Three approaches to promote de-implementation of ineffective - PowerPoint PPT Presentation

Three approaches to promote de-implementation of ineffective treatments David H. Howard Department of Health Policy and Management Emory University

How to promote abandonment of unproven technologies • Test them • Pay less for them • Don’t cover them

1. Conduct trials • High dose chemotherapy + stem cell transplantation for breast cancer • PCI for stable angina (COURAGE, ORBITA) • Arthroscopic surgery for osteoarthritis of the knee • Transfusions for patients with hemoglobin values 8- 10 g/dL • Axillary lymph node dissection for early stage breast cancer patients with 1-2 positive nodes • Bevacizumab for breast cancer

Skepticism that evidence matters As we have shown, a variety of psychological and social forces lead people toward biased positions from which they often do not move even in the face of scientific evidence. The answer is not to perform more trials but to constructively overcome the psychological preconceptions that limit the value of those trials. Ubel and Asch, Health Affairs, 2015

Monthly counts of high dose chemotherapy in women with breast cancer 400 350 August 1998 1999 May 300 Number of procedures 250 200 150 100 50 0 1/94 1/95 1/96 12/96 1/98 1/99 1/00 1/01 1/02

Abandonment of high dose chemotherapy among phase III trial site hospitals 1.0 Proportion of hospitals continuing to perform 0.9 0.8 0.7 0.6 HDC/HCT Trial sites (N = 19) 0.5 0.4 Other hospitals 0.3 (N = 103 ) 0.2 1999 May 0.1 0.0 1/98 6/98 12/98 6/99 12/99 6/00 12/00 6/01 12/01

Proportion of women undergoing axillary dissection Figure 2: Trends in the use of axillary node dissecton from SEER 0.8 Z0011 trial 3-4 positive nodes presented at ASCO 0.6 Z0011 trial published 0.4 1-2 positive nodes 0.2 0.0 2004 2005 2006 2007 2008 2009 2010 2011 2012 SOURCE: Surveillance, Epidemiology, and End Results (SEER) 18 registries.

PCI use in FL, MD, and NJ

Trends knee arthroscopy volume in Florida Howard et al. Health Aff 2012.

Transfusion rates among patients undergoing surgery for hip fracture stratified by patients minimum post-op Figure 3: Transfusion rates by minimum post-operative hemoglobin HGB Hemoglobin 0.0-6.9 (n = 314) Hemoglobin 7.0-7.9 (n = 1,034) 1.20 1.00 1.00 0.80 0.80 0.60 0.40 0.60 2009 2010 2011 2012 2013 2009 2010 2011 2012 2013 Hemoglobin 8.0-9.9 (n = 3,160) Hemoglobin >10.0 (n = 1,929) 0.60 0.15 0.10 0.40 0.05 0.20 0.00 2009 2010 2011 2012 2013 2009 2010 2011 2012 2013 The vertical dashed line indicates the date of publication of the FOCUS trial. Error bars represent 95% confidence intervals.

Use of bevacizumab in women with breast cancer Use of bevacizumab in patients with breast cancer receiving anticancer drugs Genentech submits AVADO 0.15 and RIBBON1 data ODAC votes against FDA accelerated approval for breast cancer full approval E2100 published in NEJM 0.10 ODAC votes to revoke accelerated approval FDA revokes 0.05 accelerated approval FDA approves for CRC 0.00 2004 2005 2006 2007 2008 2009 2010 2011 2012 Quarter of treatment initiation

PSA testing rates by age David H. Howard et al. Health Aff 2013;32:596-602

Mammography rates by age Figure: The proportion of women screened by age and period 1.3 0.65 2.4 0.55 0.45 0.35 0.25 4.4 2008-2009 2010-2011 0.15 35 40 45 50 Age Source: Marketscan database.

2. Pay less Congress directed CMS to selectively reduce payments to physicians under the “ misvalued code initiative”.

2. Pay less FIGURE 1: Practice expense relative value units in freestanding clinics 18 16 14 12 IMRT 10 8 Conventional 6 4 2 0 2002 2004 2006 2008 2010 2012 Year NCI R01CA208758-01A1

FIGURE 3: The share of patients receiving IMRT 35 Freestanding 25 15 Hospital-based 5 2000 2002 2004 2006 2008 2010 2012 Year NCI R01CA208758-01A1

3. Enact and enforce coverage policies

Implantable cardiac defibrillators Medicare does not cover ICDs for patients who recently had a heart attack or underwent a revascularization procedure Many hospitals implanted ICDs outside of coverage guidelines There was a False Claims Act Lawsuit ~ 2010 DOJ joined the lawsuit

A recipe for promoting abandonment Perform more trials of costly, untested tests and treatments Set clear, enforceable coverage guidelines