Outline A brief tour of practice diversity Its everywhere you look! - PDF document

5/30/2014 I think Medicine has… Practice diversity: What does it mean when everybody does it differently? 1. Too much practice diversity 2. Just enough practice diversity 3. Not enough practice diversity Avery Tung, M.D. FCCM Quality Chief for Anesthesia Department of Anesthesia and Critical Care 0% 0% 0% University of Chicago 1 2 3 Outline A brief tour of practice diversity – It’s everywhere you look! Is practice diversity bad? – The case for standardization ? (Are there any) arguments for practice diversity? – The benefit(s) of no protocol(s) – Learning – Preferences – Keeping up with the literature – True believers 12 5 cc/hr 1

5/30/2014 Marik PE et al. Does central venous pressure predict fluid responsiveness? Chest 2008;134:172-8 “43 percent of surgeons reported sometimes or always experiencing conflict about postoperative goals of care with intensivists *” ! ! **70% of intensivists JAMA Surg 2013 ;148:29-35 (AJRCCM 2009;80:853-60) 77 survey* respondents 368 ASA and ESA members surveyed regarding monitoring practices Surgeons, Anesthesiologists, Intensivists, What monitoring do you routinely use for high risk surgery? ASA ESA (n=237) (n=195) Invasive art line 95.4 89.7 CVP 72.6 83.6 Results Noninvasive BP 51.9 53.8 • 96% agreed that optimal fluid resuscitation decreased CO 35.4 34.9 the risk of adverse events PCWP 30.8 14.4 ? • COV for fluid rate >50% TEE 28.3 19 (data had >100% variance) SPV/PPV 20.3 23.6 SvO 2 14.3 15.9 Can J Surg 2009 ;52:207-14 *50 yr 90kg M s/p lobectomy Crit Care 2011 ;15:R197 2

5/30/2014 102,470 patients undergoing CABG ? 798 STS sites Primary isolated on-pump CABG Massive variability in product use 7.8 to 92.8% for RBC 0 to 97.5% for FFP 0.4 to 90.4% for Platelets Hb = 8.0 JAMA 2010 ;304:1568-75 ? Survey of Canadian perfusionists regarding blood product management 53% follow routine transfusion triggers for PRBC J Cardiothor Vasc Anesth 2008 ;22:662-9 3

5/30/2014 The case for standardization Science 1973 ;182:1102-8 When it comes to predicting… “Wide ranges of uncertainty among practitioners, wide • College grades from admissions packets variations in beliefs among • Response to shock therapy for depression experts, and wide variations in • Likelihood of violating parole actual practices all confirm • Which banks will go bankrupt what would be expected from • Etc… common sense: the complexity …the algorithm usually beats the human of modern medicine exceeds the inherent limitations of the unaided human mind ” “A search of the literature fails to reveal any studies in which clinical judgment has been shown to be superior to “Evidence based ” -David Eddy, MD statistical prediction ” JAMA 1990 ;263:1265-73 Science 1989 ;243:1668-74 4

5/30/2014 Retrospective review of 21,074 hospice patients* “Imminent death” on admission vs predictive model 994 ER patients with suspected ischemia No rule Rule* Efficiency 27% 38% (correct triage to OU) Safety 75% 97% (correct triage to ICU) JAMA 2002 ;288:342-50 J Palliat Med 2012 ;15:703-8 *N Engl J Med 1996;334:1498-1504 *5,562 deaths < 7 days Create a protocol “Guys, it’s more Measure important that outcomes you do it the • 103 ICUs and 375,757 catheter days in Michigan same way than • Complex intervention: Goals, VAP, Safety program, etc Adjust as what you think is needed the right way” Results: •  infection rates from 7.7 to 1.4 -Brent James, M.D. Remeasure • OR (infection) = 0.34 at 16-18 months NY Times N Engl J Med 2006 ;355:2725-32 Nov 3, 2009 5

5/30/2014 0.8 per 1000 catheter days (2011) 0.76 per 1000 catheter days (2011) 168,113,488 patient-days 6 5 0.3 per 1000 catheter days (2011) 4 ICU CLABSI rates 3 (infections/1000 0.97 per 1000 catheter days (2010) catheter days) 2 1 0 0.6 per 1000 catheter days (2012) * 1990-1999 2001 2009 *NNIS data summary Am J Inf Cont 1999 ;27:520-32 Is there value to practice diversity? “We always run the ball on 2 nd down” Monk: “What is the highest technique you hope to achieve?” “I always raise with two-of-a- kind” Bruce: “ To have no technique ” -Enter the Dragon Warner Bros 1973 “I always begin negotiations by offering 20% less than what I really want to pay” 6

5/30/2014 979 CXRs in 165 patients Routine vs Restricted 94 patients randomized to routine vs on demand CXR MORE relevant findings in the restricted group 519 total XRays NO difference in outcomes Int Care Med 2008 ;34:264-70 • Nonroutine group was more likely to have new findings that needed intervention (26% vs 13%) • No difference between groups in: • Ventilator days • ICU LOS • Hospital LOS • Adverse outcomes 11 ICUs, 424 patients, 4,607 routine Xrays vs 3,128 on demand No difference in outcome Lancet 2009 ;374:1687-93 Chest 2003 ;123:1607-14 Q: How do you get to Carnegie Hall? A: Practice - Anon Q: How do you become the best doctor? A: See more variability? 28 trials Does practice variability facilitate learning? Reg Anesth Pain Med 2012 ;37: 334-9 15 trainees 7

5/30/2014 32 volunteers Variable practice J Mot Behav 2010 ;42:307-16 “We all end up dead. Its just a question Human preferences of how and why ” themselves are Mel Gibson diverse! “Braveheart” 1995 8

5/30/2014 Abdominal Aortic Aneurysms • Usually detected in 154 surgeons, geriatricians, and anesthesiologists asymptomatic patients • Expands 0.2-0.4 cm annually “We hypothesized that no effect of specialty • Risk of rupture increases or recent experience on decision behavior with increasing size would exist” • Goal: operate when risk of rupture = risk of surgery JAGS 2012 J Am Geriatr Soc 2012 ; 60:1889-94 Decision: Operate now or wait? But first, a practice test! • If you decide to wait – AAA expands (& risk of rupture increases) • If you decide to operate: – 5% chance of operative mortality 9

5/30/2014 Results 4.1 4.5 4.9 5.3 5.7 Aneurysm size 0.6 1.0 1.4 2.0 5.5 Rupture risk (%) Surgeons Annual meeting Annual meeting Anesthesiologists Chicago, IL San Francisco, CA 2006 2007 N=92 N=62 1 2 3 4 5 6 7 8 9 10 JAGS 2012 # of watchful waiting periods Surgeons by condition Surgeons vs Anesthesiologists 4.1 4.5 4.9 5.3 5.7 Aneurysm size 4.1 4.5 4.9 5.3 5.7 Aneurysm size Rupture risk (%) 0.6 1.0 1.4 2.0 5.5 0.6 1.0 1.4 2.0 5.5 Rupture risk (%) Successful surgery Surgeon Surgical mortality Successful surgery Rupture* (n=63) Surgical mortality Successful surgery Anesthesia Rupture* Surgical mortality (n=92) Rupture 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 JAGS 2012 JAGS 2012 # of watchful waiting periods # of watchful waiting periods 10

5/30/2014 Surgeons by condition 4.1 4.5 4.9 5.3 5.7 Aneurysm size NHIS survey of 2,643 men from 2000 and 2005 Rupture risk (%) 0.6 1.0 1.4 2.0 5.5 Successful surgery Surgical mortality Rupture* 1 2 3 4 5 6 7 8 9 10 JAGS 2012 J Clin Oncol 2011 ;29:1736-43 # of watchful waiting periods How do you make a decision when you don’t know the odds ? • Identify the possible outcomes • Decide which outcome you LEAST want • Choose the other one 11

5/30/2014 Getting on a Southwest plane Unaccompanied minors & Businesspeople A1-A60 Families with kids ~B23 B1-B60 C1-C60 www.southwest.com How bad is that middle seat! The Early Bird process Unaccompanied minors & Middle Aisle or Businesspeople seat Window How many people will buy the Early Bird? Early Bird A B Buy ($10) A, B, or C Don’t buy C X If you buy the Early 0% 0% 0% Families with kids Bird, how good will A. B C your number be? A,B, or C Maybe you’ll get Choose carefully because regret lasts forever! C1-C60 lucky anyway! 12

5/30/2014 JAMA 2004 ;291:15-16 “You don’t know what you don’t know” -T Swift “What I didn’t anticipate was that the plaintiff’s attorney would “Mean” argue that I should have never discussed the risk and benefits Big Machine Records and just ordered the PSA ” 2010 “4 physicians testified that when they see male patients > 50 yrs, they have no discussion with the patient about screening… they just do the test! ” Adequate study design? Adequate power? Appropriateness of study group? Appropriateness of control group? 400 Appropriateness of statistics? 300 Stopped too soon? IL-6 200 Publication bias? 100 Funding bias? 0 Fraud? Before CPB 6 H post CPB 72 H post CPB HES (open) Anesth Analg 2011 ;112:498-500 Crystalloid (solid) 13

5/30/2014 You are captured by space aliens Since the coin is It is extremely unlikely (who are fascinated by human decision behavior) fair and each flip is that a fair coin could independent, the come up heads 30 They ask: probability should times in a row*. I bet • A fair, 2-sided coin is flipped 30 be 50% the coin is not really times fair. It is likely to come • Each time it lands heads Answer: B up heads the next time • What is the probability it will land too “heads” on the 31th flip? A. Less than 50% Answer: C 1. Less than 50% B. 50% 2. 50% C. Greater than 50% 0% 0% 0% 3. Greater than 50% 1. 2. 3. *p(30 heads in row)=0.00000000093 17,376 catheters and 113,652 catheter days * * *Category A = Supportive literature Crit Care Med 2012 ;40:2479-85 *Category C = Equivocal literature Anesthesiology 2012 ; 116:539-73 14