Appendix B

A CEO Checklist for High-Value Health Care

The following IOM Discussion Paper, “A CEO Checklist for High-Value Health Care,”was released in June 2012 by the IOM Roundtable on Value & Science-Driven Health Care. The document can also be found online at http://www.iom.edu/CEOChecklist.



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Appendix B A CEO Checklist for High- Value Health Care The following IOM Discussion Paper, “A CEO Checklist for High- Value Health Care,”was released in June 2012 by the IOM Roundtable on Value & Science-Driven Health Care. The document can also be found online at http://www.iom.edu/CEOChecklist. 315

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APPENDIX B 317 D is cu ss io n Pa pe r A CEO Checklist for High-Value Health Care Delos Cosgrove, Michael Fisher, Patricia Gabow, Gary Gottlieb, George Halvorson, Brent James, Gary Kaplan, Jonathan Perlin, Robert Petzel, Glenn Steele, and John Toussaint* June 2012 *Participants in the IOM Roundtable on Value & Science-Driven Health Care The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council. Advising the nation • Improving health

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318 BEST CARE AT LOWER COST AUTHORS Delos Cosgrove, MD Gary Kaplan, MD President and CEO Chairman and CEO Cleveland Clinic Virginia Mason Health System Michael Fisher Jonathan Perlin, MD, PhD President and CEO President, Clinical and Physician Services Cincinnati Children’s Hospital HCA, Inc. Medical Center Robert Petzel, MD Patricia Gabow, MD Undersecretary for Health Chief Executive Officer Department of Veterans Affairs Denver Health and Hospital Authority Glenn Steele, MD, PhD Gary Gottlieb, MD, MBA President and CEO President and CEO Geisinger Health System Partners HealthCare System, Inc. John Toussaint, MD George Halvorson Chief Executive Officer Chairman and CEO ThedaCare Center for Healthcare Value Kaiser Permanente Brent James, MD, MStat Executive Director Intermountain Institute for Care Delivery Research The authors were assisted by the following individuals: Albert Bothe, MD Peter Markell Lucy Savitz, PhD Geisinger Health System Partners HealthCare System, Inc. Intermountain Healthcare Jonathan Darer, MD, MPH J. Michael McGinnis, MD, MPP Pat Schrepf Geisinger Health System Institute of Medicine Virginia Mason Health System Duane Davis, MD Geraldine McGlynn, MEd Earl Steinberg, MD Geisinger Health System Veterans Health Administration Geisinger Health System Tejal Gandhi, MD E. Lynn Miller Leigh Stuckhardt, JD Partners HealthCare System, Inc. Geisinger Health System Institute of Medicine Uma Kotagal, MBBS, MSc Kathleen Paul Jed Weissberg, MD Cincinnati Children’s Hospital Virginia Mason Health System Kaiser Permanente Tom Lee, MD Brian Powers Robert Wyllie, MD Partners HealthCare System, Inc. Institute of Medicine Cleveland Clinic 2

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APPENDIX B 319 As leaders of health care organizations, This Checklist is intended to be a living we are acutely aware of the pressures and dynamic document, and we invite that rising health care costs place both suggestions to improve its utility on individuals, employers, and the and reach, and co-signing by our CEO government, as we are of unacceptable colleagues who wish to support these shortfalls in the quality and efficiency of strategies for effective, efficient, and care. But we have also learned, through continuously improving health care for all experiences in our own institutions and Americans. through communication and collaboration with colleagues in others, that better outcomes at lower costs can be achieved through care transformation initiatives that yield improved results, more satisfied patients, and cultures of continuous learning. These transformation efforts have generated certain foundational lessons relevant to every CEO and Board member, and the health care delivery organizations they lead. We have assembled these lessons here as a A CEO Checklist for High-Value Health Care to describe touchstone principles, illustrated with case examples, central not only to our work to date, but to sustaining and reinforcing the system-wide transformation necessary for continuous improvement in the face of rapidly increasing pressures, demands, and market changes. 3

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320 BEST CARE AT LOWER COST NEEDS AND OPPORTUNITIES Health care in the United States is at a developing concrete plans to leverage their critical point. Excessive costs are no longer buying power to reduce expenditures and tenable and mediocre outcomes are no demand high-value care—care that achieves longer tolerable. For 32 of the past 40 years, better outcomes at lower costs. health care costs have grown faster than the rest of the U.S. economy.1 Federal health These are the realities for health care care costs—expected to reach $950 billion executives today. As demand for high-value in 2012—will become the largest contributor health care builds, care delivery leaders face to the national debt.2 States, too, are being the near-term imperative to transform the crippled by health care costs. Medicaid now way their organizations operate. We know consumes almost a quarter of state budgets, the potential for improvement exists. The crowding out investments in education amount of waste in the system—estimated and infrastructure.3 In the private sector, to be at least 30 percent9—provides both escalating costs have eroded the bottom line the opportunity and the mandate for for employers who purchase health care transformation. Replacing wasteful practices for their employees and have eliminated and procedures with those marked by any appreciable gains in income for effectiveness and efficiency can improve American families during the past decade.4,5 health outcomes and bottom lines at a time when pressures are growing on both counts. { } Purchasers simply cannot afford the status quo. The Checklist’s 10 items Given the urgency Despite these reflect the strategies that, in at hand, each of us, expenditures, our experiences and those of with the assistance outcome shortfalls others, have proven effective of farsighted staff are pervasive. and essential to improving and in cooperation Population health quality and reducing costs. with many of you in measures such as life other institutional expectancy and preterm birth lag behind leadership positions, has been engaged in those of almost every other developed these kinds of efforts. To aid and accelerate nation. Patients are still harmed by medical the system-wide transformation necessary, errors. Recent assessments indicate that 10 we have assembled what we are calling “A years after the IOM report To Err Is Human CEO Checklist for High-Value Care” (the estimated that medical errors cause up Checklist). The Checklist’s 10 items reflect to 98,000 deaths in hospitals each year,6 the strategies that, in our experiences and roughly 15 percent of hospital patients are those of others, have proven effective and still being harmed during their stays.7 Poor essential to improving quality and reducing care coordination places further strain costs. They describe the foundational, on patients and the system, with roughly infrastructure, care delivery, and feedback 20 percent of discharged elderly patients components of a system oriented around returning to the hospital within 30 days.8 value, and represent basic opportunities— Faced with concerns about the cost and indeed obligations—for hospital and health quality of health care, purchasers are care delivery system CEOs and Boards to 4

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APPENDIX B 321 improve the value of health care in their What follows is an item-by-item review institutions. of the basic issues, opportunities, and expectations for the 10 items on the The strategies in this Checklist are Checklist, along with case material not, of course, of the “one-and-done” that briefly describes a sample of our variety. Rather, the items we present experiences. To improve readability and here are elements that must become core access, we have been deliberately brief components of an organization’s DNA. In in the case descriptions, but more details some ways, they represent more a credo of may be found in the material in Appendix commitment than a simple checklist, but I, where follow-up contact information is each Checklist item is every bit as vital as also provided for additional conversations. the items on the checklists routinely used Because this paper addresses the system- by pilots taking complicated aircraft into level issues that are central to achieving quickly changing conditions. Taken together, high-value health care, we do not discuss the Checklist provides a blueprint for or spotlight some important work that has improving quality and reducing cost amid a been developed around individual services changing landscape. that are often overused, unnecessary, or otherwise wasteful. In recognition of the We realize that while the elements on the utility of such analyses and inventories, we Checklist are necessary to achieve high- have included summaries of some of that value health care within an institution, they work in Appendix II. are not sufficient to reach full potential across the system. Forces outside the Ultimately, the transition to high-value control of any single institution—economic care will be led and championed by incentives that reward volume over value, executives who recognize high quality inequitable access to needed services, and lower cost as institutional aims, poor linkage of community and clinical and will be sustained by a system-wide services, and unnecessary regulatory culture of continuous improvement. When requirements—can all serve as barriers successfully implemented, these systematic to the transformation required. However improvements that reduce waste and pervasive, we cannot allow these issues to improve outcomes will maximize the value obscure the substantial gains that can be of health care delivered in the United States. achieved from the steps well within our control as leaders of our institutions. 5

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322 BEST CARE AT LOWER COST A CHECKLIST FOR HIGH-VALUE HEALTH CARE Just as we offer an invitation to each staff and Board member of our respective institutions to hold us accountable for fully engaging, implementing, and sustaining attention to every Checklist item, we invite you to be in touch as we work together to build the field of health care transformation and better health for all Americans. Foundational elements 3 Governance priority—visible and determined leadership by CEO and Board • 3 Culture of continuous improvement—commitment to ongoing, • real-time learning Infrastructure fundamentals 3 IT best practices—automated, reliable information to and from the point of • care 3 • Evidence protocols—effective, efficient, and consistent care 3 Resource utilization—optimized use of personnel, physical space, and • other resources Care delivery priorities 3 Integrated care—right care, right setting, right providers, right teamwork • 3 Shared decision making—patient–clinician collaboration on care plans • 3 Targeted services—tailored community and clinic interventions for • resource-intensive patients Reliability and feedback 3 Embedded safeguards—supports and prompts to reduce injury and infection • 3 Internal transparency—visible progress in performance, outcomes, and costs • 6

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APPENDIX B 323 FOUNDATIONAL ELEMENTS To create lasting, sustainable change, the pursuit of continuous improvement and better value for patients must define 3 Governance priority—visible and • an organization’s culture, mission, and determined leadership by CEO leadership. It is a pursuit that is never and Board complete, but with a relentless operational ethos of continuous improvement and 3 Culture of continuous • improvement—commitment to assessment, we can achieve the value ongoing, real-time learning potential for the care within our institutions and the health of the populations we serve. 3 Governance Priority Visible and determined leadership QUESTIONS WE ASK OURSELVES, OUR by CEO and Board SENIOR LEADERS, AND OUR BOARDS TO ASSESS PROGRESS: Senior executive leaders and Board members are the central stewards of • What is our strategy for continuous high-value care. Responsible for both our improvement in the effectiveness institutions’ financial health and the quality and efficiency of care, and are we of care provided, we are inherently the reinforcing it with every member of our most visible champions for a culture of organization? continuous improvement in quality and • What else can our Board and its members high-value care. Our steadfast engagement do to emphasize and help drive our with front-line staff, management, and continuous improvement efforts? other organizational leaders to evaluate performance and explore opportunities for improvement is the key ingredient to achieving high-value care. Similarly, engaging our Boards as fully informed and visible partners in our quality and value innovations will foster stronger attention to and appreciation of the rewards from related staff efforts, engender more dynamic and productive meetings on the issues, and improve the reward structure to focus on reinforcing the culture of continuous improvement. 7

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324 BEST CARE AT LOWER COST 3 Culture of Continuous Improvement Commitment to ongoing, QUESTIONS WE ASK OURSELVES AND real-time learning OUR SENIOR LEADERS TO ASSESS PROGRESS: The sustainability of efforts to improve • In what ways are our employees at the quality and value of care is contingent every level supported and empowered on an institutional culture of continuous to improve effectiveness, efficiency, and improvement. Evaluating tasks and outcomes in their daily work? processes to identify better approaches allows hospitals to reduce waste, improve • What tools have we built into our outcomes, and yield significant savings. processes for continuous feedback and Rather than prescribing behavior, managers action to improve care delivery? and executives who teach problem solving, develop standard work, and remove barriers to improvement help their employees excel. This requires a management system built on the tenants of respect for all people in the organization, in which leadership behavior is focused on humility, facilitation, and mentorship. Front-line staff are taught to 1. analyze processes to identify waste and inefficiency, 2. propose changes to eliminate wasted resources and effort, 3. test proposed solutions on a small scale, and 4. if successful, scale the improvements to the entire organization. This process is never complete. Existing workflows must be continually refined and new opportunities for improvement continually sought. A culture of continuous improvement demands that all workers apply this method to their tasks to drive iterative improvements in the efficiency of hospital operations. 8

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APPENDIX B 325 OUR EXPERIENCES { Culture of Continuous Improvement } Denver Health adopted Lean as the philosophy and toolset to use in ThedaCare implemented the Business redesigning care. Lean is built on Performance System, a management respect for people and continuous process that supports front-line improvement, and focuses on reducing workers to solve problems every waste from the customer perspective. day. This moves away from a project • Better care: Achieved lowest mentality for improvement to a system observed-to-expected hospital transformation that builds a continuous mortality (among University improvement culture. Healthsystem Consortium) • Better care: 88 percent of safety • Lower costs: Since 2006, $158 and quality indicators improved; million in financial benefit realized 85 percent of customer satisfaction despite a 60 percent increase in indicators improved; 83 percent uncompensated care of staff engagement indicators improved Virginia Mason adapted elements • Lower costs: Days cash on hand of the Toyota Production System to increased from 180 to 202 ($36 develop the Virginia Mason Production million improvement); cash-flow System (VMPS), aimed at identifying margin improved from 10.5 percent and eliminating waste and inefficiency to almost 12.5 percent in the many processes of health care delivery. • Better care: Patients spend more value-added time with providers and experience fewer errors • Lower costs: Multiple years of 4 to 5 percent margins 9

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378 BEST CARE AT LOWER COST RELIABILITY AND FEEDBACK EMBEDDED SAFEGUARDS—SUPPORTS AND PROMPTS TO REDUCE INJURY AND INFECTION CASE Sepsis Treatment Protocols at Kaiser Permanente To better diagnose and treat community-acquired sepsis, in July 2009, Kaiser Permanente established early-intervention protocols through its Sepsis Care Performance Initiative. The findings from the Initiative dramatically demonstrated the importance and impact of early intervention on clinical patient outcomes. Kaiser Permanente nursing, physician, informatics, and quality leaders translated existing guidelines into specific competencies, practices, and roles for the care delivery staff. Changes in patient care protocols in the ED and ICU provided early recognition and treatment intervention opportunities. The clinical teams became more proficient in inserting central lines and utilizing hemodynamic monitors for continual monitoring of central venous pressure, oxygenation, and mean arterial pressure through training and simulation. Patients in the early stages of sepsis were identified more quickly through EMR decision support, allowing for targeted therapy to be administered within an hour of diagnosis using resuscitation bundles of broad spectrum antibiotics, fluids, and hemodynamic support during a 6-hour period. RESULTS • Sepsis mortality reduced by over half (26 percent to 10 percent) • ~3-fold increase in the number of sepsis cases diagnosed (now 119.4/1,000 admissions) • ~3-fold increase in the number of admitted patients with blood culture who had serum lactate drawn in ED (now 97 percent) • 3.5-day decrease in the length of stay for patients with a principle diagnosis of sepsis • 93 percent of patients with sepsis treated within 1 hour of diagnosis (19 percent increase) FOR MORE INFORMATION Please contact: Ruth Shaber, MD (ruth.shaber@kp.org) xxxii

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APPENDIX B 379 RELIABILITY AND FEEDBACK EMBEDDED SAFEGUARDS—SUPPORTS AND PROMPTS TO REDUCE INJURY AND INFECTION CASE Reducing Pharmacy Errors at Partners To reduce serious medication errors, in 2003 Brigham and Women’s Hospital (BWH), a member of the Partners HealthCare System, implemented pharmacy barcoding, in which pharmacists barcode-scan all medications dispensed from the pharmacy to ensure that the medications match physicians’ orders (which are entered electronically via computerized physician order entry [CPOE]). In addition, in 2005, BWH implemented electronic medication-administration records (EMAR)/barcoding at the bedside, in which nurses scan medications prior to administration to patients, and are alerted about possible errors. RESULTS • $3.3 million in cumulative 5-year savings (costs recouped within first year) • 31 percent reduction in serious medication-administration errors • An annual savings of $2.2 million from decreased adverse drug events • Increased on-time medication availability on nursing units FOR MORE INFORMATION Please contact: Tejal Gandhi, MD, MPH (tgandhi@partners.org) xxxiii

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380 BEST CARE AT LOWER COST RELIABILITY AND FEEDBACK EMBEDDED SAFEGUARDS—SUPPORTS AND PROMPTS TO REDUCE INJURY AND INFECTION CASE Reducing MRSA at VHA Hospitals In response to growing concerns about methicillin-resistant Staphylococcus aureus (MRSA) health care–associated infections (HAIs), in 2007 the VHA implemented a MRSA Prevention Initiative to decrease MRSA HAIs in acute care VA hospitals nationwide. The focal point of this initiative consisted of a bundle of evidence-based practices known as the “MRSA Bundle”—universal nasal surveillance for MRSA, implementation of “contact precautions” for patients infected and/or colonized with MRSA, renewed emphasis on hand- hygiene practices, and an institutional culture change in which infection prevention and control became everyone’s responsibility. Furthermore, management support was provided for a newly recognized position at each medical center known as the MRSA Prevention Coordinator (MPC), who coordinates local medical center implementation efforts of the initiative with the national MRSA project office. Currently, the MRSA Prevention Initiative is being expanded to become the Multidrug-Resistant Organisms (MDROs) Prevention Initiative and will target other MDROs that contribute to health care–associated infections. RESULTS • From October 2007 to June 2010, MRSA HAI rates declined by 62 percent in VHA ICUs nationwide • During this same period, non-ICU MRSA HAI rates fell by 45 percent • Approximately 1,000 MRSA HAIs were prevented during this period • Currently, more than 70 percent of VHA facilities report zero MRSA HAIs monthly FOR MORE INFORMATION Please contact: Martin Evans, MD (martin.evans@va.gov) xxxiv

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APPENDIX B 381 RELIABILITY AND FEEDBACK 3 Internal Transparency—visible progress in performance, outcomes, and costs • CASE Chronic Disease Patient Registries at Denver Health To improve population health and reduce variation in practice among primary care providers, in 2006, Denver Health began developing preventive health and chronic disease patient registries for the 100,000 users of their community health center network. A prerequisite for this work is the use of a single-patient identifier to link care from multiple sites to a single patient. Step 1 in the registry development was the selection of high-impact and high-opportunity areas of focus: diabetes care, hypertension care, and cancer screening. Step 2 was the creation of an assignment algorithm so that each user of the primary clinics is assigned to a medical home and a primary care provider (PCP) based on services utilization in the prior 3 years. Step 3 was the development of outreach tools for individual clinicians to manage patients between visits. Step 4 was the creation of performance report cards aggregated across patients and time and populated by nearly real-time data. An essential feature of the report cards is the transparent display (i.e., without blinding) of performance by site of primary care and by PCP, which has driven reduced variation and improved overall performance. RESULTS • Colorectal cancer screening rates nearly doubled in 3 years after starting at 32 percent • Breast cancer screening rates increased by 20 percent in 3 years after many years of flat performance • Hypertension control rates increased from 60 percent to 72 percent in 3 years FOR MORE INFORMATION Please contact: Tom MacKenzie, MD (thomas.mackenzie@dhha.org) xxxv

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382 BEST CARE AT LOWER COST RELIABILITY AND FEEDBACK INTERNAL TRANSPARENCY—VISIBLE PROGRESS IN PERFORMANCE, OUTCOMES, AND COSTS CASE Internal, Non-Blinded Performance Transparency at Cleveland Clinic To engage providers in quality improvement and waste reduction, Cleveland Clinic implemented web-based business intelligence tools to collect and display provider performance data for a wide variety of metrics. By giving providers transparent access to metrics that identify variations in practice, utilization rates, and performance against internal and external benchmarks, Cleveland Clinic saw dramatic reductions in waste, improved quality, and a sustained change in culture, as practitioners take pride when they do well and foster the desire to change when they recognize the need to improve. RESULTS • >40 percent reduction in ICU central line–associated bloodstream infections (CLABSIs) • 50 percent reduction in ICU urinary tract infections per 1,000 patient days • Cost avoidance of $30,000 for each CLABSI and $5,000 for each urinary tract infection • Increased compliance in administration of pneumonia vaccinations to a sustained level near 100 percent • 13 percent increase in operating room on-time first starts • 10 percent improvement in transferred patients assigned to a receiving bed within 12 hours or less • 10 percent reduction in blood units used per 1,000 patient days FOR MORE INFORMATION Please contact: Robert Wyllie, MD (wyllier@ccf.org) xxxvi

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APPENDIX B 383 APPENDIX II Identifying Unnecessary Services The Checklist addresses the systems-level issues central in transitioning to high-value care—care that improves outcomes while reducing costs. Part of the systems-level change necessary requires identifying unnecessary services and engaging individual practitioners to be better stewards of limited resources. Summarized below are examples of recent analyses and inventories that have been developed to identify services that are often overused, unnecessary, or were otherwise wasteful. National Physicians Alliance 1 Members of the National Physicians Alliance’s Good Stewardship Working Group identified common clinical activities that could lead to higher-quality care and better use of finite clinical resources. These are presented as “top 5” lists for primary care, internal medicine, and pediatrics. • Primary care 1. Don’t do imaging for low back pain within the first 6 weeks unless red flags are present 2. Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis 3. Don’t order annual ECGs for asymptomatic, low-risk patients 4. Don’t perform Pap tests on patients younger than 21 years 5. Don’t use DEXA screening for osteoporosis for women under 65 or men under 70 with no risk factors • Internal medicine 1. Don’t do imaging for low back pain within the first 6 weeks unless red flags are present 2. Don’t obtain blood chemistry panels or urinalysis screenings for asymptomatic, healthy adults 3. Don’t order annual ECGs for asymptomatic, low-risk patients 4. Use generic statins when initiating lipid-lowering drug therapy 5. Don’t use DEXA screening for osteoporosis for women under 65 or men under 70 with no risk factors • Pediatrics 1. Don’t prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus 2. Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors 3. Don’t refer OME early in the course of a problem 4. Advise patients not to use cough and cold medications 5. Use inhaled corticosteroids to control asthma appropriately 1 The Good Stewardship Working Group. 2011. The “Top 5” lists in primary care: Meeting the responsibility of professionalism. Archives of Internal Medicine 171(15):1385-1390. Reproduced with permission from the American Medical Association. xxxvii

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384 BEST CARE AT LOWER COST American College of Physicians2 A working group of the American College of Physicians convened a workgroup of physicians to identify common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The 37 situations identified are listed below. 1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study 2. Performing coronary angiography in patients with chronic stable angina with well- controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing 3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I to II/VI short systolic, midpeaking murmurs that are audible along the left sternal border 4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3 to 5 years 5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function 6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease 7. Obtaining exercise electrocardiograms for screening in low-risk asymptomatic adults 8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results 9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure 10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles 11. Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women 12. In asymptomatic women with previously-treated breast cancer, performing follow- up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging 13. Performing DEXA screening for osteoporosis in women younger than 65 years in the absence of risk factors 14. Screening low-risk individuals for hepatitis B virus infection 15. Screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease 16. Screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years 17. Repeating colonoscopy within 5 years of an index colonoscopy in asymptomatic patients found to have low-risk adenomas 2 Qaseem, A., et. al. 2012. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 156:147-149. Reproduced with permission from the American College of Physicians. xxxviii

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APPENDIX B 385 18. Screening for prostate cancer in men older than 75 years or with a life expectancy of less than 10 years 19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk 20. Performing imaging studies in patients with nonspecific low-back pain 21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology 22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery 23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding 24. Performing serologic testing for suspected early Lyme disease 25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease 26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes 27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination 28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination 29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis or underlying heart disease is suspected 30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery 31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features 32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism 33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism 34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules >4 mm in low-risk individuals 35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma) 36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia 37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms xxxix

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386 BEST CARE AT LOWER COST ABIM Foundation’s Choosing Wisely® Campaign3 The American Board of Internal Medicine (ABIM) Foundation has worked with various physician specialty societies to identify common tests and procedures that may be overused or unnecessary. Each society developed a list of “5 Things Physicians and Patients Should Question,” which contains evidence-based recommendations for physicians and patients to consider when making care decisions. Below are the lists for the initial nine specialty societies. Eight more societies are expected to contribute lists in Fall 2012. • American Academy of Allergy, Asthma & Immunology (AAAAI) 1. Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy. 2. Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis. 3. Don’t routinely do diagnostic testing in patients with chronic urticaria. 4. Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated. 5. Don’t diagnose or manage asthma without spirometry. • American Academy of Family Physicians (AAFP) 1. Don’t do imaging for low back pain within the first six weeks, unless red flags are present. 2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement. 3. Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. 4. Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms. 5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. • American College of Cardiology (ACC) 1. Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. 2. Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients. 3. Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. 4. Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. 3 Available at http://choosingwisely.org/?page_id=13. Reproduced with permission from the American Board of Internal Medicine Foundation. xl

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APPENDIX B 387 5. Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI). • American College of Physicians (ACP) 1. Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease. 2. Don’t obtain imaging studies in patients with non-specific low back pain. 3. In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). 4. In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test. 5. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. • American College of Radiology (ACR) 1. Don’t do imaging for uncomplicated headache. 2. Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. 3. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. 4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. 5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. • American Gastroenterological Association (AGA) 1. For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals. 2. Do not repeat colorectal cancer screening (by any method) for 10 years after a high- quality colonoscopy is negative in average-risk individuals. 3. Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy. 4. For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines. 5. For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms. xli

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388 BEST CARE AT LOWER COST • American Society of Clinical Oncology (ASCO) 1. Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence- based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti-cancer treatment. 2. Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis. 3. Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis. 4. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent. 5. Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication. • American Society of Nephrology (ASN) 1. Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. 2. Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia. 3. Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes. 4. Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology. 5. Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians. • American Society of Nuclear Cardiology (ASNC) 1. Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present. 2. Don’t perform cardiac imaging for patients who are at low risk. 3. Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients. 4. Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery. 5. Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely. xlii