ChoosingwiselyWorkshop1– ESIM2017RigaYoungInternists– Mikko Parry,HelsinkiFinland
Whatdoyoumean– Choosingwisely?
Initiallyaniniative ofAbimNowspreadingalltheworld…even reaching remote locationssuch asFinland
Aim:toreduce costs andharm andrationally focus limited resources
Fromguidelinesto“avoidlines”
Shortstatementsofwhatnottodowithashortmotivationandreferencestohighqualitypapers
Understandableforbothprofessionalsaswellaspatients
Examples…
Keypoints
InvolvethepatientinmakingdecisionabouttheirhealthProvidingpatientswiththenecessarybackgroundinformationaidscommunication
AvoidUnnecessaryscreeningUselessorevenharmfultreatments
Isthisarealproblem?
Isthisarealproblem?
Doesyourpatientbelievewhatyousay?
Youarethetrainedprofessional!
Motivateanddiscussyourdecicions withyourpatient!
Donotmakedecisionsthatyoucan’tstandbehind!
Whydon’twechoosewisely?
Whatfactorsaffectyourdecisions?
TimeofdaySituationathomeStressPatientrelatedfactors
Isthepatientannoying?Howarethesymptomspresented?
Haveyouhadasimilarcasewithadismaloutcome?Unrealisitic expectations
Humanbehaviour isirrational
KnowthelimitationsofyourthinkingWetendtooverestimatethepossibilityoftheunlikelybutpotentiallyseriouseventsThewaydataispresentedaffectsthewayitisinterpreted
Wetendtooversimplifycomplexproblemsandrushintoconclusions
Howcanyouimproveyourthinkingandhabits?
Educateyourself,yourstaffandyourpatientsPeercomparisondiminishedunnecessaryantibioticprescriptionsforflufrom19.9%to3.7%
Inthefuturecomputerbasedthinkingaids?
Brainstorm…
Whatdoyoucurrentlyknowaboutthetopic?
Whatwouldyouliketoknowbetter?
Howcouldyouusetheseconceptsinyourdailyprofession?
HowcouldyouinvolveyourpatientsindecidingontheirtreatmentMakingtogether,thepatientstillis99.95%ofthetimealonewithhisdiseaseandinchargeofthetreatment
Groupwork
Familiarizeyourselveswiththecase
ApplytheconceptsofchoosingwiselyTrytojustifythedecisionsmade.
Wouldyoudosomethingdifferently?Why?
Presentthecasetotheothergroupsfordiscussion5+5min/case
Case1– Atrialfibrillation
JonathanSmithis64yearsold.Hehasbeenpreviouslywellanddoesn’ttakeanymedicationonregularbasis.Hehasbeenactivelypracticingendurancesports,suchasfinishing20fulllengthmarathonsinthepastyears.Henowpresentstotheemergencyroomwithnewlyonsetatrialfibrillationwithaventricularrateof110-127.HisBPis160/90mmHg.Hehasminorchestdiscomfort,nodyspnea.Hislaboratorytestsareasfollows:
JasminAnoschkin
Hb 142g/l (134-167g/l)Na 140mmol/l (137-145mmol/l)K 3.6mmol/l (3.3-4.9mmol/l)Creatinine 87mmol/l (60-100umol/l)Troponin T 27ng/l (<15ng/l)NT-BNP 500ng/l (<194ng/l)
Questionsfordiscussion:HowshouldwetreatMrSmith?
WhatkindofadviceshouldwegivehimforthenextoccasionofAF?Thinkabouthowtoimprovetheoverallworkflowwithsuchpatients
DoesthepatienthaveNSTEMI?ShouldweroutinelyassesstroponinorBNPlevelsofpatientswithnewlyonsetAF?
KeypointsCase1– AF
History:onsetofAF?48hoursLess48:?rateorrhythmECHO?Anticoagulation:CHADVASc 1
?comorbiditiesthatwearenotawareofNoheartdefectfleicaide
Advice:anythingthatinducedAF?ethanolabuse,hyperthyroidismNoindicationfortroponinorBNP
Case2– UTIandantibiotics
MrsTheresaSmithis84yearsold.Shelivesathomewithregularvisitsofhomecarenurses3timesaday.Shehasamedicalhistoryofarterialhypertension,hypercholesterolemia,hypothyroidism,osteoarthritisandosteoporosis.She’sonaregularmedicationincludinglosartan100mgx1,Bisoprolol 2.5mgx1,Furosemide20mgx2,Atorvastatin20mgx1,Thyroidhormonereplacement0.1mgx1,Acetosalicylic acid100mgx1,Zopiclone 7.5mgx1,Paracetamol1000mgx2-3andAlendronate70mgaweek.
Nowshecametohospitalinthenightafteralertinghernursesbecauseshefelloutofbedandcouldn’tgetup.Shewasexaminedinbed.ShewasfoundtobeafebrilewithaBPof160/90,pulseregular82,notendernessorpalpablemassesintheabdomen.Asmallbruiseonherleftthigh.Asystolicmurmurovertheaorticarchandaudibleoverhercarotidsalreadymentionedin2014duringaregularfollowup.Otherwisenothingremarkable.
Laboratorytests:Hb 117g/l (117-155g/l)CRP 8mg/l (<10mg/l)WBC 8x109/l (3.4-8.2x109/l)Na 132mmol/l (137-145mmol/l)K 3.2mmol/l (3.3-4.9mmol/l)U-dipstickLeuc+,Urinaryanalysispositiveforg- coliformbacteria
Questionsfordiscussion:Shouldweroutinelyscreenforurinaryinfectionin
thissortofpatients?Shouldshebetreatedurinaryinfection?
Whataretherisksandbenefits?Doessheneedanechocardiogram?
Howcouldweimprovetheworkflowoftakingcareoftheincreasingnumberofelderlypeoplestilllivingintheirhomesandinfrequentneedofmedicalconsultation?
JasminAnoschkin
KeypointsCase2– UTI
DonotroutinelyscreenasymptomaticpatientsNoECHOnecessaryiftheresultdoesn’taffecttreatmentAvoidoverdiagnostics infrailelderly
Case3– DVTandPE
MrJamesSmith(62yo)fromNewHampshirewasluckyenoughtowin30000€onEuroJackpot.Hedecidedtofulfilhislong-timedreamoftravelingaroundtheworld.This,however,iswhereherunoutofluckandhadtobetakenintohospitalinHelsinkionhiswaybackfromJapanbecauseofshortnessofbreathandaswollenthigh.
Uponpresentation,hehadarespiratoryrateof34/minwithanoxygensaturationof88%breathingambientair.OnECGhehadsinustachycardia of100bpm,invertedT-wavesontheprecordialleadsV1-V3,nowideningoftheQRScomplex.HisBPwas140/70mmHg.Bedsideechocardiographyshowedamildlydilatedrightventriclewithatricuspidvalvegradientof60mmHg.Noevidentthrombuscouldbevisualizedintheheartchambers.ThediagnosisofPEwassupportedbyanelevatedd-dimerof13.4mg/l(<0.5mg/l)andconfirmedbysubsequentCT-angiographyofthepulmonaryvasculature.
Questionsfordiscussion:Shouldhereceivethrombolysis?Wasthed-dimertestnecessaryinthediagnostics?
Whatquestiondoesthetestanswer?Isitsensitive?Isitspecific?Whenshouldweuseit?
JasminAnoschkin
KeypointsCase3– DVTandPE
NoindicationforthrombolysisHighriskpatientD-dimernotnecessaryinhighriskcases->CTneededirrespectiveofresultAnticoagulation6monthsRepeatECHOpriortodiscontinuation
Case4– VictimOfMedicalImagingTechnology
MrsEmilySmithis57yearsoldandhasbeentakingRamipril5mgx1formildlyelevatedbloodpressuretogetherwithoestrogenreplacementtherapyformenopausalsymptoms.MrsSmith’sbrothershadnotbeentoowelllatelyandhadtoreceivemedicalattentionduetoatrialfibrillationandpulmonaryembolism.ThismadeMrsSmithquiteanxiousandsoonafterhearingaboutherbrother’shospitalizationinFinland,shestartedhavingpalpitations,shortnessofbreathespeciallyintheeveningswhenlyingdown,withnocorrelationtoexercise.ShepresentedtotheemergencywitharestingBPof150/80,p67BPM,nosignsofischemiaonECG.Spo297%breathingambientair.
Herbloodtestswereasfollows:Hb 137g/l (117-155g/l)WBC8.2x109/l (3.4-8.2x109/l)Na140mmol/l (137-145mmol/l)K4.2mmol/l (3.3-4.9mmol/l)Creatinine87umol/l (50-90umol/l)D-dimer0.9 (<0.5mg/l)
BecauseofthemildlyelevatedD-dimerapulmonaryCTangiographywasperformed.Inthestudy,pulmonaryembolismwasruledout.Anexpansionof2.2x1.4cmwashowevernotedinherrightadrenalgland.Theapplicationofcontrastmediumfortheangiographypreventeddiagnosingthisexpansionbenignbasedonthefirststudy.
Questionsfordiscussion:Whathappensnext?Howcouldwehavepreventedthisscenario?
Shouldwehavepreventedthisscenario?
JasminAnoschkin
KeypointsCase4– VOMIT
Nosuspicionofpulmonaryembolism;noD-dimerorCTscan
Incidentaloma:ActiveorinactiveMalignantorBenign
->Assesshormonelevels,doafocusednativeCT
Case5– Screeningforcancer
MrJohnSmithisnow82yearsold.HehadaPSAscreen12yearsagoafterreadingaboutayoungmaninexcruciatingagonymetastasisedcancerinthenewspaper.HisGPfirstexaminedtheprostateclinicallywithoutanythingsuspicious.HisPSAwasmildlyelevated(8ug/l,ref.<6.5ug/l),15%unbound.Thus,hewasreferredtoseeaurologist.Transrectal biopsyoftheprostatewasperformedwithanormalhistologyasresult.LateragoodfriendofhiswasdiagnosedwithprostatecancerandMrSmiththoughtthatitwouldbewisehe’dhaveanothercheck.HisPSAcontinuedrisingandhadnowreachedalevelof9ug/lwithafreefractiondecreasedto9%.AfterdiscussingwithhisGP,theydecidedtogoforanotherbiopsy.Thistimediagnosedtobelocal,notgrowingthroughtheprostaticcapsule.TheGleasonscorewas6.
AfterdiscussingtheprognosisofthislowriskcancerMrSmithdecidednottohaveanytreatmentforthediseaseatthisstage.ThistimehoweverMrSmithbecamefebrileaweekafterthebiopsyandtestedpositiveforenterococcusfaecalis inbloodcultures.Heneededtreatmentwithbroad-spectrumantibioticsforseveralweeksandunderwentmanyrule-outstudiessuchasTEEtoscreenforbacterialendocarditis.
Questionsfordiscussion:Shouldweroutinelyscreenforcancer?Whatcriteriacanyounameforagoodscreeningtest?
JasminAnoschkin
KeypointsCase5– Cancerscreening
PSAscreeninghasnotshowntodecreasemortality
Sensitivityvs.specificityvs.priceYouneedtobeabletoimproveoutcomebyearlydetection
Summingitup
Alwaysthink,thinkandthink• Doesthismakesense?• WhyamIdoingthis?
Atthecenterstandsthepatient!
Don’tunderestimateyourpowerinaffectingyourclinic• Youarethefutureboss!