Introduction to High Value Care
in Endocrinology
Evan Klass, MD
October 29, 2015
WHY?
• Unsustainable growth in health care costs
– $253B in 1980 to $2.6T in 2010
• Estimated 30% ($750B) spent on unnecessary
care
– Avoidable costs that would not reduce quality
• Failure to rein in waste may result in poorly
focused, across-the-board cuts
– Desperate circumstances lead to desperate
measures!
choosingwisely.org
2014 physician attitude study
• 73% of physicians recognize unnecessary testing as a
problem
• 66% feel responsibility to make sure patients avoid
unnecessary tests
• 72% say the average physician orders an unnecessary
test at least once a week
• 70% say that after discussion with a patient the
patient often avoids the test
choosingwisely.org
Partners
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Consumer Reports
American College of Physicians
American Academy of Family Physicians
American Academy of Nursing
Endocrine Society
And many other professional and consumer
groups
High Value Care
• Weinberger proposes HCV as a seventh
“clinical competency”
• Laine suggests- “slow down and consider if the
test is a duplication, if it will change
management of the patient, and recognize the
potential for risk or downstream effects of
false-positives (including incidentals)”
• So it’s not a guideline but a way of thinking!
Choosing Wisely/Endocrine Society
• Avoid routine multiple daily self-glucose
monitoring in adults with stable type 2
diabetes on agents that do not cause
hypoglycemia
– Get the most bang for the buck
• Once or twice a week testing
• Vary testing times
• Intensify testing during illness or when adjusting meds.
Choosing Wisely/Endocrine Society
• Don’t routinely measure 1,25dihydroxyvitamin D unless the patient has
hypercalcemia or decreased kidney function
– Levels do not reflect whole body vitamin D stores
– Levels tend to go up (not down) in vitamin D
deficiency
– Unregulated 1,25 dihydroxy D is rare- sarcoidosis,
other granulomatous diseases
Choosing Wisely/Endocrine Society
• Don’t routinely order a thyroid ultrasound in
patients with abnormal thyroid function tests
if there is no palpable abnormality of the
thyroid gland
– The probability of identifying and unrelated
nodule and diverting attention from the functional
disorder is great
– A sonogram will not confirm the etiologic
diagnosis- nuclear scanning is preferred
Choosing Wisely/Endocrine Society
• Don’t order a total or free T3 level when
assessing levothyroxine (T4) dose in
hypothyroid patients
– T4 is converted to T3 intracellularly
– Intracellular T3 in the pituitary determines TSH
secretion, hence a normal TSH indicates adequate
thyroxine dosing
– T4 levels in those on thyroxine may be a bit higher
and T3 a bit lower than those with normal thyroid
function
Choosing Wisely/Endocrine Society
• Don’t prescribe testosterone therapy unless
there is biochemical evidence of testosterone
deficiency
– Are there clinical sx?
• Loss of libido, erectile dysfunction, and poor AM
erection
– Is there reliable biochemical support?
• Total T< 300
• Free T does not improve sensitivity or specificity
Pertinent Data Sets
• Getting the most out of consultations
• Allow effective triage
• Reduce waste