Disclosures & Funding Choosing Wisely: ACOG and SMFM No - - PowerPoint PPT Presentation

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Choosing Wisely: ACOG and SMFM recommendations

Melissa G. Rosenstein, MD, MAS Assistant Professor Division of Maternal-Fetal Medicine Department of OB/GYN & RS University of California, San Francisco Antepartum and Intrapartum Management June 8, 2018

Disclosures & Funding

• No conflict of interest

Objectives

• 1. To explain the history and background of the Choosing Wisely

campaign

• 2. To review the ACOG and SMFM Choosing Wisely

recommendations.

• 3. To explore the evidence supporting selected

recommendations.

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2010 – Affordable Care Act

• “Unfortunately, the myth that physicians are innocent bystanders

merely watching health care costs zoom out of control cannot be sustained.”

• “~1/3 of health costs could be saved without depriving any patient of beneficial care,

if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions”

• “Top Five list from each specialty so the most money could be saved most quickly

without depriving any patient of meaningful medical benefit.” Brody, NEJM 2010

Choosing Wisely

• The mission of Choosing Wisely is to promote

conversations between clinicians and patients by helping patients choose care that is:

– Supported by evidence – Not duplicative of other tests or procedures already received – Free from harm – Truly necessary

Creating the List

• Practices should be used frequently and/or

carry a significant cost.

• There should be generally-accepted evidence

to support each recommendation.

• Each item should be within the purview and

control of the organization’s members.

• The process should be thoroughly

documented and publicly available upon request.

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• Released February 21, 2013 , March 14, 2016
• Input from: Committees on Patient Safety and Quality Improvement;

Obstetric Practice; and Gynecologic Practice.

• Literature review of 10 items, 5 selected by Executive Board
• First two – collaboration with AAFP
• A list of the second set of “five items” was selected by the Committee on

Patient Safety and Quality Improvement before submission to the College’s Executive Board for approval.

• Any comments received from the Executive Board were incorporated into

the final list that was approved.

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• Released February 3, 2014 (Items 1–5);
• Released February 1, 2016 (Items 6–10)

Publications Committee reviewed the literature and evidence from SMFM’s published documents for possible topics. For SMFM’s first set of five recommendations a sub-group of the Committee initially developed a list of 10 items that the Committee then ranked for the top five with input and suggestions by the Society’s Executive Committee. The final list has been reviewed and approved by the Society’s Risk Management Committee and Executive Committee

Only Duplicate Recommendation

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McCall C; Obstetrics & Gynecology. 2013

Harms of Bed Rest

• Venous thrombosis (RR 19, 95%CI 5-80)
• Decreased bone mass (3x compared with activity)
• Depression and anxiety
• Family disruption and stress
• Financial burden
• Inappropriately values fetal well-being over

maternal and overall pregnancy well-being

McCall C; Obstetrics & Gynecology. 2013

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So why do we do it?

“the unjustified enthusiasm for treatment on the part of both patients and doctors”

Casarett, NEJM 2016 Thomas KB, Br Med J 1978

Therapeutic Illusion

• Doctors (like all people) think we have more

control than we actually do

• Explaining that health outcomes are random is

unsatisfying and contradicts popular narratives of medical prowess

• There are many motivating factors to “do

something” even when there is no evidence

Casarett, NEJM 2016

How to counteract this?

• “Before you conclude that a treatment was

effective, look for other explanations.”

• “If you see evidence of success, look for

evidence of failure.”

Casarett, NEJM 2016 CMQCC/March of Dimes, 2010

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• “Delivery prior to 39 weeks 0 days has been

associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality"

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• 8 studies compared ET (37-38wk) to FT (39-41)

– Cognitive ability in men presenting for conscription – FT 3% of a SD higher than ET – FT 5% of a SD more than ET in verbal IQ, no difference in non-verbal IQ – 10% increased risk of lower cognitive language performance in childhood (ET vs. FT, RR 1.10) – 5% increased risk of lower general school performance (RR 1.05) – 2% less likely to attain post-secondary school education (RR 1.02)

British School Children

Quigley MA, ADC- 2012

• “Higher Cesarean delivery rates result from

induction of labor when the cervix is unfavorable”

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Darney BG, Obstet Gynecol 2013 Grobman W, SMFM, Feb 2018 Dizon-Towson D, Obstet Gynecol 2005

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With Cerclage: PTB < 35wks: 75% vs. 36%, RR 2.2 (1.2 -4.0) Mortality: 23% vs. 6%, RR 2.7 (0.8 - 8.6) Berghella, Obstet Gynecol 2005 Rouse, NEJM, 2007 RCOG Green-top Guideline No. 31, 2013

• ”Studies that have attempted to screen

pregnancies for the subsequent occurrence of IGUR have produced inconsistent results”

“When looking at predictive test accuracy and test–treatment combinations in pre- eclampsia and intrauterine growth restriction, we should consider whether it is more harmful to classify a patient's results as false positive

• r as false negative.”

ROC curve 2nd tri Uterine Artery Doppler

Cnossen JS, CMAJ 2008

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WHO principles of screening:

• the condition should be an important health problem
• there should be a recognizable latent or early symptomatic stage
• the natural history of the condition, including development from latent to declared

disease, should be adequately understood

• there should be an accepted treatment for patients with recognized disease
• there should be a suitable test or examination that has a high level of accuracy
• the test should be acceptable to the population
• there should be an agreed policy on whom to treat as patients
• facilities for diagnosis and treatment should be available
• the cost of screening (including diagnosis and treatment of patients diagnosed)

should be economically balanced in relation to possible expenditure on medical care as a whole WHO, 1968

• Poor glycemic control leads to increased perinatal

mortality – includes DM2, most women on insulin – 19.23% vs. 4.7%

• Absolute Risks are low with any GDM

– At 39 weeks: 0.057% (95% CI 0.044% – 0.072%) vs. 0.036% (0.034% - 0.039%) – NND at 39 wks to prevent 1 stillbirth: 4761

Bassaw B, IJGO, 1995 Rosenstein MG, AJOG 2012

• Tests are confusing

– IgG and IgM can be present in prior infection, can be absent in acute infection

• Maternal infection only rarely leads to infant

sequelae

– CMV: 35% transmission rate, only 15-25% affected babies have sequelae – Toxo: 10-60% transmission, 90% sequelae

• Treatment is unavailable, unhelpful, expensive

ACOG Practice Bulletin #151, 2015

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Conclusions

• Providers have substantial power over costs of

health care

• Unnecessary care can lead to poor outcomes,

increased anxiety, unwarranted expense

• Do no harm ->

– Nothing is often better than something