4. High Value Care: RUQ Abdominal Pain Darwin L. Conwell, MD, MS Professor and Director, Division of Gastroenterology, Hepatology and Nutrition darwin.conwell@osumc.edu 614-366-3433 office 614-293-0861 Fax

5. Current Health Care Landscape The Facts: Health care costs increasingly unsustainable Efforts to control expenditures need to focus on VALUE in addition to COSTS HIGH-VALUE – benefits justify costs GI reimbursement is dropping Increasing denial of procedures and tests High co-pays steer patients away from academic centers Lack of quality metrics in pancreatic disease Research funding and long term sustainability is challenging

6. Abdominal Pain Challenging chief complaint 75% adolescents 50% adults Benign disease GERD, peptic ulcer Serious pathology Gastrointestinal cancer Frequently Irritable Bowel Syndrome < 50 yr minimal work-up; symptomatic treatment > 50 yr rule out malignancy; cross sectional abdominal imaging (CT scan) Introduction

7. Abdominal Pain Primary Care Physicians are responsible to determine which patients can be: 1.Safely observed 2.Treated symptomatically 3.Require further investigation ED evaluation Resuscitation: ABCs 4.Specialist Referral / Consultation Gastroenterology, Surgery Triage

8. Abdominal Pain The history should include: Location of pain Radiation of pain Factors that exacerbate or improve symptoms such as food, antacids, exertion, defecation Associated symptoms including fevers, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool History

9. Abdominal Pain Past medical and surgical history, including risk factors for cardiovascular disease and details of previous abdominal surgeries Family history of bowel disorders Alcohol intake Intake of medications including over the counter medications such as aspirin and NSAIDs Menstrual and contraceptive history in women Past Medical History

10. Abdominal Pain A typical examination will include: Measurement of blood pressure, pulse, and temperature Examination of the eyes and skin for jaundice Auscultation and percussion of the chest Auscultation of the abdomen for bowel sounds Palpation of the abdomen for masses, tenderness, and peritoneal signs Rectal examination including testing of stool for occult blood Pelvic examination in women with lower abdominal pain Physical Examination

11. Abdominal Pain Acute Minutes, hours, days; ill-appearing Non-narcotic use history Surgical abdomen: IHOP !!!!! Intractability, Hemorrhage, Obstruction, Perforation (IHOP) Pain medications help Pearl – They do not request pain medications.They request help me! Scared, anxious, ill Chronic Weeks, months, years; looks well Chronic Narcotic use history Non-surgical abdomen Pain medications ineffective Pearl - Request pain medication “by name and dose!” They are demanding; irritable, unpleasant Acute versus Chronic

12. Abdominal Pain Laboratory Studies: Acute and Chronic Pain CBC with differential Electrolytes, BUN, creatinine, glucose Liver profile Lipase Additional Chronic Pain labs: TSH, glycohemoglobin TTG ESR, CRP Fecal elastase, fecal fat Diagnostic Testing

13. Abdominal Pain Imaging StudiesPrice ($) Ultrasound420 EGD3,000 Colonoscopy3,000 MRI/MRCP2,625 Diagnostic Testing http://www.newchoicehealth.com/Directory

14. Abdominal Pain Step 1 – Recognize most are benign (IBS) and a subset have serious pathology (GI cancer) Step 2 – Acute or chronic pain Step 3- Triage serious etiology and/or surgical abdomen to ED Step 4 – Location of pain determines evaluation: RUQ Pain Step 5 – Most chronic pain is functional in young ( 50 yr age) Summary

15. Defining High- Value Care Rationale for High-Value Care -High costs and unsustainable cost increases -Overuse of screening and diagnostic tests increases costs Evaluation of High-Value – DIAGNOSTIC TESTS Principle 1: The diagnostic test should not be performed if it will not change management Principle 2: A low pre-test probability of disease is more likely to result in a false positive test result Principle 3: The true cost of a test includes the cost of test itself and downstream costs incurred because the test was performed Appropriate Use of Screening and Diagnostic Tests Qaseem, A., Ann Intern Med 2012

16. RUQ Pain The investigation and management of patients with recurrent episodes of right upper quadrant and epigastric pain is challenging, as there are numerous causes, both “organic” and “functional”. Symptoms of functional gallbladder (GB) and sphincter disorders must be distinguished from those due to cholelithiasis, pancreatitis, gastroesophageal reflux disease, irritable bowel syndrome, functional dyspepsia, and peptic ulcer disease. Peter B Cotton, et al., Am J Gastro 2010

17. National Trends in Admissions for RUQ Pain (789.01) Are Decreasing http://hcupnet.ahrq.gov/ p < 0.001

18. National Trends in Admissions from ED for RUQ Pain (789.01) are Increasing http://hcupnet.ahrq.gov/ p < 0.001

19. National Trends in Charges for RUQ Pain (789.01) are Increasing http://hcupnet.ahrq.gov/ p < 0.001

20. High-Value, Cost- Conscious Health Care for RUQ Pain Description of Abdominal Pain Constant or intermittent? Duration of pain in weeks/months Does the pain radiate? Is the pain exacerbated or improved by food? Is the pain improved by PPI/H2 blocker/antacid? Associated symptoms nausea, vomiting change in bowel habits GI bleeding,melena or hematochezia pruritus, weight loss, anorexia Essential patient information

21. High-Value, Cost- Conscious Health Care for RUQ Pain Physical exam jaundice abdominal mass rebound tenderness fever guarding Murphy’s sign ascites palmar erythema, spider angiomata Essential patient information

22. High-Value, Cost- Conscious Health Care for RUQ Pain Diagnoses to consider: Gallstones Cholangitis, cholecystitis Pancreatitis: acute or chronic Peptic Ulcer Disease GERD Sphincter of Oddi dysfunction Ischemic bowel Inflammatory bowel disease Bowel obstruction Perforation Liver disease GI cancer Irritable bowel syndrome Myocardial infarction Pulmonary embolus Differential Diagnosis

23. High-Value, Cost- Conscious Health Care for RUQ Pain Additional clinical history abdominal surgery bariatric surgery gallstones pancreatitis alcohol use NSAID use immunocompromised Essential patient information

24. High-Value, Cost- Conscious Health Care for RUQ Pain A patient with: hemodynamic instability sudden onset pain rebound tenderness fevers gastrointestinal bleeding should be referred for urgent evaluation!!!! Alarm symptoms

25. High-Value, Cost- Conscious Health Care for RUQ Pain Laboratory Tests CBC Chemistry panel AST, ALT, alkaline phosphatase, bilirubin Amylase, Lipase Pregnancy test Imaging Studies RUQ ultrasound Essential patient information Medical therapy should be directed by results of the above tests. A negative evaluation or confirmatory testing should be directed by GI consultation. More costly, studies such as endoscopy, CT, MRI and ERCP should be recommended by specialty consultants.

26. High-Value, Cost- Conscious Health Care for RUQ Pain Laboratory Tests Stool FOBT Anti-TTG Hepatitis A, B, C serology H. pylori testing Imaging Studies Abdominal CT Abdominal MRI UGI x-ray Endoscopy EGD ERCP Additional Information that may be recommended by GI Consultants

27. Cotton P, et al., Am J Gastro 2010

28. Abdominal Pain on NSAIDS

29. Perforated Duodenal Ulcer

30. Alcoholic with Acute Abdominal pain

31. Acute Pancreatitis

32. 49 year old abdominal pain

33. Mesenteric Ischemia Transverse Colon

34. 25 year old with abdominal pain

35. Autoimmune Pancreatitis

36. Anemia and abdominal pain Peptic Ulcer

37. 27 year old female with RUQ Pain Fitz Hugh Curtis

38. Increased pain, anorexia, weight loss Telephone Call PCP - 1/2009 Mutual patient Increasing abdominal pain weight loss jaundice Reviewed CT Report 2007 Findings consistent with chronic pancreatitis with no evidence of acute pancreatitis. CT 1/15/2009: Mass, malignant ascites, Metastases, biliary dilation

39. Defining High- Value Care Rationale for High-Value Care -High costs and unsustainable cost increases Evaluation of High-Value – MEDICAL OR SURGICAL INTERVENTIONS Step 1: Understand Benefits, Harms and Costs of intervention Step 2: Downstream costs associated with intervention Step 3: Consider Incremental Cost-effectiveness ratio (ICER) calculation to estimate additional costs required to obtain additional health benefit. Key measure of value. Evaluation of Medical Interventions Owens, D et al., Ann Intern Med 2011

40. Incremental Cost- effectiveness Ratio (ICER) Owens, D et al., Ann Intern Med 2011

41. High-Value, Cost- Conscious Health Care for RUQ Pain Uptodate.com Sleisenger and Fordtrans’s Gastrointestinal and Liver Diseases 9th ed. Chapters 10,52,65,66 Textbook of Gastroenterology, Yamada. 5th ed. Chapters 40, 74 ACR Appropriateness Criteria Guidelines - Right upper abdominal pain. http://www.acr.org/~/media/ACR/Documents/ AppCriteria/Diagnostic/RightUpperQuadrantP ain.pdf Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. Jun 26 2008;358(26):2804-11. References