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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
Drivers of Entitlement Spending Growth (Percent of GDP)
26%
24%
22%
20%
56%
18%
16%
14%
12%
10%
8%
Source: CBO Long-term Budget Outlook, 2010.
9
36%
64%
Excess Health Care
Cost Growth
Aging
44%
Components of Revenue and Spending
Outlays
Revenues and Financing
Interest
6%
Individual Income
Tax
27%
Borrowing
39%
Corporate Tax
5%
Other
6%
Social Insurance
Taxes
23%
Total Revenues = $2.230 Trillion
Total Financing = $3.629 Trillion
10
2011
Medicare
13%
Medicaid &
Other Health
8%
Non-Defense
18%
Defense
20%
Social Security
20%
Other Mandatory
15%
Total Outlays = $3.629 Trillion
Health Care Spending by Country
Percent of GDP (2008)
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Public
Private
Source: 2008 Data from the Organization for Economic Cooperation and Development.
11
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, CostConscious 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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
4
0%
10
5Countdown
Obtaining ECGs for screening for cardiac disease in individuals
at low to average risk for CAD represents high value care?
1.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
4
0%
10
5Countdown
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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
0%
0%
0%
0% 10
Countdown
1
2
3
4
5
Obtaining BNP measurement in the initial evaluation of
patients with typical findings of CHF represents high value care.
1.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
4
0%
10
5Countdown
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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
0%
4
5
10
Countdown
Obtaining imaging studies in patients with recurrent, classic
migraine headache and a normal neurologic exam represents
high value care.
1.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
4
0%
10
5Countdown
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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
0%
4
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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
0%
0%
0%
0%
10
Countdown
1
2
3
4
5
Obtaining imaging studies, rather than a high sensitivity Ddimer, 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.
2.
3.
4.
5.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
0%
1
0%
0%
2
3
0%
0%
4
5
10
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
0%
0%
10
1
2
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
0%
0%
10
1
2
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
0%
0%
10
1
2
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
0%
0%
10
1
2
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
0%
0%
10
1
2
Countdown
Case 5
National Breast and
2.8% ASCUS
Cervical Cancer Early
1.0% more severe lesion
Detection Program , >65 .2% CIN II or higher
Obstet Gynecol.
1998;92(5):745
Same study in women
who had a previously
normal Pap
2.2% ASCUS
.4% higher grade lesion
Obstet Gynecol.
2000;96(2):219
Heart and
Estrogen/progestin
Replacement Study –
normal pap within two
years
2.3% abnormal
0.9% high grade cervical
lesion
Ann Intern Med.
2000;133(12):942
Women's Health
Initiative, ages 50-79
risk of high grade
Obstet Gynecol.
cytological abnormalities 2006;108(2):410
(HSIL or cancer) with a
normal baseline pap (7.1
per 10,000 person-years
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
Recommendations for
discontinuing
Reference
American Cancer Society
Women may choose, if
CA Cancer J Clin 2002;
≥70 years and ≥3
52:342
consecutive negative tests
and no positive tests
within last 10 years
American College of
Obstetrics & Gynecology
Age 65-70 years if ≥3
Obstet Gynecol 2009;
consecutive negative tests 114:1409.
and no positive tests
within last 10 years
U.S. Preventive Services
Task Force
Age 65, if not at high risk
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
• MMWR. 2012 61(03):41-45
72%
83%
59%
Advice for Providing HighValue 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. Highvalue, 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.