You’ve no doubt recently returned to work after a nice holiday break and whatever peace and tranquility you may have achieved was shattered by the cacophony of emails, voicemails, urgent meetings and new projects. Such is the crazy pace and turmoil that we all exist in in 2016. Happy New Year!
Then again, I think it is fair to say that in the last few years, the healthcare industry is pretty much continually running at full steam. The focus on improving quality and outcomes across the continuum for patients has certainly shown us that there are a great many gaps in care that needed to be closed. As new care delivery models emerge and new approaches to treatment are developed, there is now, more than ever, a focus on getting the patient the care they need. Ironically, during this transformation in healthcare, we risk putting the patient at even greater risk. That risk is one of overuse, overtreatment and a road paved with good intentions.
More focus is now being given to concerns around overuse: overuse of lab tests, procedures, drugs, etc., There are many examples of overuse: Antibiotics prescribed for upper respiratory infections caused by viruses, patients with uncomplicated acute low back pain referred for MRI imaging tests, patients at the terminal stages of cancer undergo chemotherapy that is very unlikely to lengthen life but greatly reduce quality of life, or overprescribing of opioids for non-malignant chronic pain resulting in countless avoidable deaths. Overuse is also expensive. The IOM estimates that unnecessary expenditures related to overuse range from 10 to 30 percent of total health care spending with a low-ball estimate of nearly $300 billion annually.
Fortunately there are some significant efforts underway to address this pervasive problem. Most notably, the Choosing Wisely initiative, led by the American Board of Internal Medicine (ABIM), has put together recommendations and guidelines to help clinicians make better decisions. Interestingly, a key focus of the initiative is to help clinicians better communicate with patients and their caregivers and facilitate productive discussions that avoid care that will not improve quality of life and may do harm. I encourage you to visit the Choosing Wisely site and poke around a bit to better appreciate the goals of this campaign. The Choosing Wisely initiative got a big boost in funding from the Robert Wood Johnson Foundation (RWJF) in 2015 and many local, state and regional healthcare groups have launched creative efforts to reduce unnecessary treatment. Several professional groups have seriously embraced these recommendations and the spirit that created them. The American College of Radiology is one example.
As a pharmacist, I can certainly see lots of opportunities for pharmacy to contribute to these efforts. Antimicrobial stewardship, regardless of your practice setting, is a prime example. The oft-cited statistic that up to 50% of antibiotics are misused or unnecessary should be a clear target. The new National Action Plan on Antibiotic Resistance should drive improvements and pharmacy should certainly take a leadership role in these efforts. Similarly, the National Action Plan on Reducing Adverse Drug Events is another area where overuse plays out. Another notable area for improved medication use and safety related to overuse would be polypharmacy within our aging population.
A recent editorial in AJHP by Paul Abramowitz and Rita Shane (Vol 72, Sep 15, 2015) did an excellent job of highlighting specific medication-related issues that pharmacists should consider in tackling the overuse problem. They note that of the 415 evidence-based recommendations made in the initial Choosing Wisely paper, “110 (26.5%) are related to medications. Among these recommendations, the drug classes most commonly addressed are antimicrobials (21.8%), neurologic or behavioral medications (15.4%) and pain management medications (6.4%).” An example of one recommendation targeting the polypharmacy issue is:
Do not prescribe medications for patients older than 65 years or patients receiving 5 of more medications without a comprehensive review of their existing medications (including OTC, herbals, etc.) to determine whether any of the drugs should and can be discontinued.
As someone who works closely with technology, particularly clinical decision support, I see incredible value and opportunity to optimize use of IT tools to continuously survey patient medical records and data for potential overuse problems. Certainly the first step in solving the overuse problem will be identification. CDS can also provide the evidence that supports the rational for when to use or not use certain treatments thereby assisting the clinician in the evaluation process.
However, technology cannot change the culture and attitudes that are embedded in and surround the current practice of medicine in the US. An April 2014 blog on overuse in Health Affairs stated quite eloquently, “the culture in medicine needs to change towards an ethic of doing more for the patient, and less to the patient.”
Here’s wishing you and your patients less in 2016. Cheers!