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A clinician-led initiative in partnership with patients, aimed at providing patient-centred care, reducing harm and waste and improving healthcare outcomes for patients in Wales Prudent Health Care – reducing unnecessary tests and treatments 24 6 16 Paul Myres Chair AMRCW A partnership of clinicians and patients: To promote conversations between clinicians and patients which help patients to choose care that is : ◦ Supported by evidence ◦ Not duplicative of other tests or procedures already received ◦ Provides benefit to the patient ◦ Free from harm To reduce inappropriate investigations and interventions More is not necessarily better Sub-optimal care for patients of low value results from : Inappropriate clinical interventions Culture of over-medicalisation Poor application of evidence Patients not involved enough in clinical decisions We don’t know about it. Evidence not easily accessible We don’t care about the evidence – I’ve always done it this way We disagree with the evidence – my experience says otherwise Evidence is unreliable – biased, incomplete Evidence is irrelevant – not appropriate for this situation Evidence is overruled. My patient wants something different. This treatment is not available Embed a broad culture change in healthcare where clinicians and patients regularly discuss the value of treatments and make shared decisions Ensure good information is available for patients and clinicians Enable participating professional health organisations such as the health professional colleges and societies, to produce with patients lists of commonly used treatments/interventions whose necessity should be questioned Reduce harm to patients by inappropriate use of tests or interventions Scepticism – rationing by another name Over confidence – I do it already “Doctor know best” Fear of litigation – I’ll get done, if it doesn’t work Lack of time – it takes too long Lack of consensus on what works best Lack of good (accessible) information Not profitable, Perverse Incentives Each recommendation must be within the control of the professional association members Intervention should be used frequently and have significant impact on patients and/or the NHS There should be generally accepted evidence to support the recommendation The process should involve patients, be well documented and publicly available on request Effects should be measurable Avoid controversial areas 1. 2. 3. 4. 5. 6. Antibiotics for URTIs/bronchitis/sinusitis Imaging for low back pain Benzodiazepine/antipsychotics in older patients Cancer screening (overfrequent cervical, regular well person testing, PSA) Pre-operative testing in low-risk patients (EKG, stress EKG, chest x-ray, labs) Proton Pump Inhibitors for dyspepsia WG support – Clinical Lead; Evaluation UK Colleges have identified topics Selecting around 20 relevant to Wales Roll-out begins this summer Don't routinely continue with poly-pharmacy for those with frailty or in the last year of life unless this is the clear wish of the patient or their advocate Minimising the use of chemotherapy with a minimal risk of benefit in patients with advanced cancer. Do not begin primary prevention of cardiovascular disease or osteoporosis without SDM with the patient Don't initiate drug treatment for patients with isolated mild hypertension unless there has already been a cardiovascular event or there are additional risk factors such as diabetes Don't routinely check lipids in patients prescribed statins for primary prevention of cardiovascular disease Don’t routinely swab suspected viral conjunctivitis cases or routinely use antibiotics for simple viral conjunctivitis polyethylene glycol should be used in preference to lactulose in tx of chronic constipation in children Feedback from our CHC partners was that they found it difficult to understand the recommendations in their original format so we have tried to design a more approachable format. Each slide begins with what the conversation needs to cover (“Discuss”), what interventions should be avoided (“Avoid”), and finally evidence-based management options (“Consider”). Discuss •How will each result alter care? Avoid •Doing tests routinely Consider •Testing only when it will alter care. Psych Measureable Med Do-able GP Expectations Impact Relevant At the bottom are ‘traffic-light’ boxes to represent the CWW core team’s assessments of the recommendedations in terms of: Relevant: are they relevant to patients and professionals? Impact: are they a significant enough issue for this programme? (we also indicate here which professional groups they will most impact on) Expectations: do patients at present tend to expect this intervention? Do-able: is this area suitable for this approach? Measurable: will we be able to know if it is working? Avoid Discuss Consider •Routinely giving Aspirin, Heparin or Progesterone •No abnormal investigations means good prognosis •Absence of evidencebased treatments Measureable Gynae Do-able GP Expectations Impact Relevant •Doing more isn't always better •Pre-conception Folic Acid •Early & regular scans Discuss Avoid • Need to exclude skin conditions Consider • Giving repeated courses of antifungals • Other symptoms • Examine • Trial of topical steroid • Refer to vulval specialist Measureable Gynae Do-able GP Expectations Impact Relevant Core PM MHK PF Discuss Avoid •Potential benefits Consider • Assuming all possible treatment is wanted. •Potential risks • Treatment aimed at symptom control Do-able Measureable Onc Expectations Impact Relevant Core PM MHK PF Discuss Avoid Consider •Routinely continuing multiple medications, especially in the frail. •Risks from being on multiple medicines •Benefits of longterm therapies •Medicines reconciliation •Medication review •Using STOPP and START tools Measureable Do-able GP Expectations Impact Relevant Core PM MHK PF Discuss Avoid • Limited evidence of benefit Consider • Automatically starting drug treatment • Risk of sideeffects • Decision Aids • Lifestyle changes • Ongoing monitoring Measureable Do-able GP Expectations Impact Relevant Core PM MHK PF The Media, Education, Family Patients / Public WG, Public Health Priorities Budget Health or Social care organisation Health or social care practitioner Evidence based care/Incentives Access to tests and treatments International clinicianled campaign A partnership Patient-centred care Shared decision making Reducing harm Increasing value What it is A government initiative An event Cook book healthcare What it n’t A ‘Don’t Do’ list Cost-cutting Further Information Dr. Paul Myres Programme Lead for Choosing Wisely Wales [email protected] Mr Paul Flynn Clinical Lead for Choosing Wisely Wales [email protected] Dr. Marysia Hamilton-Kirkwood PHW Lead for Choosing Wisely Wales [email protected] Mrs. Helen Britton Project Manager for Choosing Wisely Wales [email protected]