clinical reasoning utilizing a cost-conscious framework kim tartaglia, md march 2012
TRANSCRIPT
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Clinical Reasoning Utilizing a Cost-
Conscious Framework
Kim Tartaglia, MDMarch 2012
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A Case-ED Presentation
O 60yo woman w/ DM2 (10yr) and RAO LUQ and L flank pain x3 daysO Subjective feversO Fatigue, L sharp chest pain and
productive cough x1 dayO Meds: Metformin, Prednisone, MTXO Fam Hx: Sister with lung cancerO h/o tobacco abuse, born in Central
America; lived in US x20y
Modified from MedEd Portal
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ED ExamO VS: 36.2, 130, 40, 129/76, 92% on 2L NCO Gen: Agitated, tachypneicO Lungs: bibasilar crackles, nontender ribsO CV: tachy, nml S1/S2, no murmurs/rubsO Abd: diffusely tender in LUQO Ext: warm, well-perfused, no edema
Modified from MedEd Portal
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What are you thinking?O Differential Diagnosis
O What is your PlanO To DiagnoseO To Treat
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ResultsO Chem7: Na-129, Bicarb-18, Cr-1.4, AG-5O CBC: WBC: 13.9, Hb-14, Plt-252O CXR: Obscured L. hemidiaphragm, ill-
defined density in right mid-lung: atelectasis vs infxn
O EKG: Sinus tach, otw nml
O How would you modify differential diagnosis?
O Any other tests you want to order?
Modified from MedEd Portal
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Other TestsO Would you order D-dimer?
O Sent twice in ED, elevated both timesO Any other labs or imaging?
O CT abd/pelvis: Multifocal pna, no other abnormality
O Fibrinogen sent twice, both nml
O Does diagnosis explain symptoms and labs?
O Are you worried about anything else?
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Day 1 ICUO Chest CT w/o contrast
O Eval effusions/infiltrate. Result: pneumonia
O Later, Chest CT: PE protocolO Negative for PE.
O CT Imaging ChargesO $3200 (Abd/Pelvis), $2000 (non-contrast),
$2400 (PE study) = $7600O Benefits/Potential Harms of CTs
Modified from MedEd Portal
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Day 2 ICU O S: Feels better although abd pain persistsO VS: T-38.9, P-113, 114/65, 92% on 3LO Pulm: Crackles L>R at basesO CV: Tachy, regular, no murmursO Neuro: alert/oriented, nonfocal
O Sputum gram stain: Many PMN and GNRO Does this change your diagnosis or make
you more comfortable?
Modified from MedEd Portal
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Day 3 ICUO Develops hypotension, atrial fibrillation,
progressive resp failure, and acute kidney injury (Cr 1.6 from 1.1)
O Intubated and BAL shows H. fluO Started on levophed (NE) for
hypotension
O What’s the explanation? Ddx?O What role did CTs play in kidney injury?
Modified from MedEd Portal
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Day 4-13 ICUO Slowly weaned off pressorsO Extubated and weaned off O2O Hb dropped to 8.2 (over 3 d) and
rec’d 2uPRBCs on day 6O Creatinine improved to nml by day 6O LFTs increased with hypotensive
episode on day 3, nml by day 12
Modified from MedEd Portal
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Day 14-18 FloorO Off abx and O2O Discharged on day 18 to rehab.O Discharge diagnoses: resolving
pneumonia with sepsis, resolved shock liver, resolved acute kidney injury, severe deconditioning
O 12 days in rehab; discharged home on day 30.
Modified from MedEd Portal
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Labs
O Chem7: checked 44 times in 30 daysO All values nml on day 14 when xferred to
floorO Checked 12 times before d/c on day 30O $274/test = $12,000
O Mg: Checked 34 times in 30 daysO Slightly elevated 9 times; no interventions O $52/test = $1768
O Phos: Checked 32 times in 27d (after AKI)O Slightly low twice; no interventionO $39/test = $1248
Modified from MedEd Portal
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LabsO CBC: Checked 30 times in 30 days
O Rec’d blood on HD 6.O Hb 10.5-12 for next 24 daysO $119/test ($142 if diff) = $3570
O What are reasons for ordering a lab?O When should you check it regularly?O When could you stop?
Modified from MedEd Portal
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Summary of Patient’s Labs
O Micro (Blood cx-8, urine cx-2, Sputum cx)….$ 2600
O CBC X 30……………………………………….$ 3570O Chem7 X 44……………………………………$12000O Mg X 34, Phos X 32……………………………$ 3016O Lactate X17……………………………………..$ 2635O Trop X14 (all nml)………………………………$ 628O LFTs X 5…………………………………………$ 1770 O D-dimer X2………………………………………$ 968O Total lab costs…………………………………..$27187
Modified from MedEd Portal
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Summary of Hospital Costs
O Hospital Services for ICU (14d) and Floor (4d): $62,200
O Inpatient rehab services (12d): $19,680O Physician charges (38 visits): $16, 131O Total charge of 30-day stay approx
$148,000
O This patient had no health insurance
Modified from MedEd Portal, 2012 charges
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Costs vs ChargesO Costs – What it costs the institutionO Charges – What the institution charges
a patient. Includes profit marginO Examples
O Blood cx: Cost-$65, Charge-$258O CT abd/pelvis: Cost-$405, Charge-$3900
(does not include professional fees to read study)
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ObjectivesO Review the cost of healthcare in the USO Discuss a framework for evaluating the
value of an interventionO Address strategies for avoiding low-value
care
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The Cost of HealthcareO Rising to unsustainable levelO In 2008, more than $2.2 trillion,
accounting for more than 16% of GDPO Major contributing factor to
approximately 50% of all bankruptcy filings in US
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The Cost of Healthcare
O Physicians direct as much as 87% of all healthcare spending
O Care delivered in context of medical education is 20-60% higher than care in non-teaching environments.
O Physicians have poor knowledge regarding costs of medical care
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How is the “Value” of an Intervention Defined
O In healthcare, value is the assessment of benefit of an intervention relative to expenditures.
O High cost interventions may be a good value if highly beneficial.
O Interventions with minimal to no health benefit are low-value, regardless of cost. (ex: routine imaging in low back pain.)
O 30% of medical decisions in US are of no value to patients
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Avoiding Low-Value Care
O Do not order a test if results do not change management (ex. CXR 4wks after pna)
O If pretest probability of dz is low, likelihood of false-positive test is higher than true-positiveO False-positives lead to additional tests that
add cost, may introduce harm, and may lead to inappropriate treatment
O True cost of test includes downstream costs of additional testing, treatment, and follow-up
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ACP’s Wasteful TestsO Ad hoc workgroup, convened 2011 to
identify overused screening and diagnostic tests.
O Members collected suggestions of low-value care and required unanimous agreement among workgroup members
O 37 situations/tests identified
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Clinical Situations in Which a Test Does Not Reflect High-Value Care.
Qaseem A et al. Ann Intern Med 2012;156:147-149©2012 by American College of Physicians
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ACP Wasteful Tests-Hospital
O Echo in asymptomatic patients w/ innocent-sounding heart murmurs (grade I-II/VI short, systolic, murmurs at LLSB)
O ECG to screen for cardiac disease in patients with low to average risk
O Measuring BNP in initial evaluation of patients with typical findings of heart failure
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ACP Wasteful Tests-Hospital
O Brain imaging (CT or MRI) in patients with syncope who have normal neuro exams
O Routine echo in evaluation of syncope, unless the history, exam, & ECG do not provide an explanation
O Pre-discharge CXR for patients with pneumonia who are making satisfactory clinical recovery
O Chest CT for pneumonia confirmed by CXR in absence of complicating features
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ACP Wasteful Tests-Hospital
O Performing imaging, rather than D-dimer, as initial test for pts w/ low probability of VTE
O Measuring D-dimer, rather than appropriate diagnostic imaging, in patients with intermediate or high probability of VTE
O Routine preoperative CXR
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Cost-effectiveness
O Interventions of no benefit are of no value and therefore are NOT cost-effective
O But what about interventions that are beneficial? O How do you determine if they are cost-
effective?
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Evaluating Beneficial Interventions
O Requires cost-effectiveness analysis (ie. quantitative assessment of benefit and cost)
O Cost-effectiveness ≠ RationingO Definition of Rationing: Restricting
interventions regardless of benefitO Cost-effectiveness analysis can help
AVOID rationing
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Incremental Cost-effectiveness Ratio
O Def: Difference in costs divided by difference in health benefit when 2 strategies are compared
OCE ratio = Costnew strategy – Costcurrent practice
Effectnew strategy – Effectcurrent practice
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Incremental Cost-effectiveness Ratio
O Health benefit measured by quality-adjusted life-years (QALYs) gained
O Cost effectiveness ratio expressed in dollars per life-year gained.
O Lower ratios imply better cost-effectivenessO Used by decision-makers to determine
whether and how a new intervention should be used
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Utilizing Cost-effectiveness Ratios
O Compare CER with well-accepted medical practice using league-table
O Interventions with CER <$100,000 per QALY gained is generally acceptable in US
O WHO: O Interventions <3 times GDP per capita are cost-
effectiveO Those <GDP per capita ($48K in US) are “very
cost-effective”O Historical standard: Hemodialysis (incremental
CER of $60-128K per QALY gained)
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Examples
O MADIT: randomized controlled study of asx pts at high risk for sudden cardiac death
O AICD pts with significant reductions in all-cause, cardiac, and arrythmic deaths
O ICD group: Avg survival 3.46yrs, cost $97, 560
O Conventional group: Avg survival 2.66yrs, cost $75,980
O Incremental CER: $27,000 per life-yr saved
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SummaryO We (Physicians) direct the vast
majority of healthcare spendingO Low-value tests are NEVER cost-
effectiveO Cost of “routine labs” adds up
quicklyO Beneficial tests require quantitative
analysis to determine if they are cost-effective (<$100K/QALY gained)