Monthly Archives: April 2015

Two ideas to reduce laboratory and radiology utilization

 

 

I attended the Southwest LHIN Primary Care Congress today, during which Dr. Jeff Turnbull of Health Quality Ontario gave a great talk that touched on the need to curb utilization wherever appropriate. Certainly reducing unnecessary diagnostic tests and therapeutics is a passion of mine, as I wrote about in a previous blog post, Resolve to be a rationally prescribing and rationally ordering physician.

Of course this is not an easy topic to address. One physician’s unnecessary test is another physician’s appropriate test. Guidelines do give us some insight into relative right and wrong, but the freedom of physician judgement is still considered relatively paramount by many. The idea of financial punitive measures for “inappropriate” testing would be met by many physicians with fierce opposition. My hope is that through education, and not legislation, that we can optimize evidence-based ordering of tests.

Physicians know that a big chunk of utilization is driven by patients who are increasingly demanding tests that may not be indicated. Many of us spend multiple visits each day explaining to patients why Test A is not indicated, and it would be naïve to think that some physicians are not giving into these demands out of sheer fatigue. So part of the solution will have to be patient education in addition to physician education.

Idea #1: The provincial government mandates that any approved laboratory or diagnostic radiology site include an itemized/total cost amount for a particular set of tests on the bottom of any report that is sent back to a physician.

Rationale: We need to be honest that most physicians have no idea what the tests they order cost the system. Giving cost feedback after the fact may influence any unnecessary ordering next time around. Education is never a bad thing, especially when we know that the physician has a 100% chance of seeing that dollar figure.

Idea #2: A website set up where Canadian physicians would choose from a drop down menu: their province, lab or radiology, and the tests intended to be ordered. Using fee codes from the province, the website would calculate the projected total amount of the testing.

Rationale: This could be used in the office to illustrate to patients the cost of any testing they are demanding. Physicians would need to be careful not to give the impression that the test is being refused because of cost, but primarily because of lack of utility. The cost must be framed as simply an additional reason not to order the test. Physicians could also use the website independently to explore the costs of tests for interest’s sake.

Other ideas that would be harder to implement:

– Change the lab requisitions to be completely blank. If you want to order a test, you have to go through all of the trouble to actually write it out. This would be met with resistance by physicians who would argue that it would take more of their time. In reality, the unnecessary tests cost far more than a few extra seconds of thought. If there are a block of tests you order for a certain condition, you can write them out for reference somewhere convenient, but the requisition must be free-form. Removing the TSH and B12 from the Ontario requisition was difficult enough, so this idea may stagnate.

– Provincial governments to create a secure database where patients could access a list of all medical costs incurred on their Health Card over the past year. The arguments against this idea are many: cost of maintaining the system, privacy, whether high-utilization patients should feel stigmatized by the overall cost, the fact this is unlikely to change patient behaviour (when they want a test, they want it now, they don’t care what their cost was over the past year.) I could live without this database, but it’s something to consider.

 

I hope that a combination of provincial governments, the CMA, provincial associations, and the Choosing Wisely campaign see some potential value in the first two ideas, as even in the absence of empiric data, I think the potential for savings is self-evident.

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Valeant Pharmaceuticals: Not exactly a model of social conscience

For 99% of the medications I prescribe, I can’t tell you the company that produces them. I prefer it that way. Let the efficacy and safety of the medication stand on its own merits, not relying on the “brand power” that the pharmaceutical companies are aiming to create. Which company makes which product plays no role in my prescribing. Unless a company does something to really upset me.

Enter Valeant Pharmaceuticals.

Up until last week, of course I had heard of Valeant Pharmaceuticals, but apart from knowing they are a Montreal-based company, I really had no opinion on them either way.

Here are a collection of news and journal articles about them over the past two months:

Pharmaceutical Companies Buy Rivals’ Drugs, Then Jack Up the Prices – Wall Street Journal, April 27, 2015

Fair pricing of “old” orphan drugs: considerations for Canada’s orphan drug policy – Canadian Medical Association Journal, February 2015

Deal-Making Valeant Pharmaceuticals Intl Inc. Shows No Signs of Slowing Down – The Motley Fool , April 23, 2015

Valeant senior executives scored US$123 million compensation in 2014 – Montreal Gazette, April 17, 2015

All of the above give excellent insight into Valeant’s actions, and I recommend taking the time to read all four. In summary, they are buying old drugs from other companies, and jacking up the prices to exorbitant costs. Then dishing out millions to their executives. It’s like they’ve seen all of the other pharmaceutical companies trying to soften their image recently, and said “Hell no, being the villain is way more lucrative!”.

So I can complain or give you a few quick tips on how to avoid Valeant products until they change their ways (I’ll give you alternatives, but no guarantees that the alternative is cheaper in your area):

1) Acne – They produce Biacna, Aczone, Retin-A, Benzamycin, and Benzaclin. Tactuo would be the alternative (check your local prices).

2) Diabetes – They produce Glumetza. You should have already been prescribing generic metformin for a sliver of the cost, but this is another terrific reason to make the switch.

3) Lipids – They produce Lodalis. Remember, Lodalis has no evidence in reducing hard CV endpoints anyways.

4) Onychomycosis – They produce Penlac and Loprox. Jublia would be the alternative (check your local prices)

5) Asthma – They produce QVAR. Pick another inhaled corticosteroid.

6) Herpes labialis – They produce zovirax. Why are you using topical acyclovir? For the 0.5 day benefit? (Spruance SL, net R, Marbury T, et al. Acyclovir cream for treatment of herpes simplex labialis: results of two randomized, double-blind, vehicle-controlled, multicenter clinical trials. Antimicrob Agents Chemother. 2002; 46:2238-43.)

Those are the obvious targets for prescribers to make a statement to Valeant against their current practices. I would be happy to soften my stance against some of their products should they start to show some sense of a social conscience.

The Supplement Fanaticism of Some Eye Professionals

As a family physician, I have noticed a familiar refrain from patients seeing me after seeing their eye professional.

“Dr. X told me to take 5000 units of vitamin D”

“Dr. X told me to take omega-3 every day for my eyes”

“Dr. X told me to start Macuhealth”

My patients will typically ask me for my opinion about these supplements because they know I try to keep up to date from a variety of resources and will be able to give them an evidence-based opinion that respects their pocket book.

WIth the exception of the AREDS2 formula for macular degeneration (and 1 small RCT showing benefit of omega-3 supplementation in dry eye syndrome), the evidence for supplementation in the treatment and prevention of eye disorders is of poor quality. It is generally a hodgepodge of animal studies, small human studies, and proposed “mechanisms” to rationalize an effect.

So in the context of poor evidence, why are seeing such zeal from these health professionals about supplements? I am confident that the majority are not advocating for supplements out of any malice or any financial interests.

I had an interesting discussion this week with a local optometrist. We share many patients, many of whom have told her my opinions on the supplements that she recommends. She seemed genuinely convinced by the evidence she has read, and provided me with her two favourite resources: Vitamin D Wiki and GrassRootsHealth. She encouraged me to check out both, sure that I would be convinced by the overwhelming content on both sites.

After only a couple of minutes of perusing the sites, I noticed a glaring problem. Where were the negative studies? Both sites fanatically promote vitamin D deficiency as a plague in our society, and believe in supplementation as a panacea to our ills. They link to hundreds of studies of generally poor methodological quality, and most favour a benefit to vitamin D. But any negative studies they include are followed by multiple points that question the validity of the study (like this one). They are not critical of positive studies with the same skepticism. It’s all studies showing benefit, without a whisper of dissent.

And if you’re supposedly the #1 resource for all things vitamin D, shouldn’t this article be on your front page this month?

These resources are written by vitamin D believers. They see any evidence through the lens of someone who already believes in vitamin D. If it is counter to their belief, it is ignored. If it supports vitamin D, it is promoted. Quite simple. That’s quackery, not science.

The GrassRootsHealth website is particularly egregious, as they feature a link to Mercola’s supplement store, and also sell vitamin D tests to consumers, the profits of which go to further vitamin D advocacy. It’s a vicious cycle of supplementation. (Aside: if you link to Joe Mercola, you have lost scientific credibility until proven otherwise).

The Macuhealth product endorsed by many optometrists is another interesting study in questionable promotion methods. Check out their website. All promotion, little evidence. And the evidence they do provide is largely mechanism-based theory, not showing the hard clinical endpoints that we would expect from a product. The link on their site for health professionals to “become a provider” is an automatic red flag. What would my patients think if I were to sign up with Pfizer to “become a provider” for Viagra? The potential conflict of interest would be enormous.

So I ask all eye professionals to be skeptical. Don’t recommend supplements out of a sense of “needing to do something”. Patients deserve to receive evidence-based advice, and to have their pocket books respected. It is an uncomfortable feeling to have patients with vision-threatening disease and not take a flyer on a potential “cure”, but we need to take a critical, science- and evidence-based approach to our recommendations.

Hospital MDs and Community MDs: Let’s start talking again

Speak to any doctor of an older generation and they will tell you the same refrain: doctors in big cities just don’t talk to each other any more. Whether it is because of community doctors becoming increasingly siloed from the hospital, or the increasing use of electronic communication, certainly the telephone is not being picked up as often as in years past.

Is there anything inherently wrong with this? Well if was just a matter of times changing and doctors finding more efficient ways to perform certain processes, then no, there wouldn’t be any problem with this. But I think it’s fair to say that the quality of communication as a whole between hospital physicians and community physicians has declined over time.

Nowhere is this communication more important than in patient transitions between community and acute care. In smaller communities where their primary care physician is also their hospitalist, the transition of the patient from community to acute care and back is seamless. But in larger centres, it is often not practical for primary care physicians to perform this role, leaving it to hospitalists or surgical teams to manage all aspects of patient care.

Let’s start off with the premise that primary care physicians often have invaluable information that would improve the acute care of our patients. Primary care physicians are considered the “quarterback” of a patient’s journey through the health care system, and typically have a great deal of insight into the patient’s medical history, social history, values, and goals. A patient’s admission to hospital is often a stressful event both for the patient, their family, and for hospital staff, who try to piece together fragments of their medical history to provide safe, high-quality care. Important details about a patient’s history may remain hidden from the hospital staff, potentially adding to morbidity and to duration of hospital stay.

 

Most will point to already-burdened schedules as the main limitation to finding time for this communication to happen. A recent article in the New England Journal of Medicine(http://www.nejm.org/doi/full/10.1056/NEJMp1411416) proposed a system whereby primary care physicians would visit their patients within 12-18 hours of admission to provide support and counselling to the family, consultation to the hospitalist team, and provide direction and scope of the patient’s workup and care. While this is a potentially useful model in some centres, it would be completely impractical in London and at London Health Sciences Centre. The logistics of having a family physician visit all newly-admitted patients within their schedules would be too challenging to overcome in the short-term. The issue of remuneration through OHIP for this would also be a significant barrier.

I recently met with my LHSC Internal Medicine colleague Dr. Andrew Appleton to discuss possible solutions to improve this communication. We weighed the idea of a Quality Improvement Project to look at introducing “mandatory communication”, whereby a trainee or staff physician would initiate a phone call with the primary care physician at admission and discharge to review medication changes, recent diagnostics ordered, recent office visits, previous admissions, previous barriers to discharge, home care, family contacts, values, goals, and follow-up plans.

We came to the conclusion that this type of QIP project would be futile for a couple of reasons. First, it would be difficult to show an improvement in hard outcomes over 6-week period we were proposing in the study. If six weeks went by without significant meaningful information shared, the entire concept of improved communication may be prematurely disregarded as a waste of time. Second, even if we were to show an improvement in hard outcomes, implementing a “mandatory” program hospital-wide would be sure to create resentment in physicians who would have to make calls even in situations where they are certain they don’t need primary care input.

So we’re left with the knowledge that sharing of information would be beneficial, but a mandatory program is not likely the way to go. Our attempt at a solution is to gradually change the culture around this communication.

At the hospital level, educate hospital teams and staff physicians that primary care physicians are generally happy to respond to telephone calls asking specific questions regarding their patient’s history and care. Family physicians are not compensated for phone calls with non-MDs, so if a non-MD is to call, these calls should not be open-ended fishing expeditions, but have a clear focus and short duration. At the beginning of each trainee block, the senior resident should encourage trainees to communicate with family physicians when appropriate, as they may not be used to doing so in other rotations or jurisdictions. (As an aside, there should be a hard look at the physician schedule of benefits in Ontario that limits compensation to 10+ minute conversations between MD and MD. I would propose a separate fee for 5 minute conversations, as well as remuneration for communications with hospital nurse practitioners.)

At the family physician level, let them know to expect a slightly higher volume of calls from hospital physicians, and to try to respond promptly to these calls. Here in London, the London Hospitals Electronic Notification Service (LENS) notifies each family physician daily about any patient admissions, discharges, or ER visits. If a family physician has a patient admitted to hospital and feels they have any relevant information to share, they should be encouraged to call the admitting staff physician directly.

This culture will not change overnight, but our hope is that if a few physicians in each community can take the lead, the lines of communication will re-open and we will see improved patient outcomes and satisfaction.