1. Eliminating healthcare waste and over-ordering of tests 2013-2014 Presentation 1 of 6

2. 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 Articulate strategies for bringing high value care into daily practice Challenge participants to identify an action plan: at least one thing to start doing and one thing to stop doing

3. What is the problem? 1 We spend too much on healthcare – 17% of U.S. GDP Since 1970, healthcare spending is rising 2.4% faster than GDP Estimated $700 billion of “healthcare waste” annually Physicians responsible for 87% of wasteful spending Within the current healthcare system, no real disincentive to curb providers’ ordering practices Physicians must lead in addressing these problems – and we are! (Choosing Wisely campaign) Trainees (YOU) must be at the front lines

4. Healthcare Waste 2 Estimated $700 Billion of “Healthcare waste” annually $250-325B in “Unwarranted use” $75-100B in “Provider inefficiency and errors” $25-50B in “Lack of care coordination”

5. Ordering more services 3 … Two areas of greatest expenditures and most rapid growth: imaging and tests Tests Imaging

6. 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

7. Clinical Case #1: Headache 35-year-old woman presents to clinic complaining of headaches every 1-2 weeks for the past few months Headaches preceded by “seeing spots” and associated with nausea R-sided, pulsatile, lasts approximately 4-8 hours Cannot identify any “triggers” What are your next steps as her provider?

8. Migraine Headaches 1. Evidence-based aid for migraine diagnosis based on HISTORY “POUND” Pulsating One-day duration (4-72 hours) Unilateral Nausea or vomiting Disabling 2. Perform neurologic examination 3. Check for red flags 6 Likelihood ratio for migraine by number of POUNDING criteria met 5 : 4 of 5 criteria – LR (+) 24 3 of 5 criteria – LR (+) 3.5 2 or fewer criteria – LR (+) 0.41

9. Step 1: Understand the benefits, harms, and costs of initial headache workup How much do you think the following cost: CT Head? MRI Brain? What are the potential downstream ‘costs’?

10. 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

11. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful

12. Clinical Case #2: HF exacerbation Mr. Cruz, a 62 y/o man with ischemic cardiomyopathy presents to the emergency department with increasing dyspnea and orthopnea Last echo 2 months ago showed LVEF 35% Returned from cruise yesterday where he was non-adherent with dietary restrictions and missed several doses of his medications Denies chest pain BP 130/70, HR 110, RR 22, 02 sat 91% on RA Exam notable for: JVP 15 cm H 2 0, bilateral crackles at lung bases, +S3, 1+ pitting edema to knees bilaterally

13. Step 1: Benefits, harms, costs evaluation and management of HF exacerbation What is your work-up for a pt with ICM presenting with worsening dyspnea and signs of HF? What factors lead us to make orders or recommendations for our patients? Which labs or initial studies do you want to order? What are the benefits, harms, and costs of each test or intervention?

14. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful What, if any, of the tests/consults/procedures may have been unnecessary in this case? 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 and 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)

15. Patient Presentation—Update Mr. Cruz was admitted for 3 days during which time: Initial CXR showed mild-mod edema and small effusions BNP 4000, creatinine 1.3 (slightly above pt’s baseline) Serial troponins (x3) were negative Initial and repeat ECG were at pt’s baseline TTE showed dilated CM with RWMA, EF 30% (stable) Daily IV diuresis with loop diuretics, twice daily BMPs Despite neg troponins cardiology recommended dobutamine stress echo Pt tells you he had a cardiac catheterization 1 yr ago that showed diffuse small vessel disease with nothing to stent

16. Approximate Costs 1 night in the hospital $1,400 Physician fees (per day): $200 Consulting physician fee (per day): $300 Troponin: $75 BNP: $75 Electrolyte panel: $50 CBC: $50 EKG: $60 CXR: $100 Transthoracic echocardiogram: $1,000 Echo/nuclear stress test: $2,000 Oral medications: $5 per pill IV medications: $80 ($50 for med and $30 for administration) And if his stress test is positive? Coronary angiography: $8,000

17. Approximate Costs—continued What is the total cost of for this patient’s 3-day admission? $ 9,895.00!!! (not including coronary angiography) In addition to direct monetary costs, what are some harms and potential downstream costs of this patient’s management? Examples: Repeated phlebotomy, possible arrhythmia during dobutamine stress, false-positive stress test leading to coronary angiography and resultant risk of contrast induced nephropathy, vascular complications at arterial puncture site, etc.

18. Case #3: DVT – A tale of two thrombi Management of DVT Two patients in an ambulatory setting were suspected to have a DVT One of the patients was sent to the emergency department and hospitalized for management of the DVT The other patient was managed as an outpatient Let’s compare costs…

19. Discussion Hospitalized patient What costs are necessary? What can be eliminated? What would be the most elegant approach to work-up and management? Outpatient What costs are necessary? What can be eliminated? What would be the most elegant approach to work-up and management? When considering DVT as a diagnosis, remember to calculate a patient’s Modified Wells score before proceeding with lab testing or imaging. www.mdcalc.com/wells-criteria-for-dvt/

20. Summary Healthcare waste is a multi-billion dollar problem Every provider must carefully weigh costs (including downstream costs), harms, and benefits and order only those interventions that add value to a patient’s care Use evidence-based guidelines and decision support tools to practice high value care Avoid unnecessary use of emergency department and hospital services wherever possible Eliminate “routine” testing by using the high value care framework

21. Commitment for your practice Using the Choosing Wisely lists and your own experiences, think about waste in your own practice and come up with at least 1 thing to start doing and 1 thing to stop doing to improve your delivery of high value care. START: STOP:

22. References 1.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. 2.Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009. 3. Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012. 4.Adapted from Owens, D. Ann Intern Med. 2011;154:174-180 5.Detsky ME, et al. Does this patient with headache have a migraine or need neuroimaging. JAMA 2006;296:1274-1283. 6.Kaniecki R. Headache assessment and management. JAMA.2003;289:1430-1433. 7.McGarry LJ, et al. Cost effectiveness of thromboprophylaxis with a low-molecular-weight heparin versus unfractionated heparin in acutely ill medical inpatients. Am J Manag Care 2004;10:632–642 8.ABIM Foundation, Choosing Wisely Campaign. www.choosingwisely.org (accessed 6/27/13). 9.Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149 – this is where the list of 37 things from ACP comes from