Reduce Waste and Improve Outcomes

1. Reduce Waste and Improve Outcomes Darilyn V. Moyer, MD, FACP Chair, ACP Board of Governors

2. Disclosures Elected Chair of BOG Not specifically asked to speak about MOC…

3. Learning Objectives • Define High Value Care • Utilize the High Value Care Curriculum and Cases • Balance benefits with harms and costs when caring for patients • Set expectations for the provision of high value care to patients, learners, and other providers

4. Outline • Introduce the HVC Initiative and the curriculum • Demonstrate several HVC Cases • Review pilot feedback • Introduce Choosing Wisely • Future

5. High Value Care Definition Care that balances clinical benefit with cost and harms with the goal of improving patient outcomes

6. What is the problem?1 • We spend too much on healthcare – 17% of U.S. GDP • Healthcare spending is the largest driver of budget deficits • Despite spending twice as much on healthcare as other developed nations, we have lower life expectancy

7. Healthcare Waste2 • Estimated $700 Billion of “Healthcare waste” annually • $250-325B in “Unwarranted use” • $75-100B in “Provider inefficiency and errors” • $25-50B in “Lack of care coordination”

8. Ordering more services3… • Two areas of greatest expenditures and mostrapid growth: imaging and tests Tests Imaging

9. Can you think of specific examples?

10. Shifting focus More care is better care High value, customized care is better care

11. The Educational Gap • Cross sectional survey from 18,102 IM residents (2012 IM-ITE survey) • Response rate 84% • Resident self-reported knowledge and practice of high value care and high value care teaching

12. Percent of IM Residents who Somewhat/Strongly Agree

13. Percent of IM Residents who Somewhat/Strongly Agree

15. IM Resident Curriculum Overview • FREE, off-the-shelf curriculum • Based on a simple, step-wise framework • Six, one-hour sessions • Small group activities involving actual cases and bills to engage learners • Facilitator’s guide accompanies each session to help faculty prepare • Program Director’s toolbox

16. Steps Toward High Value Care4 • Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering • Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful • Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) • Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns • Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste

17. Curriculum Topics and Cases • Eliminating Healthcare Waste and Over ordering of Tests • Healthcare Costs and Payment Models • Utilizing Biostatistics in Diagnosis, Screening and Prevention • High Value Medication Prescribing • Overcoming Barriers to High Value Care • (Local) High Value Quality Improvement Projects • Headache, heart failure, deep venous thrombosis • Appendicitis, sports injury, osteomyelitis • Chest pain, periodic health examination, chemoprevention • Seasonal allergies, discharge medication reconciliation • Low back pain, URI, septic joint

18. Program Director’s Toolbox • Resident survey to measure curricular effectiveness • Tools to help faculty and program directors assess resident competence in high value care milestones • Sample local high value care quality improvement projects- reports, abstracts, posters, and slide decks for oral presentations

19. Curriculum Dissemination • The curriculum has been downloaded over 27,000 times since July 2012 • Over 138 IM programs have implemented some component of the curriculum as of 2/14 • 122 programs report the initiation of local high value quality improvement projects from the curriculum

20. Online High Value Care Cases • Web-optimized cases with questions • Based on actual patients and their hospital bills • Free to all practicing physicians • CME and MOC credit (inc patient safety)

21. Online High Value Care Cases • Introductory video • Five modules (30-60 minutes each) • Take home tools with each module to help provider incorporate modules into practice • Avoid Unnecessary Testing • Use Emergency and Hospital Level Care Judiciously • Improve Outcomes with Health Promotion and Prevention • Prescribe Medications Safely and Cost Effectively • Overcome Barriers to High Value Care

22. Format • Short clinical vignette • Multiple choice question based on the case (audience participation preferred) • Questions are designed to engage learners and promote discussion- some may require guessing and some may require synthesizing information • Discussion of the answer and key points

23. Topic 5: Overcome Barriers to High Value Care • Understand the barriers to high value care in clinical practice • Explore ways to overcome some barriers to high value care • Communicate clear expectations to patients and other members of the healthcare team • Negotiate a care plan with patients that incorporates their values and addresses their concerns

24. Michael Thompson 45-year-old man who is evaluated for low back pain. • He has had the pain for 2 weeks • The pain has not remitted and is affecting his work. • He does not have fever, radiation of the pain to the legs, weakness, numbness, bowel or bladder incontinence, or any other neurologic symptoms. He is requesting an MRI scan to look for a “slipped disk.”

25. Michael Thompson cont … • He has taken acetaminophen with some relief. • His medical history is unremarkable. • He has a sedentary job, occasionally uses alcohol, and does not use illicit drugs. • He has no family history of cancer. Physical exam including a neuro exam are normal.

26. Question #1 What is the probability that an MRI of the lumbar spine will change how you manage Mr. Thompson's back pain? A. Very low B. Medium C. High D. Very high

27. Question #1 - Answer What is the probability that an MRI of the lumbar spine will change how you manage Mr. Thompson's back pain? A. Very low B. Medium C. High D. Very high

28. Question #1 Key Point • Back imaging in patients with acute-onset, nonspecific low back pain is unlikely to change management. • Most patients with low back pain feel better within a month whether they get an imaging test or not. • An MRI done in the setting of acute nonspecific low back pain can lead to incidental findings and additional procedures that may increase cost, delay recovery, and decrease sense of well-being.

29. Who needs back imaging? • Imaging is indicated in patients with: • presence of rapidly progressing neurologic symptoms • evidence of cord compression, or cauda equinasyndrome • Suspected infection or malignancy as a possible cause of the symptoms and examination findings. • Mr. Thompson has none of these red flag signs or symptoms that would increase the probability that imaging would change management.

30. Recovery from Back Pain • The overall prognosis for acute musculoskeletal low back pain is excellent. • Most patients without sciatica show substantial improvement within 2 weeks, and 3/4 of those with sciatica are substantially better after 3 months. • Therapeutic interventions should focus on relieving symptoms and maintaining function while the patient recovers.

31. Michael Thompson cont … • You ask Mr. Thompson what he is concerned about and why he wants an MRI. • He is worried that his back pain could lead to permanent nerve damage. • You tell him that his back pain is caused by muscle spasm and there is no evidence of nerve damage. • You tell him you wish more testing would help him feel better but it could actually make him feel worse.

32. Michael Thompson cont … • Empathize with his pain and treat his pain with anti-inflammatory medicine and heat. • Encourage him to continue walking every day and avoid heavy lifting. • Ask him to call you if the pain start to radiate down to his leg and if he develops any weakness in his foot or leg. • Schedule a follow-up appointment with him in 2 weeks to see how he is doing.

33. Question #2 What would you estimate the probability of Mr. Thompson leaving your office satisfied with his care after having the above conversation? A. Very low B. Medium C. High D. Very high

34. Question #2 - Answer What would you estimate the probability of Mr. Thompson leaving your office satisfied with his care after having the above conversation? A. Very low B. Medium C. High D. Very high

35. Question #2 Key Point • Patient-centered discussions that include asking patients what they are concerned about, explaining your reasons, providing empathy, and providing a clear follow-up plan improve patient satisfaction more than doing unnecessary diagnostic testing because the patient requested it.

36. Principles of patient-centered discussions Find out where the patient is coming from: “What are you afraid we will find?” “What do you think is going on and what are you worried about?” 2. Explain your reasons: “The good news is that you don't have any worrisome symptoms.” 3. Make it clear that you are on the patient's side: “I wish more testing would help you, but it could actually make things worse.” 4. Contract for a clear follow-up plan and review red flag signs and symptoms: “I want to see you in 2 weeks, but call sooner if you have leg weakness.”

37. Noel Kenmore 27-year-old woman who is evaluated for 3 days of sore throat, cough, congestion, and sneezing. • No fever or myalgia. • No significant medical history, No medications, No allergies. • Ms. Kenmore has no exposure to young children. • She asks for a prescription for antibiotics.

38. Noel Kenmore cont… On exam: • Afebrile with normal vital signs. • Her oropharynx reveals slight erythema and a single 2-mm patch of exudate on her right tonsil. • She has no cervical adenopathy, and her tympanic membranes are normal bilaterally. Her lungs are clear.

39. Question #3 Which of the following is the most appropriate next step in management? A. Start antibiotics now B. Give a prescription for antibiotics to fill in case she worsens C. Do not prescribe antibiotics D. Rapid antigen detection test for streptococcus

40. Question #3 - Answer Which of the following is the most appropriate next step in management? A. Start antibiotics now B. Give a prescription for antibiotics to fill in case she worsens C. Do not prescribe antibiotics D. Rapid antigen detection test for streptococcus

41. Question #3 Key Point Patients with only one of four Centor criteria (tonsillar exudates, tender anterior cervical adenopathy, fever by history, absence of cough) do not require antibiotics or further testing.

42. Centor Criteria • Criteria widely used and validated as a predictor of the likelihood of Group A Streptococcus bacterial infection causing pharyngitis. • These criteria are: • Tonsillar exudates • Tender anterior cervical adenopathy • Fever by history (> 38 C or 100.4 F) • Absence of cough • The absence of three or four of these criteria has a negative predictive value of 80% to 88%. This makes the Centor criteria most useful for identifying patients in whom neither microbiologic testing nor antibiotic treatment are necessary.

43. Modified Centor Criteria • The Modified Centor Criteria add the patient's age to the criteria: • Age <15 add 1 point • Age >44 subtract 1 point • 0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%) • 2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2) • 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%)

44. Ms. Kenmore cont… • You ask Ms. Kenmore why she wants antibiotics, and she tells you that she is getting on an airplane the next day to go to a series of important meetings. She is worried about strep throat. • She asks you, “How will I get antibiotics if I get sicker?”

45. Question #4 What would be your next steps in communicating with Ms. Kenmore about not prescribing antibiotics? A. Describe the epidemiologic problem of antibiotic resistance worldwide B. Explain why antibiotics will not help her, empathize, and provide a clear follow-up plan C. Scare her with warnings about antibiotic-associated diarrhea and allergic reactions D. Tell her that the antibiotics will cost the health system too much money

46. Question #4 - Answer What would be your next steps in communicating with Ms. Kenmore about not prescribing antibiotics? A. Describe the epidemiologic problem of antibiotic resistance worldwide B. Explain why antibiotics will not help her, empathize, and provide a clear follow-up plan C. Scare her with warnings about antibiotic-associated diarrhea and allergic reactions D. Tell her that the antibiotics will cost the health system too much money

47. Question #4 Key Point • Clear and concise communications focused around the patient's concerns can overcome some potential barriers to high value care.

48. Patient-Centered Discussions Find out where the patient is coming from: “Why do you want antibiotics and what are you concerned about?” Explain your reasons: “The good news is that based on your history and physical exam, it is extremely unlikely that you have an infection that would respond to antibiotics.” Make it clear that you are on the patient's side: “I wish antibiotics or more testing would help you feel better, but they actually may make things worse by placing you at risk for harm with little or no chance of benefit.” Contract for a clear follow-up plan and review red flags:“Let's talk by telephone in 2 days. I want to be sure that you are feeling better by then. Please call me sooner if you develop a high fever, tender lumps in your neck, or difficulty swallowing.”

49. Potential Barriers • Patient/family requests • Lack of guidelines • Poor familiarity with guidelines • Lack of knowledge of costs, including the impact of setting on cost • Defensive medicine (fear of litigation) • Time pressure • Explaining to patients why tests/treatments are not indicated also takes time. • Discomfort with diagnostic uncertainty • Local standards of care • Misaligned financial incentives • Lack of appreciation of harms

50. Maria Hernandez 70-year-old woman admitted for presumed CAP. • She has a history of a right TKA with a titanium implant one year ago. • During her evaluation, Mrs. Hernandez complains of a swollen right knee. On exam: • Knee is warm, erythematous, tender, and there is a large effusion. She has pain with palpation and limited range of motion. Her surgical scar is well-healed. • You are concerned about septic arthritis in her prosthetic knee. You call the orthopedic surgeon and ask for a consult for “knee pain.” He says, “order an MRI and we will see her tomorrow.” You have some concerns about this management plan.