1. High Value Cost- Conscious Care Apostolos P. Dallas, M.D. March 2, 2013

2. Disclosures None relevant to this talk None relevant to this talk

3. Objectives Review some data about inefficient health care Review some data about inefficient health care Generate ideas/opinions on screening and diagnostic tests Generate ideas/opinions on screening and diagnostic tests Review imaging in low back pain and EGD in GERD Review imaging in low back pain and EGD in GERD Be conversant about HVCCC initiative Be conversant about HVCCC initiative Worry better Worry better

4. Problem with health care costs? Problem with health care costs? 20% of Gross Domestic Product 20% of Gross Domestic Product US health care is 5 th largest country in the world US health care is 5 th largest country in the world $2.5 trillion, $765 billion potentially avoidable $2.5 trillion, $765 billion potentially avoidable $395 physician controlled $395 physician controlled $130 billion inefficient care $130 billion inefficient care $55 billion missed prevention opportunities $55 billion missed prevention opportunities

6. History of HVCCC Physician Charter on Professionalism- ABIM/ ACP/EFIM- 2002 Physician Charter on Professionalism- ABIM/ ACP/EFIM- 2002 National Physicians Alliance-Promoting Good Stewardship In Medicine National Physicians Alliance-Promoting Good Stewardship In Medicine Choosing Wisely-ABIM Choosing Wisely-ABIM “He chose poorly”

7. ACP Top Five In Choosing Wisely ACP Top Five In Choosing Wisely No screening exercise stress test in asx, low risk pts No screening exercise stress test in asx, low risk pts No imaging studies in non-specific low back pain No imaging studies in non-specific low back pain Syncope and a normal neuro exam, no CT or MRI Syncope and a normal neuro exam, no CT or MRI Low pretest probability of venous thrombo-embolism, highly- sensitive D-dimer, not imaging, as initial diagnostic test Low pretest probability of venous thrombo-embolism, highly- sensitive D-dimer, not imaging, as initial diagnostic test No preoperative CXR without clinical suspicion for intrathoracic pathology No preoperative CXR without clinical suspicion for intrathoracic pathology

8. History of HVCCC 2010 ACP initiative 2010 ACP initiative Clinical Guidelines Committee Clinical Guidelines Committee Charged with developing series of articles to inform discussion Charged with developing series of articles to inform discussion

9. History of HVCCC No discord over concept of “choosing wisely” No discord over concept of “choosing wisely” “Rationing” is a dirty word-political; cost/care together negative “Rationing” is a dirty word-political; cost/care together negative Defining terms is key Defining terms is key Educating/updating physicians Educating/updating physicians Educating/testing trainees Educating/testing trainees Educating public Educating public Affecting public policy Affecting public policy Just saying HVCCC is difficult Just saying HVCCC is difficult

11. ACP Position Regarding Resource Allocation Decisions 1 Resources devoted to developing needed data on cost-effectiveness of medical interventions 2 Transparent, publicly acceptable process for resource allocation decision 3 Public, patients, physicians, insurers, payers, and other stakeholders’ input 4 Multiple criteria: Patient need, preferences, and values, benefits, safety, societal priorities, fiscal responsibility, QALY 5 Allocation decisions mesh with societal values and reflect moral, ethical, cultural, and professional standards

12. ACP Position Regarding Resource Allocation Decisions 6 Allocation decisions should not discriminate 7 Allocation process flexible enough to address variations in regional, population-based needs 8 Informed decisions and shared decision-making 9 Medical liability reforms 10 Periodically reviewed to reflect evolving medical, societal values and changes in evidence, and assess for any cost shifting or other unwanted effects

14. HVCCC Value=Benefit/Cost Value=Benefit/Cost Health benefit: conditions diagnosed/prevented, life-years, QALY Health benefit: conditions diagnosed/prevented, life-years, QALY QALY: length and assessed quality of life QALY: length and assessed quality of life Cost-effectiveness ratio=dollars/health outcome Cost-effectiveness ratio=dollars/health outcome

15. QALY How much is life/quality of life worth? How much is life/quality of life worth? HIV screening $15,000/QALY HIV screening $15,000/QALY $50,000/QALY threshold, 1982 $50,000/QALY threshold, 1982 Today $120,000/QALY Today $120,000/QALY People willing to pay $109, 000 (Braithwaite 2008) People willing to pay $109, 000 (Braithwaite 2008) UK: 30-50k UK: 30-50k WHO: < 3x per capita gross domestic product per disability adjusted life-year gained WHO: < 3x per capita gross domestic product per disability adjusted life-year gained US- no consensus US- no consensus

16. Low Back Pain $90 billion $90 billion Similar or worse mental health, physical functioning, work/school/social limitations 1997 v 2005 Similar or worse mental health, physical functioning, work/school/social limitations 1997 v 2005 Appropriateness of imaging for LBP Appropriateness of imaging for LBP Systematic review (Chou, 2009) Systematic review (Chou, 2009) Advice for HVCCC (Chou, CGC 2011) Advice for HVCCC (Chou, CGC 2011)

17. Low Back Pain-Recommenations Focused history and PE: nonspecific, pain potentially with radiculopathy/stenosis, or pain with other spinal cause. Assess psychosocial risk Focused history and PE: nonspecific, pain potentially with radiculopathy/stenosis, or pain with other spinal cause. Assess psychosocial risk No routine imaging/diagnostic tests No routine imaging/diagnostic tests Testing if severe or progressive neuro deficits Testing if severe or progressive neuro deficits Imaging with radiculopathy/stenosis if candidate for surg or epidural Imaging with radiculopathy/stenosis if candidate for surg or epidural Provide evidence-based info to pts Provide evidence-based info to pts Use meds with proven benefits Use meds with proven benefits Use spinal manipulation, rehab, exercise, cognitive- behavioral therapy Use spinal manipulation, rehab, exercise, cognitive- behavioral therapy

18. Low Back Pain-Diagnostic Imaging Patient Discussion Risk Factor Assessment-CA, infection, cauda equina, severe/progressive neuro deficits Risk Factor Assessment-CA, infection, cauda equina, severe/progressive neuro deficits Low underlying disease prevalence with no risks Low underlying disease prevalence with no risks Natural history favorable Natural history favorable Routine imaging does not improve outcomes Routine imaging does not improve outcomes Imaging abls common, poorly correlated Imaging abls common, poorly correlated Treatment plans usually don’t change Treatment plans usually don’t change Radiation exposure Radiation exposure

19. Upper Endoscopy for GERD 40% of adults with GERD sxs 40% of adults with GERD sxs 20% on weekly basis 20% on weekly basis Of top 10 meds, 2 are acid suppressive meds Of top 10 meds, 2 are acid suppressive meds Of GERD pts, 10% have Barrett esophagus Of GERD pts, 10% have Barrett esophagus Increased risk of esoph adenocarcinoma (5 year survival <20%) Increased risk of esoph adenocarcinoma (5 year survival <20%) Men, obese have higher risk of Barrett Men, obese have higher risk of Barrett 80% of EAC in men= to man with breast CA 80% of EAC in men= to man with breast CA

20. Upper Endoscopy for GERD 13% of Blue Cross pts in PA had EGD 13% of Blue Cross pts in PA had EGD American Society of Gastrointestinal Endoscopy American Society of Gastrointestinal Endoscopy American College of Gastroenterology American College of Gastroenterology American Gastroenterological Association American Gastroenterological Association Guidelines Guidelines Up to 40% not indicated Up to 40% not indicated Alarms: dysphagia, bleeding, anemia, weight loss, recurrent vomiting Alarms: dysphagia, bleeding, anemia, weight loss, recurrent vomiting

21. Upper Endoscopy for GERD Errors: gastro but primary care is source Errors: gastro but primary care is source Serial endoscopies in GERD with no Barrett Serial endoscopies in GERD with no Barrett Exams at too short intervals Exams at too short intervals Early EGD in pts low risk and no alarm sxs Early 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 situations was previous defendant in malpractice case (Rubenstein, AM J Gastr 2008) Primary predictor of EGD in low-yield situations was previous defendant in malpractice case (Rubenstein, AM J Gastr 2008)

22. Upper Endoscopy for GERD Best Practice Advice 1. Men and women with alarm sxs and heartburn 2. Men and women with sxs and up to 8 week trial of twice daily PPI After two month course of PPI for severe erosive esophagitis. In absence of Barrett, no follow-up endoscopy After two month course of PPI for severe erosive esophagitis. In absence of Barrett, no follow-up endoscopy EGD for history of stricture with recurrent sxs EGD for history of stricture with recurrent sxs 3. May be indicated: Men >50 with chronic GERD(>5 yrs) with additional risk factors (nocturnal sxs, HH, obesity, tob, abd fat) Men >50 with chronic GERD(>5 yrs) with additional risk factors (nocturnal sxs, HH, obesity, tob, abd fat) For Barrett with no dysplasia, 3-5 years For Barrett with no dysplasia, 3-5 years For Barrett with dysplasia, more frequent depending on grade For Barrett with dysplasia, more frequent depending on grade

23. Ideas and Opinions ACP ad hoc group ACP ad hoc group Identify overused screening and diagnostic tests Identify overused screening and diagnostic tests Not rigorous enough for guideline Not rigorous enough for guideline 37 situations 37 situations

24. Appropriate Use of Screening and Diagnostic Tests Caths in SIHD Caths in SIHD Echo in benign sounding murmurs Echo in benign sounding murmurs Imaging stress as first test in pts who can exercise and have no confounding ekg Imaging stress as first test in pts who can exercise and have no confounding ekg Annual lipid screening Annual 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 hysterectomy Paps after age 65 and in total hysterectomy Routine preop labs, coags Routine preop labs, coags

25. Appropriate Use of Screening and Diagnostic Tests Screening for COPD with PFTs without resp sxs Screening for COPD with PFTs without resp sxs ANA with nonspecific sxs ANA with nonspecific sxs Follow-up imaging studies for < 4 mm pulm nodules with low risk Follow-up imaging studies for < 4 mm pulm nodules with low risk Serologic testing for Lyme disease with nonspecific sxs and no evidence of disease Serologic testing for Lyme disease with nonspecific sxs and no evidence of disease PSA >75 or with 75 or with <10 yr life expectancy

26. Future of HVC An Expected Journey High,Value and Care-all good words High,Value and Care-all good words Educating/updating physician-guidelines, HVC papers, guidance statements Educating/updating physician-guidelines, HVC papers, guidance statements Educating/testing trainees-ITE, MKSAP, boards and MOC Educating/testing trainees-ITE, MKSAP, boards and MOC Educating public-outreach Educating public-outreach Affecting public policy- statements in guidelines Affecting public policy- statements in guidelines

27. High Value Care Questions Questions