**Transcript of Cyberseminar**

**Timely Topics of Interest**

**2014 Under Secretary Award- Improving the Value of Health Care- A VA Health Service’s Researcher’s Journey to Identify, Communicate and Implement High Value Care**

**Presenter: Timothy J. Wilt, MD, MPH**

**April 21, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact**timothy.wilt@va.gov**.*

Moderator:It looks like we are just at the top of the hour so we are going to kick things off here. Today’s session is a part of our timely topics that interest Cyberseminar Series and we are presenting the Undersecretary Award Improving the Value of Healthcare. We have David Atkins Director of HSR&D here to kick off today’s session. David can I turn things over to you?

David Atkins:Yes, can you hear me okay?

Moderator:We can hear you yes. 

David Atkins:Great. Thank you. It is a real delight to introduce Dr. Tim Wilt as the recipient of the 2014 Undersecretary’s Award for Outstanding Achievement in Health Services Research. This is the highest award that we give for VA Health Services Researchers. This year as every year it is a highly competitive award but the selection Committee was unanimous in giving it to Tim Wilt. I would like to think I could take credit for it, but I cannot, this is really a vote of his peers in research, including many past awardees. I have been lucky enough to know Tim not just through the five years I have been at VA, but for more than five or ten years prior to that when I worked at AHRQ. Tim really embodies the best of research and especially the best of VA research in that he combines an unrelenting commitment to science over politics or opinion. A commitment to the veterans that we serve. A commitment to training the next generation of researchers and through that all he has had an impressive impact on practice not just in the VA but outside the VA. 

Tim really is an unusual researcher because he spans a combination of doing high profile clinical research, such as the landmark PIVOT trial which was published a little more than a year ago in the *New England Journal of Medicine* “Looking at the Early Stage of Prostate Cancer”. That was a trial that was years and years in the making and would not have succeeded without Tim’s unrelenting dedication to getting answers to an incredibly important controversial issue which is “What is the Value of Detecting and Treating Early Prostate Cancers in the Error of PSA Detection”.  Tim has expanded his interest to a wide range of interests in screening and through that has been elected to the U.S. Preventative Services Task Force and to other committees where he has really been influential in taking a rigorous look at the benefit and downsides of our attempts to screen for early disease. I think what has impressed me most about Tim is that he is not afraid to stick to science in the face of very contentious and sometimes heated arguments that are often mixed with very strong personal opinions and attempts at political influence as we have seen in arguments over screening and controversies such as mammography. I think like all good researchers he thinks science and good data, while they do not necessarily speak for themselves they really are what we owe our patients rather than opinions that we think will be less controversial or make people happy. 

Tim will be talking today about this sort of career path and how it is made an influence in some of the challenges he has faced. Without further ado I am delighted to turn it over to Dr. Tim Wilt. 

Dr. Tim Wilt:Thanks a lot David, I want to thank everyone from taking time today to be here and hear what I have to say. I would also like to give a special thanks and shout out to my colleagues both in Minneapolis and at our Minneapolis VA Center for most definite excellent RCCDUR, colleagues are downstairs join the talk I hope with popcorn, candy and some soda pop in our party, I mean our conference room downstairs. 

I want to talk a little bit about improving healthcare value let me see if I can work the screen so I can get it to move forward. I am hitting the scroll button and not getting the screen to move forward, if someone could help.

Moderator:You need to hit that arrow in the lower left hand corner first and after that you will be able to hit your scroll button. 

Dr. Tim Wilt:Lower left hand corner first.

Moderator:Yes take your mouse, lower left hand corner and click on the arrow going to the right. 

Dr. Tim Wilt:Alas, there is no arrow in the lower left hand corner. 

Moderator:Oh your internet just failed. 

Dr. Tim Wilt:Okay, in any event when the internet comes back up, unfortunately I have it right in front in me, so I want so I am going to keep rolling until I see it come back up. Is everybody else seeing things? 

Moderator:Yes and I will forward you our slides as you need them forwarded. 

Dr. Tim Wilt:Okay so the next slide please. As David mentioned, the awardee was really assessed on a variety of different metrics. In taking a look at this, I recognized both the opportunity and responsibility that this pertained to. Then I got a phone call from our hospital director kind of congratulating me about and asking me – well Tim how come they gave it to you? Next slide please. I told him it was kind of like an achievement award, he good naturedly told me well maybe it is just that you are ‘slow and old’ and I think there is something to be said for that, but I would like to view it more as being ‘steady and experienced’. Next slide. 

When Dr. Atkins and Knight called I was really left sort of speechless with nothing more than saying oh wow. But then I recognized that they had actually know about this award for a long time but it was still a month or so in the making before I found out because I understood they had to do a background check on me to make sure there was nothing in my past that would cause embarrassment to the VA. I guess because I am here today, that ensures that there was nothing embarrassing. But if they just would have asked a little further I could have probably have found them some information. Next slide. 

They could have seen this slide and this would have been me getting ready to go for a bike ride this wintertime in Minnesota at twenty-five degrees below zero. Or if they would  have dug a little deeper, next, would be this photo back in high school with me playing the part of Luther Billis in *South Pacific* and you have to love those sideburns. I guess it was not enough to keep me from the award. As any mild mannered reported from a great metropolitan newspaper I might be an action hero by off hours, but during the daytime, next slide, I am just a health services researcher. Because this is a cyberseminar many of you may not  know who I am. This is what I really look like today. Next slide. 

My area of work has been in high value healthcare. Next. 

My work focuses on the area of practice, policy and research and tries to be at the center of that and tries to make it very practical in relationship to the healthcare practice that we have. Next. 

My research goals have been to improve healthcare delivery by defining, identifying communicating and implementing high value care with an emphasis on reducing overuse of low value care. Next. 

My research focus has been in the area of health, promotion and disease, prevention, detection and treatment. Focusing on chronic conditions in older adults including cancer screening and treatment and neurological diseases. Next. 

I have used a variety of research methods to attempt to identify new evidence, evaluate existing evidence and disseminate and implement best evidence. Next slide. 

I have often thought about what has been the key to my success. Next. 

First and foremost I have to say I have been incredibly fortunate to work with outstanding individuals who have helped me learn as much as I think I have taught others. They have been creative, hardworking and fun. There have been many times when I have just been flat out lucky, something could have happened one way, and it went the other and I encourage people to think about that, the good fortune that they had and the opportunities and the luck that they might have and seize that. Next please. 

But first it has to start with a nominator. Nobody can get this award unless they are nominated for it and I had an outstanding nominator in Dr. Maureen Murdoch who came into my office and said, you are going to get the Undersecretary’s Award and I am going to nominate you. She was tireless and completely committed to getting me nominated for this and I thank Maureen for her outstanding work. Next. 

Everybody knows that the best way for us to look good is to work with really good people and I work with outstanding individuals, a great research team that I have worked with for many of them nearly twenty years including Nancy, Maureen, Indie, Rod and Brent. What we know is that when are in our phase of the career, our job is really to kind of set the vision, to motivate and inspire. Maybe get the funding, but then also learn from them as much as I help teach them and I have learned a lot from them and I thank them. Next. 

It is also to have support of central leadership. And that began with Dr. Dan Daykin who was the original Director of the Cooperative Studies Program in Health Services Rese**a**rch Program. When I first proposed the PIVOT study all the way through David Atkins who really brought over from ARC with a new idea The Evidence Based Synthesis Program which has really been fundamental in my work and I think helping to bridge the gaps between research, practice and policy. Next.  

Now also I had great leadership within our cooperative studies program and that Weismann and Karen Jones at our Cooperative Studies Program have  helped run, collect the data needed for the PIVOT study. Next. 

Then to have outstanding local leadership in Hannah Bloomfield our original Center of Excellence Director and Steve Fool who has taken that on and moved it forward to help lead our Center today. Next. 

Furthermore to have opportunities, collaborators and funders who believed in what I have done and what we do here at VA to implement practice that matters. Next. 

Then finally they have a wide and lifelong partner, Christine Ellsroot [sp] who is a general internist and researcher who is my intellectual superior, who supported and stood by me when times are good. Next. 

And when they get a little bit tough as seen here on a windy, blustery, rainy day on the summit of Mount Washington. Next slide. 

So what else? That my just about wrap it up. Well next slide. 

You probably do need a couple of good ideas and I have been fortunate enough to think they have a few of those. Next. 

In the area that I am probably most well-known and I have most focused on has been the area of prostate cancer screening and treatment. Next. 

Why prostate cancer? It is common; it is serious; it has high healthcare utilization. Next. 

And detection and treatment are uncertain with regard to PSA screening benefits, harms and costs and the wide variety of treatment options. Next. 

Further primary care physicians have an important often unrecognized role in the management and treatment decisions with their patients. Next. 

So you have to start somewhere and it is not always a glorious start. But in the era before IRB watching over everything my resident Alan Cover and I were sitting in the conference room debating about physician performance and patient perceptions during a rectal examination. Next slide. 

So we conducted a survey of patients and residents and asked them this information and really found that they had wide variability in their practice and knowledge and recommended that further training was needed in this area. Next. 

Add that on to some early healthy skepticism in the area of prostate cancer screening and treatment. We wrote a letter to the editor to accompany a paper by Dr. Johansson which said that “without evidence of benefit from controlled clinical trials the radical treatment of early stage prostate cancer remains in its experimental phase”. We disagreed with that editorial statement by Oesterling that recommended a serum PSA concentration on a digital rectal exam. Next. 

Because such an editorial position is of particular concern because an ongoing national prostate cancer screening program organized and sponsored by a pharmaceutical corporation also pressures physicians to adapt screening strategies of unproven benefit. I think that statement really became quite prominent, quote prophetic as we move forward in the area of PSA screening. Next slide. 

That led me on to working on other areas about informing patients about the uncertainty of prostate cancer screening, trying to help them reduce PSA anxiety. I have been very fortunate and privileged to work with Dr. Melissa Partin a VA HSR&D career scientist and our Center Associated Director in trying to improve messaging and decision making for our patients both in the area of prostate cancer and breast cancer screening. These papers became not only opinion pieces but really helped us to think differently and hopefully shift both how we and others have thought about the complexity and the uncertainties about cancer screening and the importance of understanding benefits, harms, costs and good communication. Next slide. 

That led Dr. Partin to conduct a randomized trial that examined the effects of two prostate cancer screening and educational interventions on patient knowledge, preferences and behaviors. Next slide. 

Dr. Partin and I and others found that mailed interventions enhance patient knowledge and self-reported participation decision making and after screening preferences. The pamphlet and video interventions were comparable  in effectiveness and the lower cost pamphlet approach is an attractive option for clinics with limited resources. Next. 

A higher value option. Next slide. 

We also used VA clinical databases to evaluate Radical Prostatectomy among  Veterans Affairs Medical Centers. Next slide. 

What we showed was that there are marked variations across age groups and year in rates of radical prostatectomy per one hundred thousand users. Next slide. 

And that there is considerable regional variation varying more than sevenfold from states in white to states in black with the rates of the radical prostatectomy per VA users. Next slide.

We therefore concluded that utilizations of radical prostatectomy increased over time and varied across geographic regions. And that differences in utilizations may be due to uncertainty regarding the effectiveness of early detection and treatment of prostate cancer. Next slide. 

That led us on to conduct a systematic review funded by the agency for health research and quality that will get the comparative effectiveness and harms of treatments for clinically localized prostate cancer. Next slide. 

We found that the results are low in their quality and consistency and very few randomized control trials existed. So rather than being able to conduct any meta-analysis we felt that the best way to present this information was graphically like this. What we showed was that there was wide in prine intervariation across treatments throughout years in overall survival. Next slide. 

We also looked at adverse effects and we also found that adverse effects were infrequently reported  vary widely and when they were reported there was often a wide variability in the definitions of those particular adverse events. Next slide. 

Therefore we conclude that the assessment of the comparative effectiveness and harms of early stage prostate cancer is difficult due to the limitations in the evidence. Next slide. 

In an attempt to address that uncertainty I proposed a randomized cooperative study to the Department of Veterans Affairs, the National Cancer Institute and the Agency for Health Research and Quality Cooperative Study #407, the Prostate Cancer Intervention Versus Observation Trial for PIVOT. Next slide. 

We attempted to use this randomized trial to address the following key clinical question that I felt was really fundamental in the way we treated patients with early stage prostate cancer. Among men with clinically localized prostate cancer detected during the early PSA era, does the intent to treat with radical prostatectomy reduce all-cause and prostate cancer mortality compared to observation? Does it help you live longer and does it help prevent death from prostate cancer? Next slide. 

It was not easy, it was not universally applauded. Here is one of our reviewers, “I am afraid that although this is an excellent question, I would recommend that this proposal not be entertained because in my opinion it would never be completed”.  Next slide. 

Fortunately we had another reviewer who said “Such a study would be far more important than virtually any study ongoing in the U.S. for prostate cancer”. Here is where I got lucky, Dr. Daykin looked me in the eye at our first planning meeting and he said “Tim there is no way we are not funding this study”. You know I just really thanked him for that and just recognized that he had a vision that this was really an opportunity for VA and VA only to lead in this area on a controversial topic and without his leadership in that, this study never would have gone forward. Next slide. 

It was a question that has been vexing the clinical community for well over a decade, Dr. Hugh Hampton Young performed the first radical prostatectomy in 1904. Next. 

The first VA trials on prostate cancer treatment were conducted in the 1960s and 1970s and actually conducted here and coordinated out of here in Minneapolis and Donald Gleason of the Gleason Histopathological Classification was a pathologist here. Next slide. 

Our plan was approved in December, 1992. Next. 

It was eighteen years later that we finally concluded with closeout. Next. 

More than two years later we published our results in the *New England Journal of Medicine*. To give you another evaluation or understanding of how long this was, I will show you the next slide. 

My first daughter was born about the time that PIVOT was conceived. Next. 

About two years later I got our funding approval for this study, it was not an April Fool’s joke, it came though on April Fool’s Day and signed by Dan Daykin. Next. 

Soon after our second daughter was born. Next. 

PIVOT continued and our family grew of age and traveled around. Next. 

My first daughter graduated from high school. Next. 

And my second daughter graduated from high school. Next. 

This was not an easy study, we went through a variety of rough times, as kind of David alluded to. It was not the most popular idea to randomly assign men with cancer to either surgery or observation. And we had difficulty with recruitment. Next. 

So then I would often get letters like this from our new Cooperative Studies Director Dr. Jack Feussner in 1999, I called it Judgment Day We Face Termination. This letter was kind of the scroll of Dr. Feussner  at the very top, says “I am increasingly concerned about the feasibility of completing this study. Please prepare a contingency plan that includes possible termination of the study”. Dr. Feussner really kind of played the bad cop with me but it really was motivated by his desire to ensure that we had a study that would answer the question, to motivate me to do all that I could for the care of our patients and for the truth of science. It really helped push me to kind of do what I could to make PIVOT be a quality study. Next. 

It took its toll on me, I mean here I am in the early years, go through PIVOT. Next. 

Look what it has done to me. But what I have also learned is – next. 

That you just have to keep plugging along. If you believe you have a good idea, and you have good people working for you, do whatever you can to kind of keep that study going as long as it is ethical in its merits. As many of you know who read *The Little Engine that Could* it is a story that is based on an engine but she is female in her gender and coming from a family with a wife and two daughters, I know the power of perseverance and persuasion. Next slide. 

We persevered and eventually the results came like this. Here is the notification of our primary outcomes. Next. 

Tim, “Rather than preface this with a drum roll or a big fanfare, thought I would just send along the primary outcome analysis for your review. I am not sure whether or not you had any inkling of this” I did not “but as you can see...” next.

Then “I am leaving the office for the day so I will leave you to digest the results overnight”. I got that email at about two in the afternoon on August tenth, I frantically picked up the phone to call Karen and she was gone, was not there. So I am stuck with this data going, what does it mean, what is it. Next slide. 

We kept plugging along, as I think anybody in this research world knows, this is about as good as it gets. Publication acceptance from the editor-in-chief of the *New England Journal* Dr. Jeffrey Drazen about accepting our article. Next slide. 

That resulted in the lead article in the *New England Journal*on July nineteenth. Next slide. 

Here are our primary results. That death from any cause was our primary outcome with the results of observation in blue radical prostatectomy in red with the median survival at ten years with ranges up to twelve years we saw the following. Next. 

Compared to observation radical prostatectomy resulted in a twelve percent relative and less than three percent absolute reduction in mortality that was not statistically significant. Next slide. 

With regard to prostate cancer, death from prostate cancer in men treated with observation was unusual occurring in about seven percent of men. Next. 

In compared to observation radical prostatectomy resulted in a thirty percent relative but only two percent absolute reduction in cancer mortality that was not significant. Next slide. 

Particularly in men likely be detected in the PSA area those with low PSAs of under ten prostate cancer mortality was unusual occurring in six percent or less and not significantly reduced by surgery. Next slide. 

In men considered to have low risk prostate cancer which makes up about fifty percent of men currently diagnosed, based on PSA, histology and tumor stage, death from prostate cancer was rare only about three percent of individuals and was not reduced by surgery through at least ten years. Next slide. 

Those results were presented then at an NIH consensus development conference on the role of active surveillance and observation, the management of men with localized prostate cancer now I believe helped improve screening and treatment value. Because by recommending observation in active surveillance as the consensus development conference panel did, you can maintain overall prostate cancer mortality and quality of life, reduce treatment harms and lower resource utilization and healthcare costs. Next slide. 

Now I am going to switch to my work in the area of Evidence Synthesis to Inform Clinical Practice and Policy. Next slide. 

While there are several that I could point to I would like to really focus on the work that we have done through the VA evidence synthesis program. Really I think it is an exemplary program that matches the needs of stakeholders and policymakers with the VA in the area of health information. This is a project and idea that I had for a while when I was with the U.S. Preventative Services Task Force and it just never got traction. That is to answer the question about the role of screening public examinations in asymptomatic average risk adult women. It is particularly important because recommendations and outcome output, screening for cervical cancer can be done much less frequently every three to five years. Dr. Hanna Bloomfield from our Center agreed and did a wonderful job at taking the lead on this project and help writing it up. Next slide.

This really would not have gone anywhere without the vision and determination of Dr. Linda Kinsinger, our DVA Operational partner and Director of the VA’s National  Center for Health Promotion and Disease Prevention who took the question out and really promoted it to VA Evidence Census Program to conduct a report in this area. Next. 

What we found is that there are no data supporting the use of the pelvic examination in asymptomatic average risk women, but it may cause pain, fear, discomfort, anxiety and/or embarrassment in about thirty percent of women. Next. 

Then Linda Humphrey who is the Scientific and Clinical Director at the Evidence Census Program and also serves on the ACP Clinical Guideline Panel took it up even further. She really encouraged and strongly supported the American College of Physicians to take this report and develop it into a clinical practice guideline which is currently in the making which I really believe will have widespread important and positive health impact to improve the lives of our women veterans. Next slide. 

I am also thinking to talk a little bit about my role in Clinical Practice Guidelines and Healthcare policy. This is an area and this includes U.S. Preventative Services Task Force as I mentioned the VA’s National Center for health promotion and disease prevention with their P-MAC guidelines group. The National Committee for Quality Assurance as well as the American College of Physicians Clinical Practice Guideline Committee. It is a wonderful opportunity to learn from incredibly thoughtful individuals here, it really allows you to see what stakeholders want and how stakeholders make decisions. Next. 

I strongly encourage you if you have the opportunity to be part of these types of committees. It provides you that platform to learn and also serves as an opportunity to amplify your voice, to positively influence healthcare practice far beyond anything I could have done as a single individual. Next. 

One of the first areas was in screening for breast cancer when I was early on in the U.S. Preventative Services Task Force. Our initial recommendation here was that the Task Force recommends against routine screening mammography of women age 40 to 49 and we go on to make some additional comments, but note that first line in there. Next. 

We recommended biennial rather than annual screening mammography for women between the ages of 50 and 74 years. Next. 

This took a lot of people by surprise, it came about during the time of the healthcare reform and was incredibly politically charged. You can see a new focus in breast cancer screening, that a mammogram shift, not a conspiracy and maybe there needs to be calmer talk about mammography. Next. 

We learned a lot from this and it was really a lot of fallout that came from it, but that which does not kill you makes you stronger. This was a note from somebody who would be one of our friends almost that they said that the “timing and manner of their release has done more to set back healthcare and the cause of evidence based medicine than anything I can imagine. The potential damage of releasing such a shocking reversal of recommendations on an extremely disease with no preparation or education of the public in the midst of a contentious debate on healthcare reform should have been so obvious that it is difficult to conclude that that damage was not inflicted on purpose. It was not obvious. What in heaven’s name were you people thinking?  Well we thought were just disseminating well thought out and evidence based clinical practice recommendations. I happen to be in favor of evidence based medicine and whether you are too’. Next. 

Well that led us to try and get out ahead of it and try to discuss it and try and explain what our recommendations were about. As you can see we have a lot to learn and by this kind of deer in the headlights look, we did not do a great job of communicating that message. We learned a lot from that message and we also learned that science is critical for driving healthcare practice and policy. Next slide. 

Not only me, but the VA again has been a leader in this area and Dr. Linda Kinsinger and the P-MAC and the National Center for  Health Promotion really let science guide them and the recommendations they made for mammography screening for breast cancer in our veterans. You can see that they essentially replicated what the U.S. Preventative Services Task Force recommendations were for our veterans. I believe that the science demonstrates that this is good healthcare, but you might imagine that this could cause a lot of political concerns and was not an easy thing to do from a political standpoint that I believe was the right and courageous thing to do for our veterans. Next slide. 

Moving on to prostate cancer. Many people would think prostate cancer was contentious but maybe mammography sort of tap things down or set the stage for it and I think everything does build on each other. I was the topic lead author on this report that came out in 2012 where we recommended against PSA based screening for prostate cancer. Next slide. 

Again, not everybody agreed or thought highly of what our recommendations were or felt that we had clearly looked at the data. Next. 

But what we also found was that physicians were becoming too along with the idea that sometimes screening can have harms as well as benefits and maybe those benefits do not outweigh the harms. Here you can see that about seventy-five percent agreed with the Task Force recommendations even though there might be a little variability in how they would implement that. Next. 

Again, the VA stood by and actually led in this area and has implemented clinical practice recommendations that are consistent with those put out by the U.S. Preventative Services Task Force. In one area up there in yellow a major portion of that is for us to be able to have decision and discussions between patients and their providers. Next slide. 

That has again allowed me the opportunity to work and support the work of Dr. Melissa Partin and her colleagues. She again has led work in the area of shared decision-making working with office and health promotion disease prevention develop. A shared decision-making tool the PSA tests for prostate cancer screening will let some doctors no longer recommend testing that evaluates the benefits and harms of screening and allows patients and their providers to make decision for themselves. This is really a valuable tool for our providers and patients. Next. 

Let me kind of close in the area of where my future goals have been made possible by the VA Undersecretary’s Award. It has given me confidence, it has given me opportunity, incentive and freedom and perhaps maybe even a bit of a bolley pulpit to explore areas of greatest interest to myself and areas that I believe that there is a national need and interest and one where I think VA is taking that lead. Next. 

So that is really to develop the VA Center for high value care or as I preliminary called it HiVACC. Next slide. 

The mission as I envision it is to bring together clinicians, educators, researchers, policymakers and patients to define, identify, communicate and implement high value care with a particular emphasis on reducing overuse of low value care. That is healthcare that has little benefit for its harms and costs not only because that is valuable in and of itself but it also opens up the opportunity to implement high value care. Next slide. Next please. Thank you. 

A lot of this work has been inspired by others, Steve Woloshin, Gail Welch and Lisa Schwartz from Dartmouth and formerly at the VA at White River Junction have really been pioneers in this area and Gail is a former Undersecretary Award winner. They are writing in the area of overdiagnosis and risk communication have really been at the front of this and have been incredible leaders and inspirational to me. They have developed also the preventing overdiagnosis course and I know many on the conference line, many have attended and learned and contributed to that. Next. 

Then the American College of Physicians, their high value cost conscious healthcare the concepts for clinicians to evaluate the benefits, harms and costs of medical interventions. Next. 

High value care is defined as good benefit relative to harms and costs. Next. 

That is again led by VA people, Linda Humphrey. Next. 

And Doug Owens and Paul Shekelle both also former Undersecretary Award winners. So the VA can be very proud of the leadership that they have taken in this area. Next. 

This is a photo of our ACP Clinical Guideline Panel. Next. 

There is me. Next. 

Paul Shekelle and Linda Humphrey. Next. 

Russ Harris whose claim to fame is not only what he does but the fact that he is married to Linda Kinsinger at our National Center for Health Promotion. Next slide. 

I have been working with Russ on a variety of things, but one area is in the area of high value cancer screening that we are currently working on. We define cancer screening according to screening intensity defined by the population screened, the frequency of screening and the sensitivity of screening. Who do you screen? How often do you screen them? What threshold or what type of test do you use to call something positive? Next. 

We developed five screening value concepts. Next. 

The screening is a cascade of events. Cancers and individuals are heterogeneous. Screening is a double-edged sword. And that screening beyond an optimal point leads to disproportionate increase in harms and costs, and is lower value. Next. 

We have also tried to encourage the thinking of these two lines—screening strategies and values. One strategy is the maximum detection strategy that which is often used today which seeks the maximized cancer detection and prevention. It is often high intensity, it starts early, goes often, it screens frequently and it uses very sensitive thresholds or tests. It is not always the highest value. While there may be small incremental benefits there are large increases in harms and cost. Next. 

Instead we would like clinicians and research and policymakers to take up the value strategy which is the science based incorporation of screening and treatment decision making factors—benefits, harms and costs. That optimizes the balance between benefits, harms and costs. It is not rationing, it is a rational and ethical cost conscious stewardship of healthcare resources. It is often lower intensity and it focuses on maximizing healthcare value, a good treatment and screening decision. Next. 

Here is an example of one in breast cancer for our high value cancer screening and a low value cancer screening strategy. Next. 

So for mammography a high value strategy one to encourage would be women in the ages 60 to 69 to encourage biennial mammography. For women 40 to 59 or 70 to 75, discuss benefits and harms once or more as patient requests with women in good health. The other biennial mammogram in women who desire that. Next. 

No value strategy might be screening women under 40 or over 75 or any women with a life expectancy less than 50 years because of the time needed for any benefit to occur. Or to use the annual mammogram of more sensitive MRI in average risk individuals or tomosynthesis or to perform a regular systemic breast self-exam or instruct them in that. We recognize these are going to be controversial but feel that they capture the value framework and provide high quality care for our patients. Next. 

The VA has already taken a leadership in some of these areas to reduce low value cancer screening including prostate cancer, cervical cancer and colorectal cancer screening. I look to them and others to be moving these initiatives forward in the future. Next. 

In summary, my career journey as a VA Health Services researcher continues to be exciting and fun and I do not plan on retiring any time in the near future. I have had a rewarding opportunity to collaborate and most importantly learn from others while contributing hopefully to improve healthcare delivery and making a positive difference in people’s lives. Next slide. 

The future is likely to be equally enjoyable and hopefully productive. Next. 

There are some lessons that I have learned that I would like to leave you with. Next. 

First, be prepared. Work hard. Understand what work you are doing. Show up. Be willing to say I am interested. Be part of things. Next. 

With your work, recognize that if you are having an impact, people are going to notice and not everybody is going to like it or have a thick skin. Next. 

And a strong stomach because again you will get push back from things. Next. 

But be curious. Ask questions. Seek answers. Next. 

Find out what your yes is. Find out what you are passionate about and how you need to get there and that sometimes means having to say no to things. But figure out how to say no in a positive fashion so that you and others know that it is trying to preserve the things that are most important to you and most important to the organization that you are working with and trying to contribute your skills to. Next. 

But also do not take yourself too seriously. Our time here is short. We do the best we can, but we have to have fun and try and reduce things. I am convinced that when we have fun with the work we do, we do more creative and better work. Next. 

Do not be afraid to fail. Be afraid not to try. Next. 

Take a risk. Be willing to make a mistake. Learn soothing new. I have tried to do that I think the funders that have supported me, particularly VA and provided me with opportunities and have been willing to take a risk and be willing to say maybe we made a mistake so that they can learn something new. Next. 

I have tried to live both my professional and personal life in such a fashion. Next. 

It has led to great rewards currently at least with no great risk. Next. 

Then conduct research that matters. Recognize that our research is applied research to directly influence and improve the healthcare that we provide our patients especially to our veterans. Next. 

Finally, remember that words matter. What we say and how we say it can make a profound and positive impact on others. Next. 

In closing, my family and I would like to conclude with two words that matter most. Next. 

Thank you. Next. Thanks. 

Moderator:Thank you so much Dr. Wilt. It is kind of different doing this with a cyberseminar rather than a live session because we are getting some questions and if you are willing to entertain a few questions here. 

Dr. Tim Wilt:Yeah I sure can. 

Moderator:Fantastic. People are wondering, is there any way that other VA’s can collaborate with you?

Dr. Tim Wilt:Sure, I listed my contact information there. I think the areas that we talked about and high value care are areas that there are many in the VA who are interested and may actually be more a leader than I am. The areas that I would like to work in include, I do not know if it popped it, the areas of developing a National Speaker Series that includes cyberseminar. Some kind of seed money for internships for medical students and post-doctoral or doctoral individuals. Then the hiring and motivation of new investigators or current investigators the area of high value care particularly in the area of reducing low value care. I know let us say I am just picking out areas but areas in health economics, decision analysis, shared decision making. There are a whole variety of areas that we would love to work with individuals. I think it is an overarching topic to so much of what we do. My area has been in general medicine in particular, cancer screening and treatment. But as I talk with people at our Center in the areas of mental health, pain management etcetera, osteoporosis screening, value of care really transcends all of what we do across medicine. I think I know I could learn and I think others can learn and contribute to this so I am happy to talk with folks. I by no means hold the holy center on this and would love to work with folks so please get in contact with me. 

Moderator:Fantastic. The next question that we have here. What do you think you learned about the challenges of communicating risk and benefits of screening to the general public? Do you have evidence that the public has moved from the general assumption that more screening and more detection is always a good thing?

Dr. Tim Wilt:I think what we learned about communicating is that screening is two-edged sword. That it can have harms as well as benefits. That screening is a process, it is not just a simple test, it is a cascade of events that leads to a whole series of things that may be beneficial for the few, but can certainly harm many and that understanding that balance of benefits and harms is critical. Do I have evidence that we are moving forward? Yes. I think we have seen some change in healthcare practice and policy. For example, cervical cancer screening several years go people were screening annually. There was no organization now that recommends annual cervical cancer screening and women I think have been very accepting of every three year cancer screening. We have seen that prostate cancer screening no organization now recommends routine PSA testing, that there is decrease PSA testing particularly men of older age groups with that. We look at organizations like consumer union or the consumer reports have gotten involved in the choosing wisely campaign and I think these kinds of messages are resonating not only at the scientific and academic level, but really more of the grassroots, the media and the public level. 

Moderator:Great thank you. One last question here. Can you comment on high risk versus average risk needing recommendations? How have you included or considered individual risk assessment for things like prostate cancer, breast cancer in making recommendations for screening. 

Dr. Tim Wilt:Thank you that is a really important question. Recommendations from the Task Force and in general most organizations are for average risk individuals and trying them makes separate recommendations based on broad categories such as gender, age, family history and race. Understanding risk is very difficult beyond some of the real obvious ones, that is a strong family history, a history of certain polyps, etcetera. Again the recommendations including that for high value screening has focused really in the area of average risk individuals. There are times when the Task Force, the VA and others has separately broken out recommendations or whether the comment apply to people at high risk. I agree that it is important to identify those individuals where we reliably can. I would say that generally that is a very difficult thing to do except if they are demonstrably higher risk let us say in breast cancer with a strong family history of breast cancer etcetera. And so that our recommendations would apply and at least form the foundation for where we can make recommendations for a broad population. Then move one way or the other, a higher risk or a lower risk person to modify those recommendations. 

Moderator:Great, thank you. That is all the questions, oh one more here. What kind of research will we need to get better information about optimal screening intensity. It does not seem feasible to conduct RCTs of multiple different screening intervals. Do we need modeling studies? Observational studies? Some combination. How do we balance quality of evidence versus feasibly of study?

Dr. Tim Wilt:Well I think that is a great question, it is an area that we have been working on. I believe that it will take multi-modality ways to get there. I believe we would all agree that randomized control trials, screening trials are the ideal approach to determining whether the benefits and the harms of screening that they are unrealistic for many situations. They can easily address one major question with some particular subgroups be it by age or gender etcetera. But clinicians want to know other things. They want to know what about with different intervals. When to start, when to stop. What about differences in risk categories. Modeling serves an important tool for that, but as we often joke among modelers, all models are wrong, some are useful. I think while we are in the process of dong some work, and have a paper under review, is in the area of  how modeling can be used by guidelines makers to collaborate and work with the results from randomized trials. Where models are most useful in my opinion, I am not a modeler by training, I imagine there are some on this conference call where I would love to collaborate more with because I think this is incredibly important area for assessing value of care. it is what we call kind of an intermediate distance between the data and the guideline needs. 

For example in breast cancer the studies really looked at screening every one to two years but we wanted to know now only was two years better than one year, but whether you start earlier and stop earlier. The distance from the data to the modeling with mammography was really kind of an intermediate distance, what we would have had a much farther distance would be data and things where there are no randomized trials let us say for MIR screening in women. or for virtual colonoscopy and colorectal cancer. Or for other areas for tests that we have not explored. Having said that, I believe that we need these kinds of studies to help contribute. I will say that my personal belief is that with screening in particular we should err on say until there is evidence at least of moderate certainty that benefits exceed the harms that the default should be to not incorporate that. Screening is a much higher bar to get over. Patients are asymptomatic, the benefit occurs to very few and long distance future but the harm including the cost occurred to potentially everyone and upfront and early. I think one of the concerns, one of the lessons I learned about prostate cancer screening is that this was a test that was widely implemented and widely embraced. and it made the randomized screening trials even that much more difficult and now we are still somewhat scratching our head as to the exact role and the exact benefits and harms. I think in the terms of practice and policy we need to be much more cautious before we get enthusiastic about screening tests, try and do the high quality studies and refine them with modeling studies. 

Moderator:Wonderful, thank you. That does conclude the questions that we received in here. I am going to give you Dr. Wilt and Dr. Atkins a moment if you want to say any final remarks. but before I do that I just want to let the audience know we are not going to do a standard feedback form for this session, but if you would like to send any feedback to Dr. Wilt, please use that Q&A screen and we will get those compiled and sent over to him.  Dr. Wilt, Dr. Atkins, do either of you have any final remarks before we close out today?

Dr. Tim Wilt:I am going to conclude by saying thank you David, thank you everybody at VA. It has been a wonderful experience. I hope that I have been able to give as much as I have gotten and I look forward to moving on in this area in the future. It continues to be just incredibly rewarding and enjoyable. Thank you. 

Dr. David Atkins:I just want to thank Tim and his wonderful team at the Center for Chronic Disease Outcomes Research in HSR&D for the work they have done.  I think Tim has given a picture of how this is really a team effort and while it takes a great leader to motivate a team and pursue things that are challenging, it cannot be done alone. Congratulations again, you join a long list of distinguished colleagues and it has been great to hear about your work. Thank you. 

Moderator:Thank you and congratulations Tim, thank you very much for taking the time to present for us today. 

Dr. Tim Wilt:Thank you. 

Moderator:We very much appreciate it. Thank you to our audience for joining us for this session today and this concludes today’s cyberseminar. Thank you. 

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