High Value Cost Conscious Care

Kenneth E. Olive, MD FACP

Disclosure

• • I am Governor of the Tennessee Chapter, American College of Physicians.

The American College of Physicians promotes its High Value Cost Conscious Care Initiative

Learning Objectives

• As a result of participating in this activity, the participant will be able to: • Discuss the issue of growing rapidly growing health care expenditures in the U.S.

• • Identify factors contributing to these growing costs Describe the roles physicians may play in helping to effectively control costs • Discuss common medical practices that increase cost without providing value to patient care

Key Points

• • • The problem What is High-Value, Cost-Conscious Care Five Cases/Five examples

The Problem

• • Rapidly growing health care spending is a significant U.S. societal problem Reducing health care spending by spending in a socially and fiscally responsible way is an important responsibility of physicians.

U.S. Health Care Costs

2500 2000 1500 1000 500 0 Billion $ 1980 1990 2008

U.S. Health Care Costs

• 2008 Average cost per person $7681 • 16.2% of Gross Domestic Product • Gross domestic product (GDP) refers to the market value of all officially recognized final goods and services produced within a country in a given period.

U.S. Federal Budget

26% 24% 22% 20% 18% 16% 14% 12% 10% 8% Drivers of Entitlement Spending Growth (Percent of GDP) 36% 64%

Excess Health Care Cost Growth Aging

56% 44% 9 Source: CBO Long-term Budget Outlook, 2010.

Components of Revenue and Spending 10 Revenues and Financing Borrowing 39% Other 6% Individual Income Tax 27% Corporate Tax 5% Social Insurance Taxes 23% Outlays

2011

Non-Defense 18% Interest 6% Medicare 13% Medicaid & Other Health 8% Social Security 20% Defense 20% Other Mandatory 15%

Total Revenues = $2.230 Trillion Total Financing = $3.629 Trillion Total Outlays = $3.629 Trillion

18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Health Care Spending by Country Percent of GDP (2008) Public Private 11 Source: 2008 Data from the Organization for Economic Cooperation and Development.

• •

Reasons Federal Health Expenditures are Increasing

Aging population Increase cost per beneficiary • • • Unhealthy lifestyles Americans have more resources and are willing to pay more Fragmentation of payment systems reduces impact of normal market competition • Patients insulated from cost of care by insurance incentivizing overspending.

• • • •

Factors Driving Increased Health Care Spending

New Drugs, e.g. Kalydeco for cystic fibrosis, $294,000/yr, Zyvox $1400-2000/course of treatment New Devices, e.g defibrillator, $50,000 New Procedures, e.g. capsule endoscopy, $2000-3000 New Tests, e.g. PET scan, $2000-8000

Conserving health care resources

• The U.S. has largely failed to address the reality that health care spending is increasing at a rate the country can’t afford. • This is a societal issue that transcends medical care itself—how much should we as a society spend using public funds on health care versus education, the environment, or defense?

Conserving health care resources

• At patient-physician level: • Physicians—in consultation with patients - should use health care resources wisely, based on evidence of safety and effectiveness, the particular needs and circumstances of the patient, and with consideration of cost. • Physicians should work to reduce utilization of marginal and ineffective services.

• • • •

What is High-Value, Cost Conscious Care?

Not just cheap care!

Value – does it provide benefit that outweighs harms?

• Example of high-cost intervention with value: anti-retroviral therapy for HIV infection.

• Example of low-cost intervention with low value: Pre-operative CXR in healthy asymptomatic patients High-value care means that health benefits of an intervention justify its harms and costs Cost-consciousness takes cost into account as one factor.

Obtaining an exercise ECG (stress test) for screening in low risk asymptomatic adults represents an area of overused testing leading to low value care ?

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Obtaining ECGs for screening for cardiac disease in individuals at low to average risk for CAD represents high value care?

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Annual lipid screening for patients not on lipid lowering drug therapy in the absence of reasons for changing lipid profiles represents an area of overused testing leading to low value care?

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 Countdown 5

Obtaining BNP measurement in the initial evaluation of patients with typical findings of CHF represents high value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Pap smears in low risk women aged >65 and in women who have had a total hysterectomy (uterus and cervix) for benign disease represents an area of overused testing leading to low value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Obtaining imaging studies in patients with recurrent, classic migraine headache and a normal neurologic exam represents high value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Performing DEXA screening for osteoporosis in women younger than age 65 in the absence of risk factors represents an overuse of testing leading to low value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 5

Obtaining a d-dimer, rather than an appropriate diagnostic imaging (extremity ultrasonography, CT angiography, V/Q scan), in patients with intermediate or high probability of VTE to rule out VTE represents high value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Obtaining imaging studies, rather than a high sensitivity D dimer, as the initial diagnostic test in patients with low pretest probability of VTE represents an area of overused testing leading to low value care.

1.

Strongly Agree 2.

Agree 3.

Neutral 4.

Disagree 5.

Strongly Disagree

0% 1 0% 2 0% 3 0% 4 0% 10 5 Countdown

Case 1

• • • • • 72 yr old woman with long-standing poorly controlled hypertension presents with increasing exertional dyspnea and orthopnea for the past week. Exam: Temp 98.6, heart rate 110, BP 142/94, wt 175 (up from 165 one month prior. Lungs - bibasilar crackles. Heart – S3 gallop, Legs - 3+ pretibial edema.

CBC and BMP are normal, initial troponin is 0.01.

ECG reveals sinus tachycardia (rate 110) and LVH.

CXR is consistent with CHF.

Case 1

Case 1

Case 1

• Does a BNP (brain natriuretic peptide) measurement add value to this patients care?

Does a BNP (brain natriuretic peptide) measurement add value to this patients care?

1.

Yes 2.

No

1 0% 0% 2 10 Countdown

Case 1

• What is the diagnosis?

Case 1

• What is the clinical probability that this patient has CHF?

Case 1

• • What is the clinical probability that this patient has CHF?

90%

Case 1

• • • What is the sensitivity and specificity of BNP for CHF?

For levels >450 • • • Sensitivity=98% Specificity=76% American Journal of Cardiology, 2005, 95(8):948-954.

In someone with a pre-test likelihood of 90% a positive test raises the likelihood to 97%

Case 1

• Cost of test ~$30 • • • • • • What other health care would $30 purchase?

Aspirin 81 mg – 30 days ~$2 Flu shot ~$25 Lisinopril 10 mg qd -30 days ~$4 Carvedilol 12.5 mg bid – 30 days ~$4 Pravastatin 40 mg qd – 30 days ~$4 • If you had to choose would the $30 be better spent on BNP or on the above medications?

Case 1

• Other potential uses of BNP • Diagnosing CHF in unexplained dyspnea, • Diagnosing asymptomatic ventricular dysfunction, • Titrating therapy

Case 1 - Conclusion

• Obtaining BNP measurement in the initial evaluation of patients with typical findings of heart failure does not represent cost-conscious, high value care.

Case 2

• • 38 yr old secretary presents to the ED with a 2 day history of non-productive cough, mild shortness of breath, and pleuritic chest pain. She is in generally good health taking not medications. She has smoked one pack per day for 15 years. History of leg DVT at age 26 while on oral contraceptives. She drove back from shopping in Knoxville yesterday. No recent surgery or childbirth.

Physical exam • Temp 98.8, pulse 80, BP 118/76, resp 16 • • Appears to be mildly uncomfortable Chest – some apparent splinting of the left hemithorax with clear lungs • Heart – normal sounds, S2 normal • Legs – no tenderness, redness, warmth, or edema

Case 2

Case 2

Should this patient have spiral CT with PE protocol to rule out pulmonary embolism?

1.

Yes 2.

No

1 0% 0% 2 10 Countdown

Case 2

• What is the clinical probability of pulmonary embolism?

Case 2

• What is the clinical probability of pulmonary embolism?

Wells Score: Symptoms of DVT (3 points) No alternative diagnosis better explains the illness (3 points) Tachycardia with pulse > 100 (1.5 points) Immobilization (>= 3 days) or surgery in the previous four weeks (1.5 points) Prior history of DVT or pulmonary embolism (1.5 points) Presence of hemoptysis (1 point) Presence of malignancy (1 point) Thromb Haemost. 2000 Mar;83(3):416-20

Case 2

• • • Score > 6: High probability Score >= 2 and <= 6: Moderate probability Score < 2: Low Probability • Assume that low probability in this case is 10% • • • • Spiral CT Sensitivity70%, Specificity=91% PV-=3.5, PV+=46 Ann Intern Med 2001; 135:88-97.

• CT cost ~$2000

Case 2

• • • D dimer cost ~$300 Sensivitity = 96%, specificity 40%

PV -=1.1, PV+=15

• Chest 2004;125;807-809

Case 2 - Conclusion

• The initial diagnostic test in patients with a low pretest probability of venous thromboembolism should be a D-dimer rather than an imaging study.

Case 3

• • • • • 55 yr old male presents to clinic with episode of syncope this morning. Standing at sink brushing teeth shortly after arising. Felt light-headed and passed out. Unconscious for a brief time only. No preceding chest pain, palpitations, or dyspnea. No focal neurologic symptoms.

In generally good health except for GE reflux, allergic rhinitis, and BPH.

Meds: omeprazole 20 mg qd, certrizine 10 mg qd, tamsulosin 0.4 mg (recently started by urologist with first dose last night).

PE: supine BP 126/84, pulse 70 • Standing BP 102/600, pulse 94 • • Neurologic exam- normal Cardiovascular exam – normal ECG - normal

Case 3

• Does he need an echocardiogram as part of his workup?

Does he need an echocardiogram as part of his workup?

1.

Yes 2.

No

1 0% 0% 2 10 Countdown

ACC/AHA Scientific Statement on the Evaluation of syncope

Circulation

2006;113:316-327

Case 3

• Echocardiogram cost ~$1200

Case 3 – Conclusion

• Routinely performing echocardiography in the evaluation of syncope is not indicated • Unless the history, physical examination, and electrocardiogram do not provide a diagnosis • OR unless underlying heart disease is suspected.

Case 4

• • • • • • A 25 yr old woman presents with a one year history of classic migraine headaches occurring monthly. She sees flashing lights in her left eye followed within 30 minutes by a severe pounding left sided headache accompanied by nausea and light sensitivity. She usually takes naproxen, goes to bed, and it resolves in a few hours. Her gynecologist, who prescribes her oral contraceptive told her these are migraines. She is concerned because an aunt died recently at age 59 of a brain tumor. Past medical history otherwise unremarkable.

Meds: oral contraceptive and naproxen prn PE: BP 108/66, p 68, resp 14, wt 124 lbs Head and neck exam normal Neuro exam normal

Case 4

• Does this patient need a brain imaging study?

Does this patient need a brain imaging study?

1.

Yes 2.

No

1 0% 0% 2 10 Countdown

American Academy of Neurology: Evidence-Based Guidelines for Migraine Headache

• Neuroimaging recommendations for nonacute headache: • Neuroimaging is not usually warranted in patients with migraine and a normal neurologic examination (Grade B).

• Consider neuroimaging in: Patients with an unexplained abnormal finding on the neurologic examination (Grade B) Patients with atypical headache features or headaches that do not fulfill the strict definition of migraine or other primary headache disorder (or have some additional risk factor, such as immune deficiency), when a lower threshold for neuroimaging may be applied (Grade C) • Neurology. 2000 Sep 26;55(6):754-62.

Case 4

• • • Cost of head CT ~$1500 Cost of head MRI ~$1900 Cost of careful history and physical examination ~$200

Case 4 - Conclusion

• Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination is not indicated.

Case 5

• • • 70 year old woman presents for annual followup visit without complaints except for wanting to make sure she is up to date on preventive issues HTN controlled on benazepril 20 mg qd Gyn G3P3, two lifetime sexual partners, no history of STDs. As an adult has had normal paps every 2-3 yrs. Her last was 3 yrs ago. No gynecologic symptoms such as bleeding or pelvic pain. No history of STDs. Widowed and not sexually active.

Does this patient need a Pap?

1.

Yes 2.

No

1 0% 0% 2 10 Countdown

Case 5

National Breast and Cervical Cancer Early Detection Program , >65

Same study in women who had a previously normal Pap Heart and Estrogen/progestin Replacement Study – normal pap within two years Women's Health Initiative, ages 50-79

2.8% ASCUS 1.0% more severe lesion .2% CIN II or higher

2.2% ASCUS .4% higher grade lesion 2.3% abnormal 0.9% high grade cervical lesion risk of high grade cytological abnormalities (HSIL or cancer) with a normal baseline pap (7.1 per 10,000 person-years

Obstet Gynecol.

1998;92(5):745

Obstet Gynecol.

2000;96(2):219

Ann Intern Med.

2000;133(12):942

Obstet Gynecol.

2006;108(2):410

Case 5

• • No published studies have directly evaluated the effectiveness of Pap screening in older women.

Declining benefit with aging • • • • other causes of death, lag time to receive benefit, false positives, higher treatment complication rates

Case 5

Organization

American Cancer Society American College of Obstetrics & Gynecology U.S. Preventive Services Task Force

Recommendations for discontinuing

Women may choose, if ≥70 years and ≥3 consecutive negative tests and no positive tests within last 10 years Age 65-70 years if ≥3 consecutive negative tests and no positive tests within last 10 years Age 65, if not at high risk

Reference

CA Cancer J Clin 2002; 52:342 Obstet Gynecol 2009; 114:1409.

Agency for Healthcare Research and Quality, Rockville, MD 2003. No 03-515A. January 2003.

Case 5

• Pap smears in low risk over age 65 with previously normal paps provide little benefit.

• • General recommendation: Women aged 65 and older with no increased risk and who have had adequate prior screening need not undergo continued screening for cervical cancer.

• • • • • •

Common Practices with Little Benefit

Routine CBC in adults (56% of visits) - $33 million Basic metabolic profiles in adults (16%) - $10 million Annual ECG (19%) - $17 million Routine urinalysis (18%) - $3 million Brand name statins instead of generics (35%) - $5.8 billion DEXA scans for women younger than 65 (1.4%) - $527 million • Arch Intern Med 2011;171(20):1856-1858.

• • •

Common Practices with Little Benefit

Ovarian Cancer Screening – an unproven and possibly harmful practice Use CA-125 and transvaginal ultrasound to screen at least sometimes: • Low risk patients – 28% • Medium risk patients – 65% Routinely use CA-125 and transvaginal ultrasound to screen: • Low risk patients – 6% • Medium risk patients – 24% • Cost estimates: $18-360 million • Ann Intern Med. 2012; 156:182-194.

•

Well Accepted Practices with Significant Benefit

2010 National Health Interview Survey (NHIS) • • • Breast cancer screening Cervical cancer screening Colon cancer screening 72% 83% 59% • MMWR. 2012 61(03):41-45

• • • • •

Advice for Providing High Value Health Care.

Decrease or discontinue use of interventions that provide no benefit, e.g. routine imaging in patients with low back pain.

Provide interventions that are effective and decrease costs, e.g. warfarin in high-risk patients with nonvalvular atrial fibrillation.

For interventions that provide additional benefit at additional cost, assess value by cost-effectiveness analysis.

Cost-effectiveness should not be the sole determinant of use but should be one factor to receive consideration Higher-cost does not always mean greater benefit.

• Ann Intern Med. 2011: 154:174-180.

References

• • Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. High value, cost-conscious health care concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011; 154:174-180.

• Brody H. Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List. NEJM. 2010; 362:283-285 Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012: 156:147-149.