Transcript High Value Care RUQ Abdominal Pain

High Value Care:
RUQ Abdominal Pain
Darwin L. Conwell, MD, MS
Professor and Director,
Division of Gastroenterology, Hepatology and
Nutrition
614-366-3433 office
614-293-0861 Fax
[email protected]
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
Abdominal
Pain
Introduction
• 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)
Primary Care Physicians are responsible to
determine which patients can be:
Abdominal
Pain
Triage
1.
Safely observed
2.
Treated symptomatically
3.
Require further investigation
• ED evaluation
• Resuscitation: ABCs
4.
Specialist Referral / Consultation
• Gastroenterology, Surgery
Abdominal
Pain
The history should include:
• Location of pain
• Radiation of pain
• Factors that exacerbate or improve
symptoms such as food, antacids, exertion,
defecation
History
• 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
Abdominal
Pain
Past Medical History
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
Abdominal
Pain
Physical Examination
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
Acute
• Minutes, hours, days; ill-appearing
• Non-narcotic use history
• Surgical abdomen: IHOP !!!!!
Abdominal
Pain
•
Intractability, Hemorrhage, Obstruction,
Perforation (IHOP)
•
Pain medications help
•
Pearl – They do not request pain
medications.They request help me!
•
Scared, anxious, ill
Acute versus Chronic
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
Abdominal
Pain
Diagnostic Testing
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
Abdominal
Pain
Diagnostic Testing
Imaging Studies
• Ultrasound
Price ($)
420
• EGD
• Colonoscopy
• MRI/MRCP
3,000
3,000
2,625
http://www.newchoicehealth.com/Directory
Step 1 – Recognize most are benign (IBS) and a
subset have serious pathology (GI cancer)
Abdominal
Pain
Summary
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); caution in older (> 50 yr
age)
Defining HighValue Care
Appropriate Use of
Screening and Diagnostic
Tests
Qaseem, A., Ann Intern Med 2012
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
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
National Trends in
Admissions for RUQ Pain
(789.01) Are Decreasing
p < 0.001
http://hcupnet.ahrq.gov/
National Trends in
Admissions from ED
for RUQ Pain (789.01)
are Increasing
p < 0.001
http://hcupnet.ahrq.gov/
National Trends in
Charges for RUQ Pain
(789.01) are Increasing
p < 0.001
http://hcupnet.ahrq.gov/
High-Value, CostConscious Health Care
for RUQ Pain
Essential patient
information
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
High-Value, CostConscious Health Care
for RUQ Pain
Essential patient
information
Physical exam
• jaundice
• abdominal mass
• rebound tenderness
• fever
• guarding
• Murphy’s sign
• ascites
• palmar erythema, spider
angiomata
Diagnoses to consider:
•Gallstones
•Cholangitis, cholecystitis
High-Value, CostConscious Health Care
for RUQ Pain
Differential
Diagnosis
•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
High-Value, CostConscious Health
Care for RUQ
Pain
Essential patient
information
Additional clinical history
•abdominal surgery
•bariatric surgery
•gallstones
•pancreatitis
•alcohol use
•NSAID use
•immunocompromised
High-Value, CostConscious Health Care
for RUQ Pain
Alarm symptoms
A patient with:
•
•
•
•
•
hemodynamic instability
sudden onset pain
rebound tenderness
fevers
gastrointestinal bleeding
should be referred for urgent
evaluation!!!!
High-Value, CostConscious Health
Care for RUQ
Pain
Laboratory Tests
• CBC
• Chemistry panel
• AST, ALT, alkaline phosphatase, bilirubin
• Amylase, Lipase
• Pregnancy test
Essential patient
information
Imaging Studies
• RUQ ultrasound
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.
High-Value, CostConscious Health Care
for RUQ Pain
Additional
Information that
may be
recommended by
GI Consultants
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
Cotton P, et al., Am J Gastro 2010
Abdominal Pain
on NSAIDS
Abdominal Pain
on NSAIDS
Perforated Duodenal
Ulcer
Alcoholic with
Acute Abdominal
pain
Alcoholic with
Acute Abdominal
pain
Acute Pancreatitis
49 year old
abdominal pain
49 year old
abdominal pain
Mesenteric Ischemia
Transverse Colon
25 year old with
abdominal pain
25 year old with
abdominal pain
Autoimmune Pancreatitis
Anemia and
abdominal
pain
Peptic Ulcer
27 year old
female with
RUQ Pain
Fitz Hugh Curtis
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
Rationale for High-Value Care
- High costs and unsustainable cost increases
Defining HighValue Care
Evaluation of Medical
Interventions
Owens, D et al., Ann Intern Med 2011
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.
Incremental Costeffectiveness
Ratio (ICER)
Owens, D et al., Ann Intern Med 2011
High-Value, CostConscious Health Care
for RUQ Pain
References
• 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.