High Value Cost-High Value Cost-Conscious CareConscious Care

Apostolos P. Dallas, M.D.Apostolos P. Dallas, M.D.

March 2, 2013March 2, 2013

DisclosuresDisclosures

None relevant to this talk None relevant to this talk

ObjectivesObjectives

Review some data about inefficient Review some data about inefficient health carehealth care

Generate ideas/opinions on screening Generate ideas/opinions on screening and diagnostic testsand diagnostic tests

Review imaging in low back pain and Review imaging in low back pain and EGD in GERDEGD in GERD

Be conversant about HVCCC initiativeBe conversant about HVCCC initiative Worry better Worry better

Problem with health care Problem with health care costs?costs?

20% of Gross Domestic Product20% of Gross Domestic Product US health care is 5US health care is 5thth largest country in largest country in

the worldthe world $2.5 trillion, $765 billion potentially $2.5 trillion, $765 billion potentially

avoidable avoidable $395 physician controlled$395 physician controlled $130 billion inefficient care$130 billion inefficient care $55 billion missed prevention $55 billion missed prevention

opportunitiesopportunities

History of HVCCCHistory of HVCCC Physician Charter on Physician Charter on

Professionalism- Professionalism- ABIM/ ACP/EFIM- ABIM/ ACP/EFIM- 20022002

National Physicians National Physicians Alliance-Promoting Alliance-Promoting Good Stewardship In Good Stewardship In MedicineMedicine

Choosing Wisely-Choosing Wisely-ABIMABIM “He chose poorly”

ACP Top Five In Choosing ACP Top Five In Choosing WiselyWisely

No screening exercise stress test in asx, low risk No screening exercise stress test in asx, low risk ptspts

No imaging studies in non-specific low back No imaging studies in non-specific low back

painpain

Syncope and a normal neuro exam, no CT or MRISyncope and a normal neuro exam, no CT or MRI Low pretest probability of venous thrombo-Low pretest probability of venous thrombo-

embolism, highly-sensitive D-dimer, not embolism, highly-sensitive D-dimer, not imaging, as initial diagnostic testimaging, as initial diagnostic test

No preoperative CXR without clinical suspicion No preoperative CXR without clinical suspicion for intrathoracic pathology for intrathoracic pathology

History of HVCCCHistory of HVCCC

2010 ACP 2010 ACP initiativeinitiative

Clinical Guidelines Clinical Guidelines CommitteeCommittee

Charged with Charged with developing series developing series of articles to of articles to inform discussioninform discussion

History of HVCCCHistory of HVCCC

No discord over concept of “choosing No discord over concept of “choosing wisely”wisely”

““Rationing” is a dirty word-political; Rationing” is a dirty word-political; cost/care together negativecost/care together negative

Defining terms is keyDefining terms is key Educating/updating physiciansEducating/updating physicians Educating/testing traineesEducating/testing trainees Educating publicEducating public Affecting public policyAffecting public policy Just saying HVCCC is difficultJust saying HVCCC is difficult

ACP Position Regarding Resource ACP Position Regarding Resource Allocation DecisionsAllocation Decisions

1 Resources devoted to developing needed data on cost-1 Resources devoted to developing needed data on cost-effectiveness of medical interventions effectiveness of medical interventions

2 Transparent, publicly acceptable process for resource 2 Transparent, publicly acceptable process for resource allocation decision allocation decision

3 Public, patients, physicians, insurers, payers, and other 3 Public, patients, physicians, insurers, payers, and other stakeholders’ inputstakeholders’ input

4 Multiple criteria: Patient need, preferences, and values, 4 Multiple criteria: Patient need, preferences, and values, benefits, safety, societal priorities, fiscal responsibility, benefits, safety, societal priorities, fiscal responsibility, QALYQALY

5 Allocation decisions mesh with societal values and reflect 5 Allocation decisions mesh with societal values and reflect moral, ethical, cultural, and professional standardsmoral, ethical, cultural, and professional standards

ACP Position Regarding Resource ACP Position Regarding Resource Allocation DecisionsAllocation Decisions

6 Allocation decisions should not discriminate 6 Allocation decisions should not discriminate

7 Allocation process flexible enough to address variations 7 Allocation process flexible enough to address variations in regional, population-based needsin regional, population-based needs

8 Informed decisions and shared decision-making8 Informed decisions and shared decision-making

9 Medical liability reforms9 Medical liability reforms

10 Periodically reviewed to reflect evolving medical, 10 Periodically reviewed to reflect evolving medical, societal values and changes in evidence, and assess for societal values and changes in evidence, and assess for any cost shifting or other unwanted effectsany cost shifting or other unwanted effects

HVCCCHVCCC

Value=Benefit/CostValue=Benefit/Cost Health benefit: conditions Health benefit: conditions

diagnosed/prevented, life-diagnosed/prevented, life-years, QALYyears, QALY

QALY: length and QALY: length and assessed quality of lifeassessed quality of life

Cost-effectiveness Cost-effectiveness ratio=dollars/health ratio=dollars/health outcomeoutcome

QALYQALY How much is life/quality of life worth?How much is life/quality of life worth? HIV screening $15,000/QALYHIV screening $15,000/QALY $50,000/QALY threshold, 1982$50,000/QALY threshold, 1982 Today $120,000/QALYToday $120,000/QALY People willing to pay $109, 000 People willing to pay $109, 000

(Braithwaite 2008)(Braithwaite 2008) UK: 30-50kUK: 30-50k WHO: < 3x per capita gross domestic WHO: < 3x per capita gross domestic

product per disability adjusted life-year product per disability adjusted life-year gainedgained

US- no consensusUS- no consensus

Low Back PainLow Back Pain

$90 billion$90 billion Similar or worse mental health, Similar or worse mental health,

physical functioning, physical functioning, work/school/social limitations 1997 v work/school/social limitations 1997 v 20052005

Appropriateness of imaging for LBPAppropriateness of imaging for LBP Systematic review Systematic review (Chou, 2009)(Chou, 2009) Advice for HVCCC Advice for HVCCC (Chou, CGC 2011)(Chou, CGC 2011)

Low Back Pain-Low Back Pain-RecommenationsRecommenations

Focused history and PE: nonspecific, pain Focused history and PE: nonspecific, pain potentially with radiculopathy/stenosis, or potentially with radiculopathy/stenosis, or pain with other spinal cause. Assess pain with other spinal cause. Assess psychosocial riskpsychosocial risk

No routine imaging/diagnostic testsNo routine imaging/diagnostic tests Testing if severe or progressive neuro deficitsTesting if severe or progressive neuro deficits Imaging with radiculopathy/stenosis if Imaging with radiculopathy/stenosis if

candidate for surg or epiduralcandidate for surg or epidural Provide evidence-based info to ptsProvide evidence-based info to pts Use meds with proven benefitsUse meds with proven benefits Use spinal manipulation, rehab, exercise, Use spinal manipulation, rehab, exercise,

cognitive-behavioral therapycognitive-behavioral therapy

Low Back Pain-Diagnostic Low Back Pain-Diagnostic ImagingImaging

Patient DiscussionPatient Discussion Risk Factor Assessment-CA, infection, cauda Risk Factor Assessment-CA, infection, cauda

equina, severe/progressive neuro deficitsequina, severe/progressive neuro deficits Low underlying disease prevalence with no Low underlying disease prevalence with no

risksrisks Natural history favorableNatural history favorable Routine imaging does not improve outcomesRoutine imaging does not improve outcomes Imaging abls common, poorly correlatedImaging abls common, poorly correlated Treatment plans usually don’t changeTreatment plans usually don’t change Radiation exposureRadiation exposure

Upper Endoscopy for Upper Endoscopy for GERDGERD

40% of adults with GERD sxs 40% of adults with GERD sxs 20% on weekly basis20% on weekly basis Of top 10 meds, 2 are acid suppressive Of top 10 meds, 2 are acid suppressive

medsmeds Of GERD pts, 10% have Barrett esophagusOf GERD pts, 10% have Barrett esophagus Increased risk of esoph adenocarcinoma Increased risk of esoph adenocarcinoma

(5 year survival <20%) (5 year survival <20%) Men, obese have higher risk of BarrettMen, obese have higher risk of Barrett 80% of EAC in men= to man with breast 80% of EAC in men= to man with breast

CACA

Upper Endoscopy for Upper Endoscopy for GERDGERD

13% of Blue Cross pts in PA had EGD13% of Blue Cross pts in PA had EGD American Society of Gastrointestinal EndoscopyAmerican Society of Gastrointestinal Endoscopy American College of GastroenterologyAmerican College of Gastroenterology American Gastroenterological AssociationAmerican Gastroenterological Association Guidelines Guidelines Up to 40% not indicated Up to 40% not indicated Alarms: dysphagia, bleeding, anemia, weight Alarms: dysphagia, bleeding, anemia, weight

loss, recurrent vomiting loss, recurrent vomiting

Upper Endoscopy for Upper Endoscopy for GERDGERD

Errors: gastro but primary care is sourceErrors: gastro but primary care is source Serial endoscopies in GERD with no BarrettSerial endoscopies in GERD with no Barrett Exams at too short intervalsExams at too short intervals Early EGD in pts low risk and no alarm sxsEarly EGD in pts low risk and no alarm sxs Why not following advice of organizations?Why not following advice of organizations? Primary predictor of EGD in low-yield Primary predictor of EGD in low-yield

situations was previous defendant in situations was previous defendant in malpractice case malpractice case (Rubenstein, AM J Gastr 2008)(Rubenstein, AM J Gastr 2008)

Upper Endoscopy for GERDUpper Endoscopy for GERDBest Practice AdviceBest Practice Advice

1. Men and women with alarm sxs and heartburn1. Men and women with alarm sxs and heartburn2. Men and women with sxs and up to 8 week trial of 2. Men and women with sxs and up to 8 week trial of

twice daily PPItwice daily PPI After two month course of PPI for severe erosive After two month course of PPI for severe erosive

esophagitis. In absence of Barrett, no follow-up esophagitis. In absence of Barrett, no follow-up endoscopyendoscopy

EGD for history of stricture with recurrent sxsEGD for history of stricture with recurrent sxs3. May be indicated:3. May be indicated: Men >50 with chronic GERD(>5 yrs) with additional Men >50 with chronic GERD(>5 yrs) with additional

risk factors (nocturnal sxs, HH, obesity, tob, abd fat)risk factors (nocturnal sxs, HH, obesity, tob, abd fat) For Barrett with no dysplasia, 3-5 yearsFor Barrett with no dysplasia, 3-5 years For Barrett with dysplasia, more frequent depending For Barrett with dysplasia, more frequent depending

on gradeon grade

Ideas and OpinionsIdeas and Opinions ACP ad hoc groupACP ad hoc group Identify overused screening and diagnostic Identify overused screening and diagnostic

teststests Not rigorous enough for guidelineNot rigorous enough for guideline 37 situations37 situations

Appropriate Use of Appropriate Use of Screening and Diagnostic Screening and Diagnostic

TestsTests Caths in SIHDCaths in SIHD Echo in benign sounding murmursEcho in benign sounding murmurs Imaging stress as first test in pts who can Imaging stress as first test in pts who can

exercise and have no confounding ekgexercise and have no confounding ekg Annual lipid screeningAnnual lipid screening BNP in pts with clear CHF (follow-up BNP)BNP in pts with clear CHF (follow-up BNP) Paps after age 65 and in total Paps after age 65 and in total

hysterectomyhysterectomy Routine preop labs, coagsRoutine preop labs, coags

Appropriate Use of Appropriate Use of Screening and Diagnostic Screening and Diagnostic

TestsTests Screening for COPD with PFTs without Screening for COPD with PFTs without

resp sxsresp sxs ANA with nonspecific sxsANA with nonspecific sxs Follow-up imaging studies for < 4 mm Follow-up imaging studies for < 4 mm

pulm nodules with low riskpulm nodules with low risk Serologic testing for Lyme disease with Serologic testing for Lyme disease with

nonspecific sxs and no evidence of nonspecific sxs and no evidence of diseasedisease

PSA >75 or with <10 yr life expectancyPSA >75 or with <10 yr life expectancy

Future of HVCFuture of HVCAn Expected JourneyAn Expected Journey

High ,Value and Care-High ,Value and Care-all good wordsall good words

Educating/updating Educating/updating physician-guidelines, physician-guidelines, HVC papers, guidance HVC papers, guidance statementsstatements

Educating/testing Educating/testing trainees-ITE, MKSAP, trainees-ITE, MKSAP, boards and MOCboards and MOC

Educating public-Educating public-outreachoutreach

Affecting public Affecting public policy-statements in policy-statements in guidelinesguidelines

High Value CareHigh Value Care

QuestionsQuestions