1. High Value, Cost-Conscious Care: Wasting the Buck Stops Here Donna E. Sweet, MD, AAHIVS, MACP Professor of Medicine The University of Kansas School of Medicine - Wichita With great thanks to Dr. Steve Weinberger, MACP for the use of his slides

2. Conflict of Interest Disclosure I have no financial relationships with a commercial entity producing healthcare-related products and/or services related to this presentation.

3. Patient Presentation (part 1)  50 year old male with 1 week history of back pain similar to intermittent episodes for past 20 years  Initial work-up: MRI (required before patient seen)  possible liver mass  Next: abdominal ultrasound  non- diagnostic  Then: repeat MRI  poor quality

4. Patient Presentation (part 2)  Yet more: MRI #3  no liver mass, but “something on the kidney”  CT scan: liver and kidney normal  Rx.: physical therapy  back pain improved  Cost of evaluation: $6200  Additional cost: substantial anxiety!

5. What’s the diagnosis? VOMIT (Victim of Modern Imaging Technology) Hayward R. BMJ. 2003; 326:1273.

6. Overriding issues in health care  Issue of the decade starting in 2000: quality of care and patient safety  Issue of the decade starting in 2010: decreasing the cost of care Jay Carney: “Every economist, whose insights into this area are worth the paper on which his or her PhD is printed, would tell you that the principal driver, when it comes to spending, of our deficits and debt, is health care spending.”

7. Cost of Health Care CMS, Office of the Actuary, National Health Statistics Group

8. Excess Cost Domain Estimates IOM. The Healthcare Imperative, 2010.

9. It Is Our Ethical and Professional Responsibility to Control Cost! From Medical Professionalism in the New Millennium: A Physician Charter (ABIM-F, ACP-F, EFIM) “While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.” “The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.” Ann Intern Med. 2002; 136:243-246

10. But who do physicians feel should be primarily responsible for controlling health care costs? Specific GroupPercentage Trial lawyers60% Health insurance companies59% Hospitals and health systems56% Pharmaceutical and device manufacturers 56% Patients52% Practicing physicians36% Tilburt, et al. JAMA. 2013;310(4):380-388.

11. Conserving resources through rational care does not mean rationing!  Rationing: decisions are made about the allocation of scarce medical resources and who receives them, leading to underuse of potentially appropriate care  Rational care: assuring that care is clinically effective, thus avoiding overuse or misuse of care that is inappropriate

12. Ann Intern Med. 2011; 154:174-180

13. High-Value Cost-Conscious Care The ACP defines high-value, cost-conscious care as delivery of services that provide benefits commensurate with their cost and that outweigh any associated harm.

14. Questions Physicians Should Ask Themselves Before Ordering Tests Did the patient have this test previously?  If so, what is the indication for repeating it? Is the result of a repeated test likely to be substantively different from the last result?  If it was done recently elsewhere, can I get the result instead of repeating the test? Will the test result change my care of the patient?  What are the probability and potential adverse consequences of a false positive result?  Is the patient in potential danger over the short term if I do not perform this test? Did the patient have this test previously?  If so, what is the indication for repeating it? Is the result of a repeated test likely to be substantively different from the last result?  If it was done recently elsewhere, can I get the result instead of repeating the test? Will the test result change my care of the patient?  What are the probability and potential adverse consequences of a false positive result?  Is the patient in potential danger over the short term if I do not perform this test?

15. Questions Physicians Should Ask Themselves Before Ordering Tests Am I ordering the test primarily because the patient wants it or to reassure the patient?  If so, have I discussed the above issues with the patient?  Are there other strategies to reassure the patient? Am I ordering the test primarily because the patient wants it or to reassure the patient?  If so, have I discussed the above issues with the patient?  Are there other strategies to reassure the patient?

16. Current Philosophy at ACP  Focus initially on the “low-hanging fruit”: interventions with low or no benefit, independent of cost  Goal: reduce inappropriate care that does not help (or even harms) patients  Ultimate outcomes: better patient care, reduced cost

17. From Reinhardt blog, NY Times, 12/24/2010

18. Diagnostic Imaging Studies in Patients in Large Integrated Health Care Systems: 1996-2010 Source: JAMA. 2012;307:2400-2409.

19. Why are diagnostic tests overused and misused?  Lack of guidance or guidelines  Lack of knowledge  Patient expectations  Inadequate time  Discomfort with uncertainty  Fear of malpractice  Habit  Erosion of physical exam skills  Consultation “thoroughness”  Personal gain

20. Overview of Goals for HVCCC  Develop guidance for physicians about appropriate use of care, focusing initially on diagnostic testing Assemble and integrate evidence-based and consensus-based recommendations  Educate target audiences about areas of overuse and misuse of care: Practicing clinicians Trainees (residents and medical students) Patients

21. Vehicles for disseminating high value care resources  Papers from ACP’s Clinical Guidelines Committee in Annals of Internal Medicine  ACP’s educational programs and products, e.g., MKSAP, live courses  Development of resources for trainees (with AAIM)  Patient education through ACP Foundation  Collaboration with consumer and other organizations

23. Ann Intern Med. 2011; 154:181-189

24. Ann Intern Med. 2012; 156:147-149. Identifies 37 clinical situations in which a screening or diagnostic test does not reflect high value care.

25. Major Categories from “The Big List”  Overuse/misuse of imaging studies Unnecessary CT and MR scans Unnecessary/inappropriate follow-up studies  Misapplication of screening studies Wrong population Incorrect timing/frequency  Routine preoperative testing

26. Major Categories from “The Big List”  Overuse/misuse of cardiac diagnostic studies Coronary angiography Echocardiography Stress imaging tests  Overused blood tests  Unnecessary/overused monitoring Blood tests Pulmonary function tests

28. Creative marketing at work

29. Other National Initiatives  National Physicians Alliance: “Top 5” Campaign  Archives of Internal Medicine: “Less is More” series  ABIM Foundation: “Choosing Wisely” Campaign

30. About Choosing Wisely® First announced in December 2011, Choosing Wisely® is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources. Participating specialty societies are working with the ABIM Foundation and Consumer Reports to share the lists widely with their members and convene discussions about the physician’s role in helping patients make wise choices. Learn more at www.ChoosingWisely.org.

31. Choosing Wisely  Partners – Round 1  ABIM Foundation (convener)  American Academy of Allergy, Asthma & Immunology  American Academy of Family Physicians  American College of Cardiology  American College of Physicians  American College of Radiology  American Gastroenterological Association  American Society of Clinical Oncology  American Society of Nephrology  American Society of Nuclear Cardiology  Consumer Reports

33. ACP’s Choice of 5 Overused Items for “Choosing Wisely” Campaign  Screening exercise ECG in asymptomatic individuals at low risk for coronary heart disease  Imaging studies in patients with non-specific low back pain  Brain imaging studies (CT or MRI) for simple syncope and a normal neurological examination  CT pulmonary angiogram as the first study in patients with low pretest probability of venous thromboembolism, rather than D-dimer  Preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology

34. The Society of General Internal Medicine (SGIM) Five Things Physicians and Patients Should Question 1.Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin. 2.Don't perform routine general health checks for asymptomatic adults. 3.Don't perform routine pre-operative testing before low-risk surgical procedures. 4.Don't recommend cancer screening in adults with life expectancy of less than 10 years. 5.Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience. 1.Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin. 2.Don't perform routine general health checks for asymptomatic adults. 3.Don't perform routine pre-operative testing before low-risk surgical procedures. 4.Don't recommend cancer screening in adults with life expectancy of less than 10 years. 5.Don't place, or leave in place, peripherally inserted central catheters for patient or provider convenience.

35. American College of Cardiology Five Things Physicians and Patients Should Question 1.Don’t perform stress cardiac imaging or advanced non- invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. 2.Don’t perform annual stress cardiac imaging or advanced non- invasive imaging as part of routine follow-up in asymptomatic patients. 3.Don’t perform stress cardiac imaging or advanced non- invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. 1.Don’t perform stress cardiac imaging or advanced non- invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. 2.Don’t perform annual stress cardiac imaging or advanced non- invasive imaging as part of routine follow-up in asymptomatic patients. 3.Don’t perform stress cardiac imaging or advanced non- invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

36. American College of Cardiology Five Things Physicians and Patients Should Question 4.Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. 5.Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI). 4.Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. 5.Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).

37. American College of Radiology Five Things Physicians and Patients Should Question 1.Don’t do imaging for uncomplicated headache. 2.Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability 3.Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. 4.Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. 5.Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. 1.Don’t do imaging for uncomplicated headache. 2.Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability 3.Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. 4.Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option. 5.Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

38. September 20, 2013 — 1.Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring 2.Don’t routinely prescribe two or more antipsychotic medications concurrently 3.Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia 4.Don’t routinely prescribe antipsychotic medications as a first- line intervention for insomnia in adults 5.Don’t routinely prescribe antipsychotic medications as a first- line intervention for children and adolescents for any diagnosis other than psychotic disorders September 20, 2013 — 1.Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring 2.Don’t routinely prescribe two or more antipsychotic medications concurrently 3.Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia 4.Don’t routinely prescribe antipsychotic medications as a first- line intervention for insomnia in adults 5.Don’t routinely prescribe antipsychotic medications as a first- line intervention for children and adolescents for any diagnosis other than psychotic disorders American Psychiatric Association Five Things Physicians and Patients Should Question

39. Do Physicians Agree That Health Care is Overused?  Survey of primary care physicians  42% believe patients in their own practice are receiving too much care (vs. 6% who say “too little”)  Perceived factors leading to overuse Malpractice concerns: 76% Clinical performance measures: 52% Inadequate time to spend with patients: 40% Arch Intern Med. 2011; 171:1582-1585

40. HVCCC and Residency Training  Habits start early in training → need to focus on students, residents, and fellows  Joint initiative to develop HVCCC program for residents: AAIM and ACP

41. Are we educating residents? (Dine CJ, et al. J Grad Med Educ. 2010; 2:175-180)  37% of residents were provided some feedback about their resource utilization; 20% reported receiving feedback regularly  16% developed a concrete plan with their attending physician for improving resource utilization; 28% reported receiving any corrective feedback  63% reported having no idea about cost of tests

42. Bringing Cost Consciousness into the Training Environment  Knowledge: understanding of what helps patients vs. what is superfluous or even harms patients  Approach: focus on appropriate care rather than saving money  Culture: recognition that more ≠ better  Faculty development: trainees mimic faculty behavior  Regulation: cost consciousness in residency competency requirements

43. Overview of AAIM-ACP curriculum (free download at www.highvaluecarecurriculum.org)  Developed by 12 IM Programs (dept. chair, program directors, and residents)  Introduces and builds on a simple, step-wise framework  Ten one hour modules with a mix of didactic and interactive teaching  Small group activities involving actual cases (inpt. and outpt.) and bills to engage learners  A Facilitator’s Guide accompanies each module to help faculty prepare

44. Ann Intern Med. 2012; 157:284-286.

45. Steps toward high value care  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 Owens, et al. Ann Intern Med. 2011;154:174-180

46. Module topics TopicCases 1 Introduction to healthcare value Pulmonary embolus; deep venous thrombosis 2 Healthcare waste, costs, and over-ordering of tests Headache; heart failure 3 Health insuranceAppendicitis; osteomyelitis 4 Healthcare costs and payment models Sports injury; asthma 5 Biostatistical conceptsChest pain; primary prevention CAD

47. Module topics TopicCases 6 Screening and preventionPeriodic health examination; smoking cessation 7 Balancing benefits with harms and costs PSA screening; pneumonia 8 High value medication prescribingSeasonal allergies; medication reconciliation 9 Overcoming barriers to high value, cost-conscious care Low back pain; upper respiratory infection 10 Local quality improvement project

48. Ann Intern Med. 2011; 155:386-388

49. Source: http://www.acgme- nas.org/assets/pdf/Milestones/InternalMedicineMilestones.pdf ACGME milestone relating to stewardship of resources

50. Challenges for program directors  Find space in a busy curriculum with reduced duty hours to incorporate these sessions  Identify and develop faculty to teach these topics and role model high-value cost- conscious care at the bedside  Need to track this additional competency in their trainees over time (ITE sub-score on HVC; ABIM/ACGME milestones)

51. Challenges for faculty  Ask appropriate questions at the point of care, e.g., Did the patient have this test previously? Will the results of this test change the care of the patient? Was it the most appropriate and cost-effective test to order? What is the probability and what are the potential adverse consequences of a false positive result?  Observe and provide feedback to trainees on their provision of high value care

52. Tough additional challenges in controlling costs  End of life care  Physician financial conflict of interest  Defensive medicine  Over-pricing  Price transparency  Decreasing hospitalization and ER utilization

53. Is This Test Overpriced?

54. The Bottom Line  Health care costs are unsustainable  Nearly 1/3 of health care costs are wasted  Physicians have control over a significant component of these wasted costs  Current physician practice and training have not focused on avoiding waste  The culture of residency training must change to assure cost-consciousness  Avoiding overuse and misuse must become a core value and competency for residents

55. SOLUTION

56. Do you recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin?

57. Do you do imaging for uncomplicated headache? When do you image?

58. Do you do imaging studies in patients with non-specific low back pain? Is it overused?

59. Do you do preoperative chest X-rays? How many times a week do you do them?

60. Do you use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee?