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 recognition of harms from overuse2) foster local

discussions 3) change local culture

Which scenario probably represents medical overuse?

A. Pre-operative testing prior to cataract surgery in a patient who feels well

B. Using insulin to decrease A1C from 8 to 6.5 in an elderly patient with type 2 diabetes

C. Prescribing TMP/Sulfa for UTI in a patient 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 & BF. A, B, & DG. These all represent overuse

How overuse may manifest

• Overtesting – when benefit of test is nil and likely outweighed by risks (pap after hysterectomy for benign dz)

• Overdiagnosis – diagnosing "pseudo-disease” (screen detected prostate ca in elderly)

• Overtreatment – treating pseudo-disease harm (bisphosphonate for osteopenia)

• Preference misdiagnosis – treating/testing a patient who if fully informed would decline the service (regret after atypical femoral fx)

Why does overuse matter?

• 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 obligation to avoid

unnecessary harm• It’s wasteful!

Institute of Medicine 2012. “Best Care at Lowest Cost: The Path to Continuously Learning Healthcare in America.” Accessed April 30, 2013. http://www.iom.edu/bestcare

$210

Wait, how much?!

1/3 of the pieWASTED

1/4 of this wasteOVERUSE

More on why it matters. Easy to ignore – harms may be downstream or counterintuitive e.g. harm from prostatectomy 2 yrs after PSA detected cancer

Labels – patients do worse when told they are sick

Lots to diagnose with good prognosis if left alone e.g. 70% of men > 70 yrs have occult prostate cancer

Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. I. Prior probability and effectiveness of tests. Ann Intern Med 1997;126:394-406

What we are looking for

• Clinical vignettes about 1) overuse resulting in harm or harm that was narrowly avoided; or 2) misdiagnosis of patient preferences that subsequently led to overuse and harm, or harm that was narrowly avoided.

• Emphasize importance of doing “as much as possible for the patient and as little as possible to the patient”

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 vignette headed “Story from the Front Lines” (an engaging story with enough clinical information for readers to understand the clinical issues) and a summary of the clinical issues headed “Teachable Moment” (succinct summary of the clinical issues, stating the evidence for overuse and suggesting an alternative approach).

References: 5 or fewer.

Reasons to participate

• $$ prizes for best vignettes on quarterly/annual basis (Colorado ACP).

• Housestaff completing 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 presentations, fulfill scholarly requirement. Your peers have presented cases at regional and national conferences.

• GET PUBLISHED – Teachable Moments, JAMA Internal Medicine – So far: Meredith Neiss, Pai Liu, Shelby Badani, Mysha Mason

Narratives written by trainees describing: (1)unnecessary care resulting in harm or harm that was narrowly avoided or (2) the misdiagnosis of patient preferences that subsequently led to unnecessary care and harm or harm that was narrowly avoided.

Manuscripts should be 600-800 words, provide a clinical vignette that documents overuse of medical care, and a summary of the evidence that documents the care provided was unnecessary.

Logistics

• Send a one liner first week OBMT to brandon.combs@ucdenver.edu

• If case approved, CMR arranges writing day• Case due end of writing day• Get an attending involved!• Revisions completed within 1 month• Final case published to website, entered into

competition• Submit for publication in JAMA IM (consent

required)

Twitter: @DoNoHarmProject

Website http://www.medschool.ucdenver.edu/gim/donoharmproject

THANK YOU!