6/7/2018 Disclosures & Funding Choosing Wisely: ACOG and SMFM • No conflict of interest 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 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. 1
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6/7/2018 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 Creating the List • Practices should be used frequently and/or carry a significant cost. • The mission of Choosing Wisely is to promote • There should be generally-accepted evidence conversations between clinicians and patients to support each recommendation. by helping patients choose care that is: • Each item should be within the purview and – Supported by evidence control of the organization’s members. – Not duplicative of other tests or procedures • The process should be thoroughly already received documented and publicly available upon – Free from harm request. – Truly necessary 3
6/7/2018 • 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. 4
6/7/2018 • 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 5
6/7/2018 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 McCall C; Obstetrics & Gynecology. 2013 6
6/7/2018 So why do we do it? 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 “the unjustified enthusiasm for treatment on • There are many motivating factors to “do the part of both patients and doctors” something” even when there is no evidence Casarett, NEJM 2016 Casarett, NEJM 2016 Thomas KB, Br Med J 1978 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.” CMQCC/March of Dimes, 2010 Casarett, NEJM 2016 7
6/7/2018 • “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" 8
6/7/2018 British School Children • 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) Quigley MA, ADC- 2012 • “Higher Cesarean delivery rates result from induction of labor when the cervix is unfavorable” 9
6/7/2018 Darney BG, Obstet Gynecol 2013 Grobman W, SMFM, Feb 2018 Dizon-Towson D, Obstet Gynecol 2005 10
6/7/2018 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 ROC curve 2 nd tri Uterine Artery Doppler “When looking at predictive test accuracy • ”Studies that have attempted to screen and test–treatment combinations in pre- pregnancies for the subsequent occurrence of eclampsia and intrauterine growth IGUR have produced inconsistent results” restriction, we should consider whether it is more harmful to classify a patient's results as false positive or as false negative.” Cnossen JS, CMAJ 2008 RCOG Green-top Guideline No. 31, 2013 11
6/7/2018 WHO principles of screening: • Poor glycemic control leads to increased perinatal • the condition should be an important health problem mortality • there should be a recognizable latent or early symptomatic stage – includes DM2, most women on insulin • the natural history of the condition, including development from latent to declared disease, should be adequately understood – 19.23% vs. 4.7% • 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 • Absolute Risks are low with any GDM • the test should be acceptable to the population • there should be an agreed policy on whom to treat as patients – At 39 weeks: 0.057% (95% CI 0.044% – 0.072%) vs. • facilities for diagnosis and treatment should be available 0.036% (0.034% - 0.039%) • the cost of screening (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical – NND at 39 wks to prevent 1 stillbirth: 4761 care as a whole Bassaw B, IJGO, 1995 WHO, 1968 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 12
6/7/2018 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 13
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