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High Value Cost-Conscious Care

High Value Cost-Conscious Care

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High Value Cost-Conscious Care

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  1. High Value Cost-Conscious Care Apostolos P. Dallas, M.D. March 2, 2013

  2. Disclosures None relevant to this talk

  3. Objectives • Review some data about inefficient health care • Generate ideas/opinions on screening and diagnostic tests • Review imaging in low back pain and EGD in GERD • Be conversant about HVCCC initiative • Worry better

  4. Problem with health care costs? • 20% of Gross Domestic Product • US health care is 5th largest country in the world • $2.5 trillion, $765 billion potentially avoidable • $395 physician controlled • $130 billion inefficient care • $55 billion missed prevention opportunities

  5. History of HVCCC • Physician Charter on Professionalism- ABIM/ ACP/EFIM- 2002 • National Physicians Alliance-Promoting Good Stewardship In Medicine • Choosing Wisely-ABIM “He chose poorly”

  6. ACP Top Five In Choosing Wisely • No screening exercise stress test in asx, low risk pts • No imaging studies in non-specific low back pain • Syncope and a normal neuro exam, no CT or MRI • Low pretest probability of venous thrombo-embolism, highly-sensitive D-dimer, not imaging, as initial diagnostic test • No preoperative CXR without clinical suspicion for intrathoracic pathology

  7. History of HVCCC • 2010 ACP initiative • Clinical Guidelines Committee • Charged with developing series of articles to inform discussion

  8. History of HVCCC • No discord over concept of “choosing wisely” • “Rationing” is a dirty word-political; cost/care together negative • Defining terms is key • Educating/updating physicians • Educating/testing trainees • Educating public • Affecting public policy • Just saying HVCCC is difficult

  9. ACP Position Regarding Resource Allocation Decisions 1 Resources devoted to developing needed data on cost-effectiveness of medical interventions 2 Transparent, publicly acceptable process for resource allocation decision 3 Public, patients, physicians, insurers, payers, and other stakeholders’ input 4 Multiple criteria: Patient need, preferences, and values, benefits, safety, societal priorities, fiscal responsibility, QALY 5 Allocation decisions mesh with societal values and reflect moral, ethical, cultural, and professional standards

  10. ACP Position Regarding Resource Allocation Decisions 6 Allocation decisions should not discriminate 7 Allocation process flexible enough to address variations in regional, population-based needs 8 Informed decisions and shared decision-making 9 Medical liability reforms 10 Periodically reviewed to reflect evolving medical, societal values and changes in evidence, and assess for any cost shifting or other unwanted effects

  11. HVCCC • Value=Benefit/Cost • Health benefit: conditions diagnosed/prevented, life-years, QALY • QALY: length and assessed quality of life • Cost-effectiveness ratio=dollars/health outcome

  12. QALY • How much is life/quality of life worth? • HIV screening $15,000/QALY • $50,000/QALY threshold, 1982 • Today $120,000/QALY • People willing to pay $109, 000 (Braithwaite 2008) • UK: 30-50k • WHO: < 3x per capita gross domestic product per disability adjusted life-year gained • US- no consensus

  13. Low Back Pain • $90 billion • Similar or worse mental health, physical functioning, work/school/social limitations 1997 v 2005 • Appropriateness of imaging for LBP • Systematic review (Chou, 2009) • Advice for HVCCC (Chou, CGC 2011)

  14. Low Back Pain-Recommenations • Focused history and PE: nonspecific, pain potentially with radiculopathy/stenosis, or pain with other spinal cause. Assess psychosocial risk • No routine imaging/diagnostic tests • Testing if severe or progressive neuro deficits • Imaging with radiculopathy/stenosis if candidate for surg or epidural • Provide evidence-based info to pts • Use meds with proven benefits • Use spinal manipulation, rehab, exercise, cognitive-behavioral therapy

  15. Low Back Pain-Diagnostic ImagingPatient Discussion • Risk Factor Assessment-CA, infection, cauda equina, severe/progressive neuro deficits • Low underlying disease prevalence with no risks • Natural history favorable • Routine imaging does not improve outcomes • Imaging abls common, poorly correlated • Treatment plans usually don’t change • Radiation exposure

  16. Upper Endoscopy for GERD • 40% of adults with GERD sxs • 20% on weekly basis • Of top 10 meds, 2 are acid suppressive meds • Of GERD pts, 10% have Barrett esophagus • Increased risk of esoph adenocarcinoma (5 year survival <20%) • Men, obese have higher risk of Barrett • 80% of EAC in men= to man with breast CA

  17. Upper Endoscopy for GERD • 13% of Blue Cross pts in PA had EGD • American Society of Gastrointestinal Endoscopy • American College of Gastroenterology • American Gastroenterological Association • Guidelines • Up to 40% not indicated • Alarms: dysphagia, bleeding, anemia, weight loss, recurrent vomiting

  18. Upper Endoscopy for GERD • Errors: gastro but primary care is source • Serial endoscopies in GERD with no Barrett • Exams at too short intervals • Early EGD in pts low risk and no alarm sxs • Why not following advice of organizations? • Primary predictor of EGD in low-yield situations was previous defendant in malpractice case (Rubenstein, AM J Gastr 2008)

  19. Upper Endoscopy for GERDBest Practice Advice 1. Men and women with alarm sxs and heartburn 2. Men and women with sxs and up to 8 week trial of twice daily PPI After two month course of PPI for severe erosive esophagitis. In absence of Barrett, no follow-up endoscopy EGD for history of stricture with recurrent sxs 3. May be indicated: Men >50 with chronic GERD(>5 yrs) with additional risk factors (nocturnal sxs, HH, obesity, tob, abd fat) For Barrett with no dysplasia, 3-5 years For Barrett with dysplasia, more frequent depending on grade

  20. Ideas and Opinions • ACP ad hoc group • Identify overused screening and diagnostic tests • Not rigorous enough for guideline • 37 situations

  21. Appropriate Use of Screening and Diagnostic Tests • Caths in SIHD • Echo in benign sounding murmurs • Imaging stress as first test in pts who can exercise and have no confounding ekg • Annual lipid screening • BNP in pts with clear CHF (follow-up BNP) • Paps after age 65 and in total hysterectomy • Routine preop labs, coags

  22. Appropriate Use of Screening and Diagnostic Tests • Screening for COPD with PFTs without resp sxs • ANA with nonspecific sxs • Follow-up imaging studies for < 4 mm pulm nodules with low risk • Serologic testing for Lyme disease with nonspecific sxs and no evidence of disease • PSA >75 or with <10 yr life expectancy

  23. Future of HVCAn Expected Journey • High ,Value and Care-all good words • Educating/updating physician-guidelines, HVC papers, guidance statements • Educating/testing trainees-ITE, MKSAP, boards and MOC • Educating public-outreach • Affecting public policy-statements in guidelines

  24. High Value Care Questions