High Value Cost Conscious Care Kenneth E. Olive, MD FACP
Disclosure • I am Governor of the Tennessee Chapter, American College of Physicians. • The American College of Physicians promotes its High Value Cost Conscious Care Initiative
Learning Objectives • As a result of participating in this activity, the participant will be able to: • Discuss the issue of growing rapidly growing health care expenditures in the U.S. • Identify factors contributing to these growing costs • Describe the roles physicians may play in helping to effectively control costs • Discuss common medical practices that increase cost without providing value to patient care
Key Points • The problem • What is High-Value, Cost-Conscious Care • Five Cases/Five examples
The Problem • Rapidly growing health care spending is a significant U.S. societal problem • Reducing health care spending by spending in a socially and fiscally responsible way is an important responsibility of physicians.
U.S. Health Care Costs Billion $
U.S. Health Care Costs • 2008 Average cost per person $7681 • 16.2% of Gross Domestic Product • Gross domestic product (GDP) refers to the market value of all officially recognized final goods and services produced within a country in a given period.
Drivers of Entitlement Spending Growth (Percent of GDP) 56% 36% 44% 64% Source: CBO Long-term Budget Outlook, 2010. 9
Components of Revenue and Spending Revenues and Financing Outlays 2011 Total Revenues = $2.230 Trillion Total Financing = $3.629 Trillion Total Outlays = $3.629 Trillion 10
Health Care Spending by Country Percent of GDP (2008) Source: 2008 Data from the Organization for Economic Cooperation and Development. 11
Reasons Federal Health Expenditures are Increasing • Aging population • Increase cost per beneficiary • Unhealthy lifestyles • Americans have more resources and are willing to pay more • Fragmentation of payment systems reduces impact of normal market competition • Patients insulated from cost of care by insurance incentivizing overspending.
Factors Driving Increased Health Care Spending • New Drugs, e.g. Kalydeco for cystic fibrosis, $294,000/yr, Zyvox $1400-2000/course of treatment • New Devices, e.g defibrillator, $50,000 • New Procedures, e.g. capsule endoscopy, $2000-3000 • New Tests, e.g. PET scan, $2000-8000
Conserving health care resources • The U.S. has largely failed to address the reality that health care spending is increasing at a rate the country can’t afford. • This is a societal issue that transcends medical care itself—how much should we as a society spend using public funds on health care versus education, the environment, or defense?
Conserving health care resources • At patient-physician level: • Physicians—in consultation with patients - should use health care resources wisely, based on evidence of safety and effectiveness, the particular needs and circumstances of the patient, and with consideration of cost. • Physicians should work to reduce utilization of marginal and ineffective services.
What is High-Value, Cost-Conscious Care? • Not just cheap care! • Value – does it provide benefit that outweighs harms? • Example of high-cost intervention with value: anti-retroviral therapy for HIV infection. • Example of low-cost intervention with low value: Pre-operative CXR in healthy asymptomatic patients • High-value care means that health benefits of an intervention justify its harms and costs • Cost-consciousness takes cost into account as one factor.
Obtaining an exercise ECG (stress test) for screening in low risk asymptomatic adults represents an area of overused testing leading to low value care ? • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Obtaining ECGs for screening for cardiac disease in individuals at low to average risk for CAD represents high value care? • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Annual lipid screening for patients not on lipid lowering drug therapy in the absence of reasons for changing lipid profiles represents an area of overused testing leading to low value care? • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Obtaining BNP measurement in the initial evaluation of patients with typical findings of CHF represents high value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Pap smears in low risk women aged >65 and in women who have had a total hysterectomy (uterus and cervix) for benign disease represents an area of overused testing leading to low value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Obtaining imaging studies in patients with recurrent, classic migraine headache and a normal neurologic exam represents high value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Performing DEXA screening for osteoporosis in women younger than age 65 in the absence of risk factors represents an overuse of testing leading to low value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree
Obtaining a d-dimer, rather than an appropriate diagnostic imaging (extremity ultrasonography, CT angiography, V/Q scan), in patients with intermediate or high probability of VTE to rule out VTE represents high value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Obtaining imaging studies, rather than a high sensitivity D-dimer, as the initial diagnostic test in patients with low pretest probability of VTE represents an area of overused testing leading to low value care. • Strongly Agree • Agree • Neutral • Disagree • Strongly Disagree 10 Countdown
Case 1 • 72 yr old woman with long-standing poorly controlled hypertension presents with increasing exertionaldyspnea and orthopnea for the past week. • Exam: Temp 98.6, heart rate 110, BP 142/94, wt 175 (up from 165 one month prior. Lungs - bibasilar crackles. Heart – S3 gallop, Legs - 3+ pretibial edema. • CBC and BMP are normal, initial troponin is 0.01. • ECG reveals sinus tachycardia (rate 110) and LVH. • CXR is consistent with CHF.
Case 1 • Does a BNP (brain natriuretic peptide) measurement add value to this patients care?
Does a BNP (brain natriuretic peptide) measurement add value to this patients care? • Yes • No 10 Countdown
Case 1 • What is the diagnosis?
Case 1 • What is the clinical probability that this patient has CHF?
Case 1 • What is the clinical probability that this patient has CHF? • 90%
Case 1 • What is the sensitivity and specificity of BNP for CHF? • For levels >450 • Sensitivity=98% • Specificity=76% • American Journal of Cardiology, 2005, 95(8):948-954. • In someone with a pre-test likelihood of 90% a positive test raises the likelihood to 97%
Case 1 • Cost of test ~$30 • What other health care would $30 purchase? • Aspirin 81 mg – 30 days ~$2 • Flu shot ~$25 • Lisinopril 10 mg qd -30 days ~$4 • Carvedilol 12.5 mg bid – 30 days ~$4 • Pravastatin 40 mg qd – 30 days ~$4 • If you had to choose would the $30 be better spent on BNP or on the above medications?
Case 1 • Other potential uses of BNP • Diagnosing CHF in unexplained dyspnea, • Diagnosing asymptomatic ventricular dysfunction, • Titrating therapy
Case 1 - Conclusion • Obtaining BNP measurement in the initial evaluation of patients with typical findings of heart failure does not represent cost-conscious, high value care.
Case 2 • 38 yr old secretary presents to the ED with a 2 day history of non-productive cough, mild shortness of breath, and pleuritic chest pain. She is in generally good health taking not medications. She has smoked one pack per day for 15 years. History of leg DVT at age 26 while on oral contraceptives. She drove back from shopping in Knoxville yesterday. No recent surgery or childbirth. • Physical exam • Temp 98.8, pulse 80, BP 118/76, resp 16 • Appears to be mildly uncomfortable • Chest – some apparent splinting of the left hemithorax with clear lungs • Heart – normal sounds, S2 normal • Legs – no tenderness, redness, warmth, or edema
Should this patient have spiral CT with PE protocol to rule out pulmonary embolism? • Yes • No 10 Countdown
Case 2 • What is the clinical probability of pulmonary embolism?
Case 2 • What is the clinical probability of pulmonary embolism? Wells Score: Symptoms of DVT (3 points) No alternative diagnosis better explains the illness (3 points) Tachycardia with pulse > 100 (1.5 points) Immobilization (>= 3 days) or surgery in the previous four weeks (1.5 points) Prior history of DVT or pulmonary embolism (1.5 points) Presence of hemoptysis (1 point) Presence of malignancy (1 point) ThrombHaemost. 2000 Mar;83(3):416-20
Case 2 • Score > 6: High probability • Score >= 2 and <= 6: Moderate probability • Score < 2: Low Probability • Assume that low probability in this case is 10% • Spiral CT • Sensitivity70%, Specificity=91% • PV-=3.5, PV+=46 • Ann Intern Med 2001; 135:88-97. • CT cost ~$2000
Case 2 • D dimer cost ~$300 • Sensivitity = 96%, specificity 40% • PV -=1.1, PV+=15 • Chest 2004;125;807-809
Case 2 - Conclusion • The initial diagnostic test in patients with a low pretest probability of venous thromboembolism should be a D-dimer rather than an imaging study.
Case 3 • 55 yr old male presents to clinic with episode of syncope this morning. Standing at sink brushing teeth shortly after arising. Felt light-headed and passed out. Unconscious for a brief time only. No preceding chest pain, palpitations, or dyspnea. No focal neurologic symptoms. • In generally good health except for GE reflux, allergic rhinitis, and BPH. • Meds: omeprazole 20 mg qd, certrizine 10 mg qd, tamsulosin 0.4 mg (recently started by urologist with first dose last night). • PE: supine BP 126/84, pulse 70 • Standing BP 102/600, pulse 94 • Neurologic exam- normal • Cardiovascular exam – normal • ECG - normal
Case 3 • Does he need an echocardiogram as part of his workup?
Does he need an echocardiogram as part of his workup? • Yes • No 10 Countdown
ACC/AHA Scientific Statement on the Evaluation of syncope Circulation 2006;113:316-327