work with their patients to quickly address and optimally manage other chronic underlying conditions,” he says. “This could prevent untimely death or readmission following a stroke or TIA.”

Does preemptive management of these conditions with life style interventions and best medical therapy reduces the mortality and morbidity of associated stroke? We don’t know for sure, but it is plausible.

We must not think that since chronic conditions are so common it is ok to be lax in their management. Nor should we believe that nothing more can be done to promote health and well-being. Rather, as patients and providers, we must work tirelessly to manage these conditions and take back control of our health and ultimately our lives.

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Thu, Apr 20 8:00am · Economies of scale: volume in health care

The concept is simple, if you perform the same procedure over and over; day in and day out, you tend to do it better, quicker, and safer than your counterpart who has only done it a few times, or infrequently. It’s referred to in other lines of work as “economies of scale.” The application of this concept dates back to Henry Ford and his novel use of this concept in the assembly line. However, unlike the assembly line with the ability to easily distinguish how many cars are generated, and the uniform safety of those cars and parts, health care still struggles to define these measures.

Researchers at the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, working with several clinical departments, have been finding that hospitals that perform the same procedure or treat the same condition repeatedly do it better than those who treat relatively few of the same condition or procedure. Increasing evidence also shows this relationship for some non-surgical therapies as well. There are better outcomes for patients, fewer complications, which translates into shorter length of stay, decreased mortality and increased survival just to name a few.

Under the direction of Sean Dowdy, M.D., a gynecologic surgeon and chair of the division of Gynecologic Surgery at Mayo Clinic, a team of researchers from Mayo Clinic’s Department of Obstetrics and Gynecology and the center studied this very issue. They published a paper in Obstetrics & Gynecology showing that despite clear guidelines to performing minimally invasive surgery for stage I-III endometrial cancer, this approach is only performed in a small portion of patients. Women are less likely to receive the accepted standard of care when performed at hospitals that treated the fewest of these patients.

Additionally, Ronald Go, M.D., a hematologist-oncologist published a paper in Cancer that showed non-Hodgkin lymphoma and a paper in the Journal of Clinical Oncology multiple myeloma patients treated at higher volume facilities may survive longer than those treated at lower volume facilities and have lower mortality, respectively.

Jeff Karnes, M.D., discussing options with a patient.

Another example of this is highlighted by the recent publication in Journal of Urology authored by Jeff Karnes, M.D., a urologic surgeon and chair of the Division of Community Urology, and other center researchers, describing the use of robots to assist in prostate cancer surgery.

The adoption of robotic-assisted radical prostatectomy (RARP) began in 2001, and gained rapid momentum as the technique of choice over the next decade, becoming the new gold standard by 2009. There is still debate around the efficacy of robot-assisted radical prostatectomy versus the pre-2009 gold standard of open radical prostatectomy. Because, while there is well-accepted evidence of the volume-outcome relationship of open radical prostatectomy, little evidence exists to show proficiency by volume results in better outcomes when conducting robot-assisted surgeries.

Dr. Karnes’ team found, “in 2011, 70% of hospitals averaged one RARP per week or less, accounting for 28% of RARPs. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications, postoperative complications, perioperative blood transfusion, prolonged hospitalization, and mean total hospital costs.”

“Basically, we showed that larger volume hospitals and medical centers – where they are doing several a week or more – have better outcomes across this group of criteria,” says Dr. Karnes. “There is a clear dependency until a facility reaches about 100 RARPS a year, at which time further related improvement is minimal.”

“However, we also noted that a substantial proportion of RARPs are performed at low-volume hospitals,” Karnes says. “While further studies are necessary to identify additional determinants of perioperative outcomes and hospitalization costs, these results have important implications for health policy,” he states. “These types of findings seem to justify the centralization of major surgeries.”

This isn’t a new concept, but provides an ever growing body of evidence that should change thinking. The authors cite the fact that in 2002 in the United Kingdom, the National Health Services mandated radical prostatectomy be conducted only at centers that treated at least 50 such cases each year.

While the United States health care system may not be to this point, the work done by these teams is beginning to become a well-accepted fact of medicine and surgery; patients who go to a high volume center experience better outcomes. In an attempt to lower costs and make health care a free market, we must let informed patients make these crucial decisions about their care. Patients can arm themselves with this information when they are deciding on where to have a procedure. Policy makers and payers must heed this evidence and work to change the antiquated version of how we receive health care to allow patients to receive their care at these high volume centers.

Dr. Dowdy is also the Deputy Director of Practice within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, where he works to effectively align the work of the CSHCD with the strategic priorities of the clinical practice at Mayo Clinic. Dr. Go has recently completed the Kern Health Care Delivery Scholars Program.

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Tue, Mar 7 7:00am · Choosing Wisely—At odds with Diagnostic Accuracy?

Primary Sjögren’s syndrome is a chronic autoimmune disease where your body attacks its self.  This happens because some of the white blood cells and several proteins made by these and other cells attack on normal functioning salivary glands (i.e. those in your mouth—leading to cavities, ulcers, and tooth degradation) and tear glands (i.e. your eyes).  However, the assault does not stop at just the glands; it wreaks havoc on your entire body, making you feel tired and run down. If you have Sjögren’s syndrome you also likely have painful, swollen joints that make it hard to enjoy even everyday activities. Sjögren’s can also affect the heart, lungs, brain and kidneys as well.

The diagnosis of primary Sjögren’s syndrome is not straightforward, taking an average of three years to reach a diagnosis after when symptoms started.  Patients often present with vague symptoms that could be caused by many other conditions or even side effects from common medications.

Recent, strict guidelines put forth from the American-European Consensus Group Classification Criteria are very clear on the diagnostic criteria for accurate diagnosis of primary Sjögren’s syndrome.  They include having four out of the six diagnostic criteria:

  1. Ocular symptoms – Dry eyes for more than three months, foreign-body sensation, use of tear substitutes more than three times daily
  2. Oral symptoms – Feeling of dry mouth, recurrently swollen salivary glands, frequent use of liquids to aid swallowing
  3. Ocular signs – Schirmer test performed without anesthesia (< 5 mm in 5 min), positive vital dye staining results
  4. Oral signs – Abnormal salivary scintigraphy findings, abnormal parotid sialography findings, abnormal sialometry findings (unstimulated salivary flow < 1.5 mL in 15 min)
  5. Positive minor salivary gland biopsy findings
  6. Positive anti–SSA or anti–SSB antibody results in the blood

Using data from the Rochester Epidemiology Project, Mayo Clinic researchers performed the first population based study in the United States of primary Sjögren’s syndrome to look at the prevalence of Sjögren’s syndrome in Olmsted County, Minnesota.  Out of those diagnosed with Sjögren’s, only 22 percent of patients met the diagnostic criteria put forth by the American-European Consensus Group due to the lack of certain diagnostic tests (i.e. dry eye testing, salivary gland biopsy).

In an era where we expect clinicians to be on the cutting edge of many data driven guidelines and be the protector to our limited number of resources how do clinicians come to terms with these various crusades such as Choosing Wisely™ and Diagnostic Accuracy?

Choosing Wisely refers to performing tests that provide high value at relatively low cost and eliminating expensive tests that provide low value. This could seemingly be at odds with Diagnostic Accuracy, which is the expectation for medical providers to be able to give an accurate and timely explanation for a person’s health problem.

How are clinicians meant to handle such cases?  Where does the physician’s gestalt factor in?  While guidelines help standardize care, surely physicians did not go to medical school to simply follow an algorithm.  Has the art of diagnosis been lost?

For example, one of the tests recommended for proper diagnosis of primary Sjögren’s syndrome is a lip biopsy – but physicians are not ordering this test. A lip biopsy is not without consequence and long-term implications, including the potential of a permanently numb lip.  Given this, is there a role for a physician to say, “yes, I think this is what you have—you may be sub-clinical, but I do not think it is worth the expense and complications of further testing.”

Is there harm in this assumption of diagnosis based on other less-invasive tests and observations?  Or is the harm actually performing the invasive tests?

Is there room for Choosing Wisely and Diagnostic Accuracy to meet in the middle; to allow physicians to use their clinical judgment versus ordering more tests?

Eric Matteson, M.D.

“The results of this study highlight the conceptual differences between disease diagnosis and classification criteria,” says study author Eric Matteson M.D., a rheumatologist and health sciences researcher at Mayo Clinic. “Classification criteria are tools designed specifically for clinical research. Their main objective is to guarantee that primary Sjögren’s syndrome patients included in different studies (especially clinical trials) will be similar and that a comparison of different studies will be possible.”

He cautions that classification criteria are not designed to be used as clinical tools to diagnose the disease.

“Indeed, as the results of the current study clearly show, in a real-life community setting physicians rarely use several of the tests included in classification criteria for primary Sjögren’s syndrome to diagnose the disease in individual patients, drastically decreasing the sensitivity of classification criteria,” he says.

Thus, the balance between Diagnostic Accuracy and Choosing Wisely has a tension; albeit perhaps a healthy tension.  Somewhat of a check and balance in a health care system where we try to limit low value testing, but at the same time allow physicians to apply their knowledge and experience in decision-making.  We must make progress on decreasing high cost tests and the notion of unending resources in our medical system. At the same time, we must continue to study and improve the accuracy of diagnosis, in order to more safely care for patients. But throughout this journey, carry the understanding that we live in a dynamic, colorful world; one that is not black and white (like the classification system), but full of possibilities.

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Meghan Knoedler, M.S., B.S.N, R.N.

About the Author: Meghan Knoedler, M.S., B.S.N., R.N., is a Health Services Analyst for the Center for the Science of Health Care Delivery with a policy, practice, and translation focus.

Tue, Feb 21 8:00am · New ray of light for those who struggle with weight loss: low-level laser therapy

The struggle to lose weight is complex and full of challenges. For those who have struggled with their weight, finding hope and solutions can be difficult despite understanding the detrimental health consequences.

There is no question that losing weight is challenging.  As a result, procedures exist that aim to remove fat cells from the body.  A well-known procedure is liposuction, a surgical procedure which requires general anesthesia. In liposuction, fat cells are suctioned out through strategically-placed incisions. It carries with it a number of risks and side effects that range from cosmetic to life threatening. An emerging alternative to liposuction is Food and Drug Administration (FDA)-approved low-level laser therapy (LLLT); LLLT is more focused on contouring the body after weight loss has already happened to focus on target areas that may be more resistant to fat loss.

LLLT is a laser therapy treatment with few side effects. With LLLT, the patient and provider decide the body location that needs attention (weight loss).  Patients simply lay down under the LLLT machine, the lasers are positions accordingly and the lasers go to work penetrating and poking holes in fat cells, thereby removing the fat from the cells and shrinking them. One treatment consists of the patient being treated while on their back and the flipping over and being treated while on their stomach. When treatment is finished, you can get dressed and go back to your normal life with no down time. This should be repeated for a series of treatments with each treatment lasting about 1 hour.

Mayo Clinic researcher Ivana Croghan, Ph.D., has spent much of her career studying tobacco dependence and obesity. She is especially interested in the way these

Ivana Croghan, Ph.D.

conditions intersect with women’s health.

Knowing the importance of behavioral intervention for weight loss, Dr. Croghan and her research colleagues study various therapies in combination with behavioral intervention to determine safety and effectiveness. In a recent study, published in the BioMed Central journal BMC Obesity, Dr. Croghan and her team examined the feasibility and safety of using LLLT for weight loss when combined with behavioral intervention and the weight loss medication lorcaserin.

Dr. Croghan and team found that, “When combined with behavioral intervention, lorcaserin and LLLT may be effective components of a comprehensive approach to the treatment of overweight and obesity in the clinical setting.”

 

Dr. Croghan, although optimistic about the potential of LLLT, cautions, “While exploring this treatment and devising ways to help people in their weight loss journey, this treatment, like many diets and weight loss medications, should not be considered a miracle treatment. LLLT alone will not help someone lose weight or maintain the weight loss, unless the individual embraces a permanent change in lifestyle.”

Given the nature of a pilot study, more research will be needed to determine long-term effectiveness, recommended number of treatments, and frequency of those treatments. But their findings do provide a new ray of light for people who struggle to lose weight and possibly another option in the toolbox to combat obesity.

To learn about some of Mayo Clinic’s clinical trials for weight loss and other health care concerns, visit the Mayo Clinic Clinical Trials website.

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Dec 27, 2016 · Using the Discovery-Translation-Application cycle to enhance recovery after surgery

old-way-new-way

Seventeen years is the average amount of time it takes for research to reach the patient bedside.  But this is not always the case, as a team of clinician researchers in gynecological surgery are showing. “It shouldn’t take 17 years for new discoveries to reach patients,” says Sean C. Dowdy, M.D., deputy director for practice in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and chair, Division of Gynecologic Surgery, “One of our goals at the Kern Center is to not only discover new ways of delivering quality health care, but to improve the interface between discovery and translation to facilitate wide-spread dissemination. This is the only way to truly transform our practice, and the practice world-wide.”

dowdy

Sean C. Dowdy, M.D.

Dr. Dowdy practices what he preaches. His team began looking at enhanced recovery after surgery (ERAS) for patients undergoing gynecologic surgeries, publishing their findings in 2013. The team studied the effects of a protocol designed to improve perioperative recovery for patients undergoing major operations for gynecologic cancer, and later published international guidelines (Part I and Part II) on best practices. The guidelines addressed elements including preoperative and postoperative diet, intraoperative and post-operative pain control, nausea and vomiting prophylaxis, fluid balance, and activity.

The study team of ERAS 1.0 reported that, “Implementation of enhanced recovery was associated with excellent pain management with reduced opioid requirements, reduced length of stay with stable readmission and complication rates, excellent patient satisfaction, and substantial cost reductions.”

After ERAS 1.0 was fully implemented throughout the division, ERAS 2.0 was designed to continue the cycle of improvement, says Dr. Dowdy.  In ERAS 1.0, opioid use was reduced by 80% in the first 48 hours. For ERAS 2.0, “We wanted to determine if using an extended release form of bupivacaine injected into the surgical incision [standard bupivacaine was used in ERAS 1.0] would improve pain control and further reduce opioid requirements.”

The team’s findings, published in November 2016, showed that, “Substituting liposomal bupivacaine [extended release form] for the standard preparation resulted in an additional 50 percent reduction in opioid requirements. Furthermore, patient-controlled anesthesia requirements decreased from 30 percent to less than 5 percent without an increase in pharmacy costs.”

“These findings are important for improving patient recovery after laparotomy, but also positively impact the opioid epidemic.  The goal is to have acceptable pain relief, while trying to prevent long-term opioid dependence.” says Dr. Dowdy.

Beyond suffering caused by nausea, vomiting, and pain after surgery, opioids combined with anesthesia reduces the ability of to move contents through the gastrointestinal tract, and may result in a common and unpleasant complication, called ileus.  ERAS 2.0 resulted in a nearly 50 percent reduction in adynamic ileus, from 20% to 11%.

Dr. Dowdy and his team continue to work to disseminate the team’s findings and bring best practices to those outside of Mayo Clinic so patients all over the world can benefit.  As part of an Agency for Healthcare Research and Quality contract, Dr. Dowdy will be the content expert for gynecologic surgery with the goal of disseminating enhanced recovery to 1000 service lines in 5 surgical specialties over the next 5 years.

Considering that each version of ERAS spanned the discovery-translation-application cycle over approximately 3 years in comparison to the average of 17 years, we can use this as a learning opportunity to accelerate the speed at which research is adopted into practice. As such, he and the team are preparing to initiate ERAS 3.0 in coming months to further improve perioperative recovery by fine-tuning elements of the prior ERAS pathways. In addition, they hope to increase standardization across surgeons to reduce variations in length of stay and decrease readmission rates.

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Dec 20, 2016 · New breast cancer treatment increases chances women can save their breasts

breast-canerA very close family friend was just recently diagnosed with breast cancer. Even before all of her tests results came back she said, “Take both of my breasts, I don’t care.”  When someone you know or love is diagnosed with breast cancer, it’s terrifying.  All too commonly, our minds go to surgery.  This is what we believe will save our mom, our sister, our friend from breast cancer.  For my friend, like many others, the thought of cancer growing inside of her was scary and surgery to remove the cancer was her first thought.

Many women with early stage breast cancer have the choice between breast conserving surgery and mastectomy. Historically management of breast cancer has involved surgery to remove the tumor first, followed by systemic treatment with chemotherapy, hormonal therapy or both. However, new treatment paradigms are emerging that place the systemic treatment first and surgical removal of the tumor as secondary.

The American College of Surgeons Oncology Group Z1031 trial, of which Mayo Clinic was a participating site, demonstrated that neoadjuvant endocrine therapy, or endocrine therapy given before surgery, increased breast-conserving surgery rates for postmenopausal patients with clinical tumor stage 2-4c estrogen receptor-positive breast cancer. Practically speaking, this means that women receiving neoadjuvant endocrine therapy had their tumor size shrink significantly. Thus, utilizing the neoadjuvant endocrine therapy approach can increase the number of women that are able to receive breast-conserving surgery.  Meaning that they can have their breasts spared by removing only a small portion of their breast tissue.

This treatment breakthrough may be the “silver lining” for some.

Breast conserving surgery when compared to mastectomy has many positives: it is less invasive and less expensive, it has shorter recovery time, women experience less body disfigurement and ultimately fewer surgeries are required.

If this new approach is so great, why is it that the uptake of this approach has not sky-rocketed?

boughey

Breast surgeon and senior author Judy Boughey, M.D.

For breast surgeon, Judy Boughey, M.D., this is the reason that drove her to study the question in the first place. “Incorporation of clinical trials into standard clinical practice typically takes many years. This is suboptimal and there are many ongoing efforts to encourage the results of clinical trials to impact patients in a shorter timeline.”

To that end, Boughey and her team wanted to look at national trends of use of neoadjuvant endocrine therapy before, during and after the ACOSOG Z031 clinical trial and evaluate its influence on rates of breast conserving surgery.  The results are thus unsurprising:  the rates of use of neoadjuvant endocrine therapy increased slightly, but overall remain very low. There remains an important opportunity to raise awareness about the benefits of neoadjuvant endocrine therapy and increase its use across the country.

Furthermore, studying patients treated with neoadjuvant endocrine therapy can help identify patients that are very responsive to endocrine therapy and may do well in the long term without chemotherapy. This subsequent trial, the Alliance A011106 (Alternate) trial, is underway nationally and is open at Mayo Clinic.

Many patients have the overwhelming preference to have the cancer removed from their body first and the concept of systemic treatment first can be challenging for patients to understand. Sometimes it seems the research and innovation cannot come fast enough. Yet other times, here we are, new research and new treatment paradigms at our fingertips, yet we hesitate as patients and as providers.  More rapid translation of research into practice in an era of rapid discovery is in order to keep patient care up-to-date with research offering greater ability to impact care and change lives.

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Nov 29, 2016 · Rising health care costs: Are physicians Choosing Wisely?

choicesPhysicians are burned out.  The reasons for which are seemingly endless:  for one, the health care system is asking them to continually add more to their plate.  More diagnosis codes, more communication and oversight with more complex patients, more administrative duties such as charting and patient emails and portal systems, yet no more time.

Physicians are expected to stay on top of ever-changing guidelines, and provide their patients effective, compassionate, high value care.  More and more, reimbursement is tied to patient experience, but yet doctors have less time to actually spend WITH their patients ensuring the best possible experience.

It’s a nasty spiral that is difficult to control.  Then, add on the increasingly complex issue of cost containment and the ever-elusive task of trying to define “value” in health care.

The simple answer is value equals quality over cost.  But nothing in health care is that simple.

In one effort to improve value in health care, the Choosing Wisely® campaign seeks to reduce the excessive spending within the American health care system by defining value in a simple way for physicians to implement in their practice.  The campaign also aims to engage the patient in the conversation, ensuring that the care is supported by evidence, does not duplicate other services provided, is free from harm and truly necessary.

Launched in 2012, the campaign assembled a committee of physicians in numerous specialties to come up with a “Top 5” list of low value procedures.  Low value procedures cost an estimated at $750 billion a year, which is nearly 25 percent of our nation’s current annual health care expenditures. Thus, to identify these low value services is a noble and worthy challenge.

Some examples from the American Academy of Family Physicians’ low value list include: routine antibiotics for acute sinusitis, early imaging for low back pain, and annual cardiac testing for those who are low risk and showing no symptoms.  Eliminating the waste from the three primary care specialties’ “Top 5,” the campaign estimates could save $5 billion annually.

In order to make change, we must first understand the issue and then we can make positive change to policies. For this cost savings to come to fruition, it is key that physicians feel a sense of responsibility to contain health care costs and participate in the recommended Choosing Wisely campaign.

grover

Lead Author, Michael Grover, D.O.

Michael Grover, D.O., and a team of researchers from Mayo Clinic wanted to determine the current extent to which physicians are providing the low value services identified in the “Top 5” for Family Medicine.  The team published an article that appeared in Journal of Primary Care and Community Health summarizing findings from a March 2016 study using an audience response system.  More recently, they published their survey findings in Journal of the American Board of Family Medicine.

The researchers found that physicians who were more cost-conscious had a greater knowledge of current, recommended guidelines.  Additionally, there was an association between a physician’s degree of familiarity with the Choosing Wisely campaign and the degree of cost-consciousness they reported. Importantly, the more cost-conscious minded physician reported providing the five low value services less frequently.

This study gives us another key piece of the puzzle to target ways to improve physician involvement in and familiarity with the Choosing Wisely campaign. Helping health care providers become more effective in providing value-based health care is a win for patients, physicians and the health care system.

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The low-value services considered in this research are described by the American Academy of Family Physicians on the Choosing Wisely website:

  • Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
  • Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
  • Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
  • Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
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