1. Providing High Value Cost Conscious Care: Introduction to Health Care Value Bindu Swaroop, MD Department of Medicine University of California, Irvine

2. Learning Objectives Understand some of the current problems with health care spending Define high value, cost conscious care Introduce the five step model for delivering high value, cost conscious care Articulate strategies for bringing high value care into daily practice

3. What is the Problem? We spend too much on healthcare- $2.6 trillion in 2010, representing 17.6% of the GDP IOM report in 2009: ▫ About 30 cents of every health care dollar is wasted ▫ $750 billion in inefficient health care spending ▫ "Left unchanged, health care will continue to underperform, cause unnecessary harm, and strain national, state, and family budgets"

4. Wasted Healthcare In 2009: Unnecessary services $210 B Inefficient services $130 B Excess administrative costs $190 B Prices too high $105 B Missed prevention opportunities $ 55 B Fraud $75 B

5. Wasted Healthcare In 2009: Unnecessary services $210 B Inefficient services $130 B Excess administrative costs $190 B Prices too high $105 B Missed prevention opportunities $ 55 B Fraud $75 B

6. Ordering more services 3 … Two areas of greatest expenditures and most rapid growth: imaging and tests Tests Imaging

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8. What is High Value, Cost Conscious Care? Providing the best possible care to our patients and Simultaneously reducing unnecessary costs to the healthcare system

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11. Value, Cost and Health Care Cost ≠ Value Cost ≠ Cost of Test Cost includes cost of test and downstream costs, benefits and harms High-cost interventions may provide good value because they are highly beneficial Low-cost interventions may have little or no value if they provide little benefit or increase downstream costs

12. Steps Toward High Value, Cost Conscious Care Five-Step Framework: High-Value, Cost-Conscious Care Step 1 Understand the benefits, harms, and relative costs of the interventions that you are considering Step 2 Decrease or eliminate the use of interventions that provide no benefit and/or may be harmful Step 3 Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) Step 4 Customize a care plan with the patient that incorporates their values and addresses their concerns Step 5 Identify system-level opportunities to improve outcomes, minimize harms, and reduce health care waste

13. Case Presentation 70 y/o female POD#3 from laparoscopic cholecystectomy Patient recovering well with plan for discharge While ambulating became acutely SOB, tachycardic and hypotensive Complained of right shoulder and chest pain associated with diaphoresis

14. Step 1: Benefits, Harms, Costs What is your work-up? What factors lead us to make these orders or recommendations? How much does this cost?

15. Benefits, Harms, Costs TestBenefitHarmCosts CT Angio TTE EKG D-dimer BNP Troponin (serial) ABG LE U/S Doppler Hypercoagulable work up

16. Benefits, Harms, Costs TestBenefitHarmCosts CT Angio Best sensitivity for identifying PE TTE Assess RV strain EKG Identify arrythmia, non-invasive D-dimer Easy to obtain, helpful in ruling out PE if negative BNP Troponin (serial) ABG LE U/S Dopplerno contrast, non- invasive Hypercoagulable work up

17. Benefits, Harm, Costs TestBenefitHarmCosts CT Angio Best sensitivity for identifying PE Contrast, radiation, incidental findings TTE Assess RV strain Low specificity EKG Identify arrythmia, non-invasive D-dimer Easy to obtain, helpful in ruling out PE if negative Low specificity BNP Troponin (serial) Repeated phlebotomy ABGArterial Stick LE U/S Dopplerno contrast, non- invasive Hypercoagulable work up Low yield in patient with clear risk factor for PE

18. Benefits, Harms, Costs TestBenefitHarmCosts CT AngioBest sensitivity for identifying PE Contrast, radiation, incidental findings $294.40 TTE$147.29 EKG Identify arrythmia, non-invasive $79.18 D-dimer Easy to obtain, helpful in ruling out PE if negative Low specificity$65.88 BNP$18.75 Troponin (serial)Repeated phlebotomy $26.01 (x 1) ABGArterial Stick$35.94 LE U/S Dopplerno contrast, non- invasive $125.23 Hypercoagulable work up Low yield in patient with clear risk factor for PE $79.18

19. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful Which tests had the potential to change management? -CT Angio -D-dimer -Fibrinogen -BNP -Serial Troponin -Hypercoagulable panel -TTE -LE Ultrasound -ABG

20. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful Which tests had the potential to change management? -CT Angio -D-dimer -Fibrinogen -BNP -Serial Troponin -Hypercoagulable panel -TTE -LE Ultrasound -ABG

21. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful Which tests had the potential to change management? -CT Angio: $294 -D-dimer -Fibrinogen -BNP -Serial Troponin -Hypercoagulable panel -TTE -LE Ultrasound -ABG Total Cost: $871.85

22. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful

23. Step 3: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs Use comparative-effectiveness and cost- effectiveness data In this case: Well’s or Geneva Score to determine pre test probability Mini Lectures | Residency Program | Residency Program | Department of Medicine | School of Medicine | University of California, Irvine

24. Wells’ Score Clinical symptoms of DVT (leg swelling, pain with palpation) 3.0 Other diagnosis less likely than pulmonary embolism 3.0 Heart rate >1001.5 Immobilization (≥3 days) or surgery in the previous four weeks 1.5 Previous DVT/PE1.5 Hemoptysis1.0 Malignancy1.0 Traditional clinical probability assessment (Wells criteria) High>6.0 Moderate2.0 to 6.0 Low<2.0 Simplified clinical probability assessment (Modified Wells criteria) PE likely>4.0 PE unlikely≤4.0

25. Simplified Geneva Score VariableScore Age >651 Previous DVT or PE1 Surgery or fracture within 1 month1 Active malignancy1 Unilateral lower limb pain1 Hemoptysis1 Pain on deep vein palpation of lower limb and unilateral edema 1 Heart rate 75 to 94 bpm1 Heart rate greater than 94 bpm2 Score of less than 2 is low probablility for PE, score of less than 2 plus a negative D-dimer results in a likelihood of PE of 3%

26. Diagnostic Algorithm

27. Effective Use of CTA in Setting of Suspected Pulmonary Embolism By Sasan Sani MD.

28. Methods 40 CTA exams Performed 3/10-3/25 were analyzed retrospectively 55% of these studies were noted to have “PE Rule Out” as their indication Laboratory and imaging results were reviewed on Quest Documentation (H&Ps, progress notes, DC summaries, consultations) were also reviewed on Quest Well’s Score and Geneva Score were calculated according to the collected data Data limited by information provided in notes

29. Departments

30. Wells’ Score

32. Results Only 2 (9%) out of the 22 CT angiograms performed showed evidence of PE 80% of patients had a Well’s score in the range of “Unlikely PE” (<4) 50% of these patients had a score of <2 (low probability) D-dimer was checked for only two out of all the patients ▫one positive D-dimer in setting of PE ▫one negative in the setting of a negative CTA Lower extremity ultrasound was also performed for 4 patients (18%) ▫Only one patient had evidence of DVT, and this patient was diagnosed with PE as well

33. Discussion Previous studies performed have shown similar results In a cross-sectional study reviewing 589 pulmonary CTA ordered in the emergency department PE was found in 9% A total of 33% had findings that supported alternative diagnoses 24% had incidental findings that required diagnostic follow up ▫13% new pulmonary nodule ▫9% new adenopathy The conclusion was that CTA was more than twice as likely to find an incidental pulmonary nodule or adenopathy than a PE

34. Conclusion Patients should be risk stratified appropriately and diagnostic algorithms should be used prior to ordering diagnostic tests CT angiograms should be utilized in high probability patients or those with suspected PE and a positive D-dimer result

35. Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns “And no one thought to get a potassium level?”

36. Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” -Hippocrates (460-377 B.C.) “And no one thought to get a potassium level?”

37. Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” -Hippocrates (460-377 B.C.) Patient Centered Care: “Providing care that is respectful of and responsive to individual patient preferences, needs, values, and ensuring that patient values guide all clinical decisions” (IOM 2001) “And no one thought to get a potassium level?”

39. Quiz: What is the patient charged? One bag of normal saline given IV: Actual bill: $158.55

40. Quiz: What does is the patient charged? A comprehensive metabolic panel: Actual bill: $1,212.00

41. Quiz: What is the patient charged? One set of blood cultures: Actual bill: $510 (remember, we usually order 2 sets)

42. Quiz: What is the patient charged? Electrocardiogram: Actual bill: $706 (just for the tracing, not including interpretation by a physician)

43. What is the patient charged? Troponin (x 1): Actual bill: $402 (remember, we usually order x 3)

44. Quiz: What is the patient charged? CT Head w/o contrast: Actual bill: $2930

45. ED Bill Community hospital in Southern California Patient fell, seen in ED for evaluation Clinically stable Discharged from ED Total cost billed to patient (not including physician fees): $10, 122.75

46. Disclaimer Cost of test and charge to patient is complex and involves many factors, and is not just monetary Clinical reasoning and individualized care are very important Cost-conscious care is not about discouraging appropriate care, nor denying beneficial services

47. Steps Toward High Value, Cost Conscious Care Five-Step Framework: High-Value, Cost-Conscious Care Step 1 Understand the benefits, harms, and relative costs of the interventions that you are considering Step 2 Decrease or eliminate the use of interventions that provide no benefit and/or may be harmful Step 3 Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) Step 4 Customize a care plan with the patient that incorporates their values and addresses their concerns Step 5 Identify system-level opportunities to improve outcomes, minimize harms, and reduce health care waste

48. Summary START: Using validated clinical tools and follow diagnostic algorithms to avoid overuse of tests Asking yourself before you order the test if the results will change what you do for the patient STOP: routinely obtaining studies if results will not alter your management