Eliminating Healthcare Waste and Overordering of Tests 2015
Eliminating Healthcare Waste and Overordering of Tests 2015 - 2016 Presentation 1 of 7 Learning Objectives Define and recognize the importance of high value care. Introduce a simple five-step model for delivering high value care. Discuss the cost implications of several common clinical scenarios and the evidence-based guidelines for appropriate diagnosis and treatment. Identify clinical reasoning tools to assist in management of uncertainty.
Why Worry About Cost Now? Health Care Costs in the US in Billions of Dollars *30% of these costs are wasted care (around $765 billion in 2009) What is the problem? 1
Since 1970, healthcare spending is rising 2.4% faster than GDP. Estimated $765 billion of healthcare waste annually. Physicians responsible for 87% of wasteful spending. Physicians must lead in addressing these problems and we are! (Choosing Wisely campaign) Trainees (YOU) must be at the front lines. Estimated Sources of Excess Costs in Health Care (2009)2 Unnecessary Services $210 Billion
Excessive Administration Costs $190 Billion Prices That Are Too High $105 Billion Fraud $75 Billion Inefficient Service Delivery $130 Billion
Missed Prevention $55 Billion IOM 2010 Ordering more services 3 Tests Imaging
Two areas of greatest expenditures and most rapid growth: imaging and tests Why do Residents Over-Order Tests? 1. 2. 3. 4. 5. Duplicating role modeled behavior Desire to be complete
Pre-emptive ordering/rushing an evaluation/unnecessary duplication of tests Discomfort with diagnostic uncertainty Curiosity 1. 2. 3. 4. 5.
6. Lack of knowledge of the costs and harms Defensive medicine Patient requests Faculty demand No training in weighing benefit relative to cost and harm Ease of access to services when patient is hospitalized
Steps Toward High Value Care 4 Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering. Step two: Decrease or eliminate the use of interventions that provide no benefits and/ or may be harmful. Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data). Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns .
Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste. Case #1 Ms. B is 57 year-old woman presenting to the ED with chest pain. She has a history of recurrent UTIs; she denies dysuria or urinary frequency. Afebrile WBC count 5.5
Should she have a routine urinalysis and urine culture? Case #1 How would you manage this patient? Additional testing? Treatment? Do your recommendations change if she has an indwelling Foley catheter?
Step 1: Understand the benefits, harms, and costs of diagnostic testing How much do you think the following cost: Urinalysis? Urine culture? 7 days of oral ciprofloxacin? What are the potential downstream costs?
Case #1: Follow Up Urinalysis: cloudy, 11-50 WBC, 11-50 RBC, 2+ bacteria Urine culture: >100,000 E. coli Ms. B was discharged to complete 7 days of oral ciprofloxacin. She returned 10 days later with fever, abdominal pain and diarrhea. Stool Clostridium difficile assay was positive. She was intolerant to metronidazole and was switched to oral vancomycin x 10 days.
Case #1: Approximate Charges Initial episode of care: Urinalysis $94 Urine culture $94 Ciprofloxacin 500 mg po bid x 7 days $23 Downstream: C. difficile PCR assay $38 Metronidazole x 10 days
$36 Vancomycin po x 10 days $2,284 Illness and lost days of work due to C. difficile colitis Steps Toward High Value, Cost-Conscious Care 4 Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering.
Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful. Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data). Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns. Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste. Step 2: Decrease or eliminate care that provides no benefit
and/or may be harmful. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful. Diagnostic Uncertainty How do you handle uncertainty? Does uncertainty prompt you to order potentially unnecessary tests and treatments?
Uncertainty Increases Resource Use5 We show that increased physician anxiety due to uncertainty and increased concern about disclosing uncertainty to patients translate into higher charges. Even after adjusting for multiple confounders, each standard deviation of change in several uncertainty scales corresponded to a change of mean charges of between 5% and 17%. Allison J, Kiefe A, Cook E, et al. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making 1998 18: 320 Diagnostic Uncertainty What tools are available to help you handle
diagnostic or therapeutic uncertainty? 1. Specialty-specific validated clinical decision support tools 2. Specialist, attending and colleague group input 3. Clinical observation of the patient/close follow up Case #2 Mr. M is a 75 year-old man with OA presenting with acute-on-chronic right hip pain. He slipped out of bed this morning and is now unable to bear weight on his right leg.
Exam is notable only for moderate tenderness over the right hip. Hip and pelvis x-rays were negative for fracture. Should he have further imaging? Which type? Clinical Decision Support Tools American College of Radiology: Appropriateness Criteria http://www.acr.org/Quality-Safety/Appropriateness-Criteria
ACR Appropriateness Criteria: Acute Hip Pain Suspected Fracture Case #2: Follow Up CT pelvis was performed and was nondiagnostic. Pain persisted and he remained unable to bear weight. MRI was obtained and revealed a nondisplaced femoral fracture in the setting of severe osteoarthritis. Patient underwent nonemergent repair of the fracture. Case #2: Approximate Charges This hospitalization:
Femur x-ray: $700 Pelvis x-ray: $800 CT hip/pelvis: $3000 MRI hip: $4000 4 nights in the hospital: $12,000
Femur fracture repair: $12, 415 Downstream: Delay in therapy, leading to increased morbidity/mortality Radiation exposure MRI in this case: High Cost Low Value Remember that High Cost Low Value and likewise Low Cost High Value. High-cost interventions may provide good value because they are
highly beneficial (ICD for selected patients with heart failure and low EF, screening colonoscopy). Low-cost interventions may have little or no value if they provide little benefit or increase downstream costs (BNP measurement in patient with clear heart failure, annual Pap smears in an average-risk woman). Clinical Case #3: Syncope Mr. P., a 42 year-old man with hypertension treated with HCTZ, presents to the emergency department after passing out. He was outside working in his garden on a hot afternoon when he started to feel ill and then suddenly lost consciousness. His wife witnessed the event and noticed that he fell to the ground and was unresponsive for about 10 seconds. He did not hit his
head. He then woke up and returned to his baseline mental status. T 37.5oC BP 110/70, HR 95, RR 12, 02 sat 98% on ambient air Exam notable for: dry mucus membranes, no cardiac murmurs, normal neurologic exam Step 1: Benefits, harms, costs Evaluation and Management of Syncope What is your workup for a patient with syncope? Which labs or initial studies do you want to order? What are the benefits, harms,
and costs of each test or intervention? Patient PresentationUpdate Mr. P. was admitted for 2 days during which time: ECG was normal; TTE was also obtained and revealed mild LVH Head CT revealed no abnormalities. Carotid duplex ultrasound revealed 10-50% stenosis, bilaterally. Lab evaluation with CBC, BMP, troponin were all within normal limits. He was monitored on telemetry, which revealed occasional PVCs.
He was given 1 liter of normal saline and discharged on hospital day 2. Case #3: Approximate Charges* 1 night on telemetry $7,000 Physician fees (per day): $200 Consulting physician fee (per day): $300 Electrolyte panel: $175 Daily x 2 = $350 CBC: $170 Daily x 2 = $340
CXR: $500 Head CT: $3,000 TTE: $3,000 Carotid duplex ultrasound: $1,900 ER visit level 3 (moderate
severity): $2,300 IV fluid bolus: $150 *Charges from CA Chargemaster website and patient bills; actual charges vary by institution Approximate Costscontinued What is the total charge for this patients 2-day admission? Approximately $19,000 In addition to financial costs, what are some harms and potential downstream costs of this patients management? Examples: Repeated phlebotomy, IV catheter-related
phlebitis or infection, days of work lost, etc. Discussion When does a patient with syncope require a limited workup versus an extensive evaluation? When does a patient with syncope require inpatient admission? Key: When managing a patient with syncope, risk stratify your patient to assist in the decision to admit or treat as an outpatient. San Francisco Syncope Rule6 C - History of congestive heart failure
H - Hematocrit < 30% E - Abnormal ECG S - Shortness of breath S - Triage systolic blood pressure < 90 A patient with any of the above measures high risk for a serious outcome such as death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return Emergency Department visit and hospitalization for a related event. Limitations of Decision Rules Only apply to the population where they were tested.
SF syncope rule: single medical center Should be used in addition to but not in place of good clinical judgment Use at the same step in the workup where they were studied. SF syncope rule: used only AFTER obvious life-threatening causes of syncope had been ruled out; thus, this aid should not be used in the initial syncope evaluation Decision rules for high-risk conditions must have a high sensitivity so you don't miss them and send the patient home. SF syncope rule: the lower end of the CI for sensitivity is 90%, so if it were strictly applied, you could send up to 10% of patients with high risk syncope home Step 2: Decrease or eliminate care that
provides no benefit and/or may be harmful. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful. Summary Healthcare waste is a multibillion dollar problem. Every provider must carefully weigh costs (including charges and downstream costs), harms, and benefits and order only
those interventions that add value to a patients care. Acknowledge the role of diagnostic uncertainty. Use evidence-based guidelines and decision support tools to aid in the practice of high value care. References 1. 2. 3. 4.
5. 6. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000-2005. Boston: Health Reform Program, Boston University School of Public Health; 2005. TheHealthcare Imperative: Lowering Costs and Improving Outcomes Workshop Series Summary. The Institute of Medicine Web site. http ://iom.nationalacademies.org/Reports/2011/The-Healthcare-Imperative-Lowering-Costs-and-Improving-Outcomes .aspx?_ga=1.219462233.1572788654.1438188089 . Published February 24, 2011. Accessed December 15, 2015. Medicare Payment Advisory Commission. A Data Book: Healthcare Spending and the Medicare Program; 2012. Adapted from Owens, D, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of
Physicians. High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011 Feb 1;154(3):174-80. [PMID: 21282697] Allison J, Kiefe C, Cook E, Gerrity M, Oray E, Centor R. The association of physician attitudes about uncertainty and risk taking with resource use in a Medicare HMO. Med Decis Making 1998 18:320. [PMID: 9679997] Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med. 2006 May;47(5):448-54. [PMID: 16631985]
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