1. Introduction to Health Care Value Providing High-Value Cost-Conscious Care: 2012-2013 | Presentation #1 0f 10

2. Learning Objectives Define and emphasize the importance of high-value, cost- conscious care Introduce a simple five-step model for delivering high-value, cost- conscious care Discuss the cost implications of two common presentations of VTE disease (PE and DVT) Articulate strategies for bringing high-value care into daily practice Challenge participants to identify an action plan: at least one thing to start doing and one thing to stop doing

3. Patient Presentation – Mrs. G 59 y/o woman POD#3 from laparoscopic cholecystectomy Patient was recovering well and plan was for discharge today Then, was ambulating with PT and became acutely SOB and hypotensive to SBP 80s She complained of right shoulder pain, became diaphoretic and was brought urgently to the CCU where a stat TTE revealed a newly dilated RV

4. A Common Inpatient Diagnosis: PE Annual incidence in the U.S. estimated to be 600,000 (based on study of >42 million deaths) With introduction of CT-A the incidence estimates have increased to 112.3 per 100,000 Untreated PE is associated with a 30% mortality rate! Recurrent embolism is most common cause of death 5-10% of deaths in hospitalized patients 1 Cartoon by Dan Pirraro www. Bizarro.com Thompson et al, “Overview of Acute Pulmonary Embolism. Uptodate.com, accessed 11/11/11

5. The Economic Burden of PE The overall economic burden of PE in the U.S. is estimated to be over $1.5B per year in healthcare costs Some estimates suggest that PE results in healthcare costs of more than $30,000 per incident 2 Several studies have determined that prevention of PE in hospitalized patients is cost- effective, costing just $3,000 per pulmonary embolism event avoided 3

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

7. Step 1: Benefits, Harms, Costs Initial Work-up for PE  What is your work-up for pulmonary embolism?  What factors lead us to make orders or recommendations for our patients?  Which labs or initial studies do you want to order?  How much does this cost? Cartoon by T. McCracken www.mchumor.com

8. Benefits, Harms, Costs TestBenefitHarmCosts CT-PE protocol D-dimer Fibrinogen BNP Troponin (x 4) ABG LE Doppler Hypercoagulable work-up

9. Patient Presentation - Update After getting TTE that showed RV dysfunction and +McConnell’s sign, our patient had the following studies performed: CT-PE protocol  +bilateral subsegmental PEs D-dimer Fibrinogen BNP Troponin x 4 : 0.5  1.6  1.3  0.6 ABG LE Doppler U/S  Negative for DVT

10. Step 1: Know the benefits, harms and costs of the interventions that you offer patients NOTE: This is an actual case and charges are directly from a copy of her hospital bill TTE ($2,917) CT-PE protocol ($3,558 + $462 contrast + risk of contrast reaction + radiation exposure) D-dimer ($410) Fibrinogen ($100) BNP ($338)

11. Step 1: Know the benefits, harms and costs of the interventions that you offer patients (continued) Troponin x4 ($116 x 4 = $464 + risk of repeated phlebotomy) ABG ($110 + risk of arterial stick) LE Doppler U/S ($1,397) Hypercoagulable panel ($2,250 - $3,050) Cost of diagnostic work-up (not including all of the routine labs, etc. obtained): > $12,756

12. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful Which tests had the potential to change management? CT-PE protocol D-dimer Fibrinogen BNP Troponin x 4 Hypercoagulable panel WASTE

13. Disclaimer The prices listed are estimates based on actual hospital bills o There are a lot of complexities to how things are priced and how much a specific patient is charged o The goal is to give an idea of magnitude o Costs reported here are hospital charges (found on a bill) Clinical reasoning and individualized care are very important Cost-conscious care is not about discouraging appropriate care, nor denying beneficial services

14. 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

15. Case #2 Management of DVT o Two patients in an ambulatory setting were found to have a DVT o One of the patients was sent to the Emergency Department and hospitalized for management of the DVT o The other patient was started on LMWH and managed as an outpatient Split into two groups to review the two cases, with the associated healthcare bills Use the five-step model for each patient to identify what to eliminate and what would be the best approach

16. Discussion Hospitalized patient o What costs surprised you? o What can be eliminated? o What would be the most elegant approach to work-up and management? Outpatient o What costs surprised you? o What can be eliminated? o What would be the most elegant approach to work-up and management? EBM Update: Younger patients with calf DVTs, without incapacitating pain have equal outcomes for $1,402/pt compared to hospitalized patients at $5,465 (1999 dollars) 5

17. Summary START: To use validated clinical scores (Wells Criteria, Revised Geneva Score) and follow diagnostic algorithms to avoid overuse of tests To ask yourself before you order the test if the results will change what you do for the patient STOP: Do NOT routinely obtain LE U/S studies and hypercoagulable panel in patients with acute PE Stop routinely sending patients with suspected DVT to the ED

18. Bibliography 1)Thompson et al, “Overview of Acute Pulmonary Embolism.” Uptodate.com, accessed 11/11/11 2)MacDougall DA, et al. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 2006;63(suppl 6) 3)McGarry LJ, et al. Cost effectiveness of thromboprophylaxis with a low-molecular-weight heparin versus unfractionated heparin in acutely ill medical inpatients. Am J Manag Care 2004;10:632–642 4)Adapted from Owens, D. Ann Intern Med. 2011;154:174-180 5)Pearson S, Blair R, Halper A, Eddy E, McKean S. An outpatient program to treat deep venous thrombosis with low-molecular weight heparin. Effective Clinical Practice. 1999; 2:210-7