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Patti Ragan, PhD, MPH, PA-C Brenda Quincy, PhD, MPH, PA-C

AAPA San Francisco, CA.May 24, 2015

Avoiding “Testorrhea” and Practicing Evidence-Based

Evaluation in the Clinical

SettingEvaluation

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By the end of this session, participants will be able to: Describe the burden and risk of unnecessary

testing Identify commonly overused and misused tests

in a number of disciplines Use available resources to teach effective

evidence-based test utilization concepts Discuss challenges to practicing evidence-

based testing in the various clinical practice settings

Educational Objectives

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Ordering routine pre-operative labs (CBC, liver chemistries, and BMP) in an otherwise healthy patient undergoing elective surgery

Performing imaging studies in patients with non-specific low back pain

Ordering pre-discharge CXR in a patient with CAP making good clinical progress

Performing exercise ECG in low-risk asymptomatic patients

Measuring BNP in the initial evaluation of patients with typical findings of CHF

Ordering a CT evaluation rather than an ultrasound in a child of suspected appendicitis

Thumbs up or thumbs down?

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In 2008, estimated to be at $2.2 trillion, accounting for 16.2% of the nations gross domestic product (GDP) Approximately $7681 per person

Amount spent does not correlate with quality of care

Areas frequently cited as contributors to out of control costs are drugs, devices, procedures and tests

Need to assess cost versus benefit (and harms)

Need to dispel the myth, “if some medical care is good, then more is better” In a study examining consumer attitudes toward evidence- based care published in Health Affairs in 2010, it was seen as a way to withhold or deny care

Health Care Costs in US

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Do consumers know what the costs are? What is covered by a health plan vs. what is not Do we as providers discuss “costs” with patients?

Consumer website (and apps) to negotiate for costs as “location” is a big factor in determining cost

So let’s see what some of those costs are… Healthcare Blue Book costs: https://

healthcarebluebook.com/page_Default.aspx

New Choice Health : Healthcare Marketplace for Transparencyhttp://www.newchoicehealth.com/?gclid=CKWRktLy1r8CFQto7AodFT4AIw

• Health Care Cost Institute• http://www.guroo.com

“ Health Care Blue Book” Fair Market Cost of Common Tests and Procedures

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• 73% say the frequency of unnecessary tests and procedures is a very or somewhat serious problem

• 66% feel they have a great deal of responsibility to make sure their patients avoid unnecessary tests and procedures

• 53% say that even if they know a medical test is unnecessary, they order it if a patient insists

• 58% say they are in the best position to address the problem, with the government as a distant second (15%)

• 72% say the average medical doctor prescribes an unnecessary test or procedure at least once a week

• 47% say their patients ask for an unnecessary test or procedure at least once a week

• 70% say that after they speak with a patient about why a test or procedure is unnecessary, the patient often avoids it

Survey Results on Physician Views on Use of Tests and Procedures

•http://www.choosingwisely.org/survey-physicians-are-aware-that-many-medical-tests-and-procedures-are-unnecessary-see-themselves-as-solution

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Figure 5: In your own practice, is this a reason you sometimes end up ordering an unnecessary test or procedure? IF YES: Is this a major

reason or minor reason? Tota l n = 600

Malpractice concerns 52%

Just to be sa fe

Want more information to

reassure m yself

30%

36%

Patients insisting on test

Wanting to keep patients

happy

Feel patients should make final decision

N ot enough tim e w ith pa tien ts

13%

13%

23%

28%

Major reason

Fee-for-serv ice system 5%

New technology in practice 5%

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To guide clinical decision making

What parameters do we use to decide if a test will be useful? Sensitivity, Specificity, PPV, NPV, Likelihood Ratios

The American College of Physicians goes one step further and says high value care “stipulates that the health benefits of an intervention justify its harms and costs”

What is the Purpose of Testing?

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Purpose: Diagnostic tests– to detect disease in symptomatic persons Screening tests – to detect disease in asymptomatic,

apparently healthy persons

Validity Correctly determine who has the disease and who does not

Sensitivity – positive test if disease is present Specificity – negative test if disease is absent

Reliability Getting a similar result when the test is repeated under the

same conditions

Likelihood Ratios probability of finding in a patient with disease

probability of finding in a patient without disease

Diagnostic and Screening Tests

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Diagnostic Testing Workshee

t

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Avoid ordering tests indiscriminately

Keep in mind the risk to benefit ratio

Know the limitations of the test

Avoid repeating test without an indication

Consider cost of the test

General Considerations for Ordering Tests

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Has the patient had this test previously? What is the indication to repeat it? Is it likely to change? Can I simply get the result?

Will the test result change the care of the patient?

What is the probability of a false positive result? Consequences?

Is the patient in danger in the short term if I do not perform this test?

Am I ordering the test primarily because the patient wants it or to reassure the patient? If so, have I discussed this issue with the patient? Are there other strategies to reassure the patient?

Questions to Ask Before Ordering Tests

. Laine C. (2012) High Value Testing Begins with a Few Simple Questions (editorial). Ann Int Med. 156(2):162-163

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Choosing Wisely website http://www.choosingwisely.org/

Numerous partner organizations Provide guidance on their top 5 recommendations and

specific ways to convey this information http://www.choosingwisely.org/partners/

Choosing Wisely video modules to help facilitate conversations with patients on appropriate use of health care resources http://www.choosingwisely.org/resources/modules/

Resources from Professional Societies

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Patients may “decline” testing that is indicated in their specific individual circumstances (narrow interpretation) because a site recommends it is unnecessary

Fee-for-service model creates incentives for clinicians to order testing and treatment, so tendency to push up health care costs This is an attempt by physicians to self-determine what gets cut rather than waiting for

the government or insurance companies to mandate

Opens the door for the government or other interested parties to demand additional cuts?

Today’s guidelines may be tomorrow's prior authorizations or exclusions. By identifying tests and treatments that often are unnecessary, physicians may have given payers a reason to deny coverage for them. Example: Breast screening mammography reimbursement more limited after new

guidelines came out

For example, Choosing Wisely states that screening ECGs should not be ordered routinely. So if a physician suggests a baseline ECG for a patient without symptoms but significant cardiac risk factors, will this test be reimbursed? (what can be justified)

Devil’s Advocate: “Be Wise about Choosing Wisely”

Source: http://www.medscape.com/viewarticle/780843_4

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Not just a problem in US

In Canada, estimated that 10-50% of laboratory testing may be unnecessary and threatens sustainability of system

Curriculum designed for family physician residents at University of Calgary

Based on College of Family Physicians evaluation competency of “selectivity” – adapting and selective in approach to a specific situation and patient

Laboratory Tests, Interpretation and Use of Resources

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Single 4 hour session

Phase 1 – general introduction

Phase 2 – visit to general laboratory for interactive didactic session covering 7 components of the curriculum

Phase 3 – Tour of Clinical testing areas Q & A

Family Physician Resident’s Laboratory Curriculum

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Problems associated with the use of laboratory testing

Sources of laboratory error

Definitions of normal and abnormal laboratory test results

Appropriate use of laboratory requisition forms

Laboratory quality assurance methods

Laboratory collection processes

Costs of common laboratory tests

Family Physician Resident’s Laboratory Curriculum Components

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Please rate your knowledge of the following. Rank response 1-5, with 5 being the highest: Problems associated with unnecessary use of laboratory testing Role of family physicians in preventing laboratory errors Definitions of normal and abnormal laboratory test results Appropriate use of laboratory requisition forms Principles of laboratory quality assurance Laboratory collection processes (patient appointments,

laboratory tests, ECGs and mobile collections) Costs of common laboratory tests

Post-session only: Overall, was this session useful?

Pre and Post Course Self-Assessment

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Reasons to order tests

Justifying the need for a test Patient and system costs

Further Investigation Referral Patient anxiety

Focus on evidence-based screening tests & guidelines

Component 1 – Problems with Laboratory Testing

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Misconception: most of testing errors are pre- or post-analytic Three types of lab errors

Pre-analytic: test selection error, incorrect or insufficient specimen, mislabeling

Analytic: errors in the laboratory: equipment malfunction, calibration, reagent problems

Post-analytic: misinterpretation of test result or results not getting back to ordering practitioner

Component 2 – Sources of Laboratory Errors

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Results: Concepts of: true positive, false positive, true negative

and false negative Laboratory error

Interpretation depends on: Prevalence or pre-test probability Test sensitivity and specificity

“Normal” or reference ranges, critical values

Understanding importance of false positives and false negatives and “overinterpretation” of test results without the appropriate clinical context

Component 3 – Definitions of Normal and Abnormal Test Results

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Clinical Context

Required information

Special criteria – stat tests, standing orders, etc.

Sample cases - Knowing when to order a culture, how to get the best sample and interpretation of the results

Asking questions of laboratory personnel, pathologist or microbiologists as needed

Component 4 – Use of Laboratory Requisition Forms/Ordering

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Discussed in the context of analytic errors and reducing errors

Primarily provided background information on reasons for test delays and cancellations

Idea of using appropriate calibration, controls samples, etc.

Component 5 – Laboratory Quality Assurance Methods

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Primarily provided introduction to the specific services available to collect tests, how to access mobile collection, how to enroll patients in a standing order database, how to access on-call pathologists and how to access the lab center for results

Electronic health records and computer access simplifies some of these activities

Component 6 – Laboratory Collection Processes

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Numerous tables provided to give visual assessment of cumulative health costs and expenses charged to the health system

Discussion of usefulness of particular tests

Component 7 – Costs of Laboratory Tests

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Statistically significant difference (p < .001) in all pre and post curriculum responses

May be most effective in medical learners who have already been exposed to basic concepts, and with some patient experience

Part of the move toward patient centered homes and patient centered medical care

Overall Assessment of Curriculum

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When? First year or second year? Didactic or clinical phase? Yes and yes!

Where? Lab medicine/diagnostics course Case-based clinical reasoning course Clinical year call-back sessions Advanced clinical reasoning course in the fall prior

to starting rotations in January Clinical Rotations with student learners!

Application to PA Education

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Setting Characteristics Primary Care

Screening Tests What is evidence-based vs. more controversial in benefits vs.

risk? What gets reimbursed?

Surgical or surgical subspecialties Screening without risk factors?

Emergency Medicine Concern about “missing” a red flag Over diagnosis due to overutilization of tests

Organization Factors Easy availability of test/procedure within the facility/system Productivity incentives

Challenges in the Practice Setting

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A 32 year-old male presents with low back pain x 2 days. He describes the pain as achy and localized to the lumbar area bilaterally. It began Saturday evening after he spent the entire day helping some friends move a lot of heavy furniture. The ache is continuously present (6-8/10) and seems worsened with bending or if he spends too much time in one position. He reports no prior history of low back pain or injury. He denies radiation of the pain, numbness or tingling in the legs or feet or bowel or bladder incontinence. He has tried OTC ibuprofen with minimal relief. His brother-in-law had a similar episode (except his pain went down the back of his leg) a few years ago, with a disk herniation on MRI and subsequent back surgery.

Example 1 – Imaging for Low Back Pain

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Back- symmetric with no visible deformities or skin lesions. Nontender to palpation except for moderate tenderness in the paravertebral muscles bilaterally in the lumbar area. ROM is full but uncomfortable. Full ROM and 5/5 strength testing at the hips, knees and ankles bilaterally. Sensation intact to light touch and pinprick in the L2-S1 dermatomes. DTRs intact and equal bilaterally in lower extremities.

What is the working diagnosis?

What lab or diagnostic studies are indicated? Justify your response.

Example 1 - Physical Exam

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What are the problems associated with early imaging?

What are the possible sources of error?

Is there a clear normal versus abnormal?

What information do we need to include with the order?

What are the costs of the imaging options?

To image or not to image??

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A 53 year-old female presents for a well woman exam. She reports feeling generally well. Her last menstrual period was 2 years ago. She had mild hot flashes for several months but they occur only occasionally now. She has no chronic illnesses and denies a history of serious illnesses, injuries or hospitalizations other than for the birth of her 2 children. Her only “medication” is a daily OTC multiple vitamin for women over 50. Her only real concern today is whether she needs to have an osteoporosis test. She has an older neighbor who has experienced multiple vertebral fractures and she read somewhere that a woman’s risk for bone loss increases after menopause.

What additional history is needed?

What advice should this patient be given regarding osteoporosis prevention?

Will you order a BMD?

Example 2 – Routine DEXA

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PMH is negative for prior fracture and FH is negative for osteoporosis. She has gained 10 lbs in the past 2 years (BMI = 26) so she started walking 5 days a week in the past month. She denies alcohol or tobacco use.

Does she have risk factors for osteoporosis?

Is a BMD indicated?

Additional History & PE Findings

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What are the problems associated with screening BMD?

What are the possible sources of error?

Is there a clear normal versus abnormal?

What information do we need to include with the order?

What is the cost?

BMD or no BMD?

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A 60 year-old male presents for a physical exam and requests an EKG and stress test. His wife suggested he come in for the evaluation because one of their seemingly healthy friends recently had a heart attack. The patient reports walking on a treadmill 3-4 times per week for 45 minutes. He denies chest pain, palpitations, shortness of breath, dizziness or lightheadedness with exertion. The exam reveals blood pressure 118/78 and an excellent lipid profile.

Will you order the ECG and stress test? Why or why not?

How will you approach the discussion with the patient?

Example 3 – Routine Cardiac Screening

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What is the patient’s primary concern/goal?

What are the risk factors for heart disease?

Is this patient at high risk for heart disease?

What are the pros and cons associated with false positive or negative findings for a screening ECG/stress test in a low risk patient?

Consider the Clinical Context..

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Provide clear recommendations

Elicit patient beliefs/questions

Provide empathy, partnership, legitimation

Confirm agreement/overcome barriers

Communicating with Patients about Tests

Source: http://modules.choosingwisely.org/modules/m_02/default_FrameSet.htm

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Point of Care Evidence Based Resources Examples

Up-To-Date at http://www.uptodate.com

Agency for Healthcare Research and Quality: National Clearinghouse Guidelines

PubMed clinical queries using diagnosis filter

Other Tools for Decision-Making

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How do you as clinicians provide guidance to new learners in your setting?

What are challenges in your particular setting?

What are your suggestions for patients who want tests that are not indicated?

What are some special circumstances when evidence-based guidelines aren’t sufficient to guide testing?

Pearls from the Field…

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1. Laine C. (2012) High Value Testing Begins with a Few Simple Questions (editorial). Ann Int Med. 156(2):162-163.

2. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, et al. Appropriate Use of Screening and Diagnostic Tests (2012). ). Ann Int Med. 156(2):147-150.

3. Abbot M, Paulin H, Sidhu D , Naugler C. Laboratory Tests, Interpretation and Use of Resources (2014). Can Fam Physician. e167-e172.

4. Plotzker R. 5 Excesses in Diabetes and Endocrinology (2013). Medscape. http://www.medscape.com/viewarticle/782406_2 Accessed May 27, 2014.

5. Quincy B, Ragan P. (2012) Increasing diagnostic certainty: The clinical value of the likelihood ratio. JPAE. 23(3):46-50.

6. Survey: Physicians Are Aware That Many Medical Tests and Procedures are Unnecessary, See Themselves As Solution: Accessed on July 21, 2014 at: http://www.choosingwisely.org/survey-physicians-are-aware-that-many-medical-tests-and-procedures-are-unnecessary-see-themselves-as-solution/

7. Cassel C, Guest JA. Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care. JAMA. Doi10.1001/jama.2012.476 Accessed on April 11, 2012.

8. Choosing Wisely. Accessed on July 21, 2014 at: http://www.choosingwisely.org/ 9. Mintz M. Be Wise when Choosing Wisely. Accessed on July 24, 2014 at: http://

www.medscape.com/viewarticle/780843_4

References