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

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

Jun 25, 2023 450 likes •669 views

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

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Three approaches to promote de-implementation of ineffective treatments

David H. Howard Department of Health Policy and Management Emory University

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How to promote abandonment of unproven technologies

  • Test them
  • Pay less for them
  • Don’t cover them
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  • 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
  • 1. Conduct trials
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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

Skepticism that evidence matters

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50 100 150 200 250 300 350 400 1/94 1/95 1/96 12/96 1/98 1/99 1/00 1/01 1/02 Number of procedures May 1999 August 1998

Monthly counts of high dose chemotherapy in women with breast cancer

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

Abandonment of high dose chemotherapy among phase III trial site hospitals

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Z0011 trial presented at ASCO Z0011 trial published 1-2 positive nodes 3-4 positive nodes

0.0 0.2 0.4 0.6 0.8 2004 2005 2006 2007 2008 2009 2010 2011 2012

SOURCE: Surveillance, Epidemiology, and End Results (SEER) 18 registries.

Figure 2: Trends in the use of axillary node dissecton from SEER

Proportion of women undergoing axillary dissection

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PCI use in FL, MD, and NJ

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Trends knee arthroscopy volume in Florida

Howard et al. Health Aff 2012.

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0.40 0.60 0.80 1.00 1.20 0.60 0.80 1.00 0.20 0.40 0.60 0.00 0.05 0.10 0.15

2009 2010 2011 2012 2013 2009 2010 2011 2012 2013 2009 2010 2011 2012 2013 2009 2010 2011 2012 2013 Hemoglobin 0.0-6.9 (n = 314) Hemoglobin 7.0-7.9 (n = 1,034) Hemoglobin 8.0-9.9 (n = 3,160) Hemoglobin >10.0 (n = 1,929)

The vertical dashed line indicates the date of publication of the FOCUS trial. Error bars represent 95% confidence intervals.

Figure 3: Transfusion rates by minimum post-operative hemoglobin

Transfusion rates among patients undergoing surgery for hip fracture stratified by patients minimum post-op HGB

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FDA approves for CRC E2100 published in NEJM FDA accelerated approval for breast cancer Genentech submits AVADO and RIBBON1 data ODAC votes against full approval ODAC votes to revoke accelerated approval FDA revokes accelerated approval 0.00 0.05 0.10 0.15

2004 2005 2006 2007 2008 2009 2010 2011 2012

Quarter of treatment initiation

Use of bevacizumab in patients with breast cancer receiving anticancer drugs

Use of bevacizumab in women with breast cancer

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PSA testing rates by age

David H. Howard et al. Health Aff 2013;32:596-602

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4.4 2.4 1.3

0.15 0.25 0.35 0.45 0.55 0.65 35 40 45 50

Age 2008-2009 2010-2011

Source: Marketscan database.

Figure: The proportion of women screened by age and period

Mammography rates by age

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

  • 2. Pay less
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  • 2. Pay less

IMRT Conventional

2 4 6 8 10 12 14 16 18 2002 2004 2006 2008 2010 2012

Year

FIGURE 1: Practice expense relative value units in freestanding clinics

NCI R01CA208758-01A1

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Freestanding Hospital-based

5 15 25 35 2000 2002 2004 2006 2008 2010 2012

Year

FIGURE 3: The share of patients receiving IMRT

NCI R01CA208758-01A1

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  • 3. Enact and enforce coverage

policies

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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

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A recipe for promoting abandonment

Perform more trials of costly, untested tests and treatments Set clear, enforceable coverage guidelines