Bree Collaborative Meeting November 18 th , 2015 | Seattle Public Library
Agenda Chair Report Action Item : Approve September 16 th Meeting Minutes Final Adoption : Prostate Cancer Screening Report and Recommendations Action Item : Adopt Prostate Cancer Screening Report and Recommendations Current Topic Update: Oncology Care Membership Spotlight: Amerigroup New Topics Selection Action Item : Select two new topics Slide 2
September 16 th Meeting Minutes Slide 3
Update: Psychotropic Drug Use in Children Chair: Bree Member Paula Lozano, MD, MPH, Group Health Cooperative Robert Hilt, MD, Director of Partnership Access Line, Seattle Children's Robert Penfold, PhD, Co-investigator, Mental Health Research Network, Group Health Research Institute Donna Sullivan, PharmD, MS, Special Assistant to the Chief Medical Officer, Washington Health Care Authority Currently reaching out to other members: Parent advocate from Seattle Children's Health Plan representative Washington State Medical Association Plan first meeting for January Slide 4
Update: AMDG Opioid Prescribing Guideline Implementation Convened group for preliminary conversations: Gary Franklin, Dan Lessler, Kathy Lofy, Jaymie Mai, Hugh Straley, Mark Stephens, Michael Von Korff Alignment with other state efforts Expand group, regular meetings, charter Dental Health Plans Slide 5
Update: Implementation Bree Implementation Team Healthier Washington Accountable Care Programs Practice Transformation HUB Slide 6
Prostate Cancer Screening Workgroup Final Rick Ludwig, MD, Chief Medical Officer, Accountable Care Organization, Providence Health & Services Chair, PSA workgroup November 18 th , 2015
Members Providers Rick Ludwig, MD (Chair), Accountable Care Organization, Providence Health & Services Eric Wall, MD, MPH, UnitedHealthcare Shawn West, MD, Edmonds Family Medicine Bruce Montgomery, MD, Seattle Cancer Care Alliance Urology John Gore, MD, MS, University of Washington Medicine Jonathan Wright, MD, MS, FACS, University of Washington/Fred Hutchinson Cancer Research Center Patient Advocates Steve Lovell, Patient and Family Advisory Council State Agencies Leah Hole-Marshall, JD, Department of Labor & Industries Insurers Matt Handley, MD, Group Health Cooperative Slide 2
Our Report • Problem Statement • Prostate Specific Antigen Test Accuracy • Screening Harms • PSA Testing Guidelines • Shared Decision Making • Treatment Trends • Workgroup Discussion • Recommendations for Stakeholders • Primary Care • Hospitals • Health Plans • Employers/Health Care Purchasers • Washington State Health Care Authority • Implementation and Measurement Slide 3
Guidelines … .differ on whether health care providers should initiate a discussion about PSA testing with all men in the appropriate age range and risk category or only discuss screening if the patient initiates the discussion. Slide 4
Public Comments Overview 58 comments total 47 through online survey 11 through email 25 submitted by self-identified patients “Yes : the breadth of clinical opinion internationally, accurately captured in the Work Group's thorough research, should be a component of the shared decision making model, so that patients are fully informed .” “Early detection is fundamental for best treatment outcomes. Continue more PSA testing .” “Everyone is different. But a biopsy won't kill you .” “I'm concerned patients will be denied testing (and/or doctors sanctioned for doing it). Not a few of the patients I see are high risk and don't know it .” “The best means of limiting harm is to tackle the issue of overtreatment of the disease rather than potentially impact the ability of patients to have access to screening.” Slide 5
Public Comment Changes Add overdiagnosis to executive summary and clearer language that shared decision making is a process not a document. Add “ Although the cost of the PSA test itself is low, the potential for downstream complications due to follow-up tests and potentially unnecessary treatment is high.” “associated with” changed to “can cause” Add “ Not included in the “Not Screened” figure are the men who would be diagnosed with prostate cancer without the PSA test .” Add “ The workgroup also discussed the psychological benefit of a negative PSA test to reassure patients of health status. However, the inaccuracy of the PSA test and the psychological harms from a false positive PSA test must also be taken into consideration .” Slide 6
Public Comment Changes Add “ The Bree Collaborative acknowledges the importance of the physician-patient relationship and the importance of physicians meeting individual patient needs.” Edited language to read “If patient decision aids are used to assist in the discussion, aids should strive to be those certified by Washington State when available. Patient decision aids should not be used alone without a comprehensive, patient-centered discussion .” To Employers add “Do not include PSA testing for prostate cancer screening in employee health fairs or incentivize PSA testing in a wellness program (e.g., granting points towards a reduction in deductible for those self-reporting a PSA test ).” Slide 7
Stakeholder Recommendations Primary Care (and others who screen for prostate cancer) The Bree Collaborative recommends against routine screening with PSA testing for men: At average risk 70 years and older, At average risk under 55 years old, Who have significant co-morbid conditions, or with a life expectancy less than 10 years. The Bree Collaborative acknowledges the importance of the physician- patient relationship and the importance of physicians meeting individual patient needs. Primary care clinicians should review evidence regarding PSA testing for prostate cancer screening. The shared decision making process should be formalized and documented in the patient’s medical record . If patient decision aids are used to assist in the discussion, aids should strive to be those certified by Washington State when available. Patient decision aids should not be used alone without a comprehensive, patient-centered discussion. For primary care clinicians, we recommend two possible pathways depending on the physician’s interpretation of the evidence: Clinicians who believe there is overall benefit from screening with PSA testing should engage in a formal and documented shared decision-making process prior to ordering this test for average risk men between 55-69 years old. Clinicians who believe there is overall harm from screening with PSA testing should not initiate testing but should engage average-risk men aged 55-69 in a formal and documented shared decision making process prior to testing if the patient requests a PSA test. Only men who express a definite preference for screening after discussing the advantages, Slide 8 disadvantages, and scientific uncertainty should have screening with PSA testing.
Stakeholder Recommendations Primary Care (and others who screen for prostate cancer) Men who are at higher risk of prostate cancer because of African American descent, a family history or first degree male relative diagnosed with prostate cancer prior to age 65, Agent Orange exposure, or having a known or suspected familial genetic predisposition to breast, ovarian cancer, or prostate cancer (e.g. BRCA1, BRCA2) should be given the opportunity to discuss the harms, benefits, and scientific uncertainty about PSA testing using a formal and documented shared decision-making process including conversations about increased risk. This conversation can begin earlier than age 55. Only men who express a definite preference for screening should have PSA testing. Medical facilities should train clinicians on the shared decision- making process, make available patient decision aids, and allow for tracking of the shared decision- making process within the patient’s medical record. Slide 9
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