1. High Value Care Ryan Nall MD Assistant Clerkship Director Internal Medicine Slides used with permission of Dr. Marty Muntz, Medical College of Wisconsin

2. What is value? Value = Quality/Cost Quality = Patient Experience, Outcomes Cost = Financial + Other

4. High Value Care: Urinary Catheter

5. Problem Catheter associated bacteriuria: most common health care–associated infection worldwide. – In US : ~40% of hospital-acquired infections. Incidence of bacteriuria associated with indwelling catheterization: 3%–8% per day. 15% of nosocomial bacteremia are attributable to the urinary tract infection.

6. Cost Other Antibiotic Resistance Initial inappropriate antimicrobial use: up to 59% of the time Catheter associated bacteriuria: reservoir of antimicrobial-resistant organisms Prolonged hospitalization, readmission Urosepsis, Death Financial Catheter associated UTI: Additional $676 per case Bacteremia associated with CA-bacteriuria: Additional $2836 per case Total cost : $500 Million/year Centers for Medicare & Medicaid Rule: Will not reimburse the extra cost of treatment!

7. What can be done? Reduce the use of urinary catheterization – Use only when indicated – Do not use for the convenience of providers and/ or patient. Remove the catheter as soon as it is no longer needed

8. High Value Care: GI prophylaxis in Hospitalized Patients

9. How did it all start Stress ulcers in critically ill patient: ~75%. Mortality from stress-related bleeding in critically ill patients ~50%. GI prophylaxis became common in critically ill patient. This practice was extrapolated to general medical floor!

10. Current Situation ~71% of patients in general medicine wards receive GI prophylaxis without an appropriate indication. 48% of these patients are subsequently discharged on Acid suppressive therapy.

11. Cost Other Patients on Acid suppressive therapy have: – 2-3 times increase in incidence of C diff associated Diarrhea – 2 times increase in incidence of Community Acquired Pneumonia – Drug interaction – Adverse reaction Financial Medication alone, for an average academic medical center, >$111,000/year

12. Evidence At present, there is NO evidence to support routine GI prophylaxis in not critically ill general medical floor patients. GI prophylaxis in general medicine patients is, currently, NOT recommended.

13. High Value Care: Blood Transfusion

14. Problem Blood products are limited resources Blood transfusions are often done without following current guidelines

15. Cost Other HIV, HCV, HBV transmission TRALI (transfusion related acute lung injury) TACO (transfusion related circulatory overload) Hemolysis Life-threatening reaction Fever Financial Single Red Blood Cell Unit costs $700 - $1200 in the US US hospitals use an estimated 24 million blood products per year

16. Current Guidelines The AABB recommends: In stable or ICU adult patients you may CONSIDER blood transfusion at a hemoglobin </=7 g/dL In adult with cardiovascular disease you may CONSIDER with hemoglobin </= 8 g/dL Consider transfusion if symptoms are present

17. What can be done? Reduce the use of liberal blood transfusions Avoid using strict hemoglobin targets

18. High Value Care: Continuous Telemetry Monitoring

19. Problem Continuous telemetry monitoring is used routinely in low risk clinical situations which add little value to care

20. Cost Other Patient discomfort (another tether) False positives resulting in errors in patient mgmt Alarm Fatigue Nursing/Physician time Financial 160 per day

21. Current Guidelines The ACC/AHA recommends: Class I: Indicated in most, if not all patients in this group Class II: May be of benefit but isn’t considered essential for all patients Class III: Not indicated because of patient’s low risk of a serious event

22. Class IClass IIClass III Status post cardiac arrestPost acute MI (beyond 72hrs)Low risk post operative ACS (at least 24 hrs)Chest pain syndromeLow risk obstetrics Newly diagnosed high risk coronary lesions Uncomplicated PCIHemodialysis Cardiac surgery (48-72 hrs)Administered an antiarrhythmic or who require adjustment of drugs for rate control Rate controlled afib PCI with complicationsUndergone implantation of a PM lead/Not PM dependent Temporary PM or transcutaneous pacer pads Undergone uncomplicated ablation of arrhythmia AV blockRoutine coronary angiography Arrhythmia complicating WPW with rapid anterograde conduction Subacute heart failure Long QT and associated arrhythmiaBeing evaluated for syncope Intraaortic balloon pumpPts with DNR with arrhythmias that cause discomfort Acute heart failure Indication for intensive care Undergoing diagnostic/therapeutic procedures requiring sedation/general anesthesia Hemodynamically unstable arrhythmia

23. What can be done? Avoid use of telemetry in situations where there is low likelihood of benefit Re-evaluate the need for telemetry daily

24. High Value Care: Repetitive Blood Tests

25. Cost Other Hospital Acquired Anemia (HAA) is associated with higher mortality and worse health status Diagnostic blood loss from phlebotomy is an independent risk factor of HAA Needle stick daily or more Financial Basic Chemistry: $86 Hepatic Function Panel: $223 CMP: $259 Magnesium: $31 CBC w/diff: $31.50 CBC w/o diff: $41

26. Indications for Repetitive Testing Active Bleeding Previous abnormal labs Treatment that can alter labs Change in status

27. Results of Decreased Testing Shown to decrease costs in different studies: – $2 million over 3 years – ~$2,500 – $10,000 saved per week

28. What can be done? Inform those who order lab tests of the costs Avoid repetitive testing by analyzing the need for each test Monitor patients’ hemoglobin as diagnostic blood loss occurs

29. References - Catheter Hooton TM, Bradley SF, Cardena DD, Colgan R, Geerlings SR, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Clin Infect Dis [Internet]. 2010 [cited 2012 Sep 4];50(5):625-663 National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004; 32:470–485. Haley RW, Hooton TM, Culver DH, et al. Nosocomial infections in U.S. hospitals, 1975–1976: estimated frequency by selected characteristics of patients. Am J Med 1981; 70:947–959. Karchmer TB, Giannetta ET, Muto CA, et al. A randomized crossover study of silver-coated urinary catheters in hospitalized patients. Arch Intern Med 2000; 160:3294–3298

30. References – GI prophylaxis Fennerty MB. Pathophysiology of the upper gastrointestinal tract in the critically ill patient: rationale for the therapeutic benefits of acid suppression. Crit Care Med. 2002; 30:S351-5 Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health-Syst Pharm. 2007; 64:1396-400 Laheij RJ, Sturkenboom MC, Hassing RJ et al. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA. 2004; 292:1955-60. Dial S, Delaney JA, Barkun AN et al. Use of gastric acid-suppressive agents and the risk of community- acquired Clostridium difficile-associated disease. JAMA. 2005; 294:2989-95. Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol. 2006; 101:2200-5.

31. References – Blood Transfusion Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999; 340:409-17. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB.Red blood cell transfusion: A clinical practice guideline from the AABB. Ann Intern Med [Internet]. 2012 Jul 3 [cited 2012 Sep 4];157(1):49-58. Consensus conference. Perioperative red blood cell transfusion. JAMA. 1988 Nov 11; 260(18):2700-3. Advancing Transfusion and Cellular Therapies Worldwide. AABB name change. [Internet]. 2012 [Cited 2012 Oct 15]. Available from: www.aabb.org/about/who/Pages/namechange.aspx. Lancet. 2013;381:1791-1792, 1845-1875

32. References - Telemetry Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MW, Macfarlane PW, Sommargren C, Swiryn S. Van Hare GF. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circ. 110:2721–2746. Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM, Gibbons RJ, Alpert JS, Eagle KA, Gardner TJ, Gregoratos G, Russell RO, Ryan TJ, Smith SC. ACC/AHA guidelines for ambulatory electrocardiography: Executive summary and recommendations a report of the American Co llege of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography) developed in collaboration with the North American Society for Pacing and Electrophysiology. Circ [Internet]. 1999 Aug 24 [cited 2012 Sep 4];100(8):886-93. Snider A, Papaleo M, Beldner S, Park C, Katechis D, Galinkin D, Fein A. Is telemetry monitoring necessary in low- risk suspected acute chest pain syndromes? Chest [Internet]. 2002 Aug [cited 2012 Sep 4];122(2):517–523. Henriques-Forsythe MN, Ivonye CC Jamched U, Kamuguisha LKK, Onwuanyi AE. Is telemetry overused? Is it as helpful as thought? Cleve Clin J Med [Internet]. 2009 Jun [cited 2012 Sep 4];368-372. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM, American Heart Association, American Stroke Association Stroke Council, Clinical Cardiology Council. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic PeripheralVascular Disease and Quality of Care Outcomes in Research Interdisciplinary

33. References – Blood Draws Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during Acute Myocardial Infarction. Arch Intern Med [Internet]. 2011 Oct 10 [cited 2012 Sep 4];171(18):1646-1653. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients?: The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med [Internet]. 2005 June [cited 2012 Sep 4];20(6):520–524. Stuebing EA, Miner TJ. Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy. Arch Surg [Internet]. 2011 May [cited 2012 Sep 4];146(5):524-7.