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Providing High-Value Cost-Conscious Care:. 2012-2013 | Presentation #1 0f 10. Introduction to Health Care Value. Define and emphasize the importance of high-value, cost-conscious care Introduce a simple five-step model for delivering high-value, cost-conscious care

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Providing High-Value Cost-Conscious Care:

2012-2013 | Presentation #1 0f 10

Introduction to Health Care Value

Define and emphasize the importance of high-value, cost-conscious care

Introduce a simple five-step model for delivering high-value, cost-conscious care

Discuss the cost implications of two common presentations of VTE disease (PE and DVT)

Articulate strategies for bringing high-value care into daily practice

Challenge participants to identify an action plan: at least one thing to start doing and one thing to stop doing

Learning Objectives

59 y/o woman POD#3 from laparoscopic cholecystectomy

Patient was recovering well and plan was for discharge today

Then, was ambulating with PT and became acutely SOB and hypotensive to SBP 80s

She complained of right shoulder pain, became diaphoretic and was brought urgently to the CCU where a stat TTE revealed a newly dilated RV

Patient Presentation – Mrs. G

Annual incidence in the U.S. estimated to be 600,000 (based on study of >42 million deaths)

With introduction of CT-A the incidence estimates have increased to 112.3 per 100,000

Untreated PE is associated with a 30% mortality rate! Recurrent embolism is most common cause of death

5-10% of deaths in hospitalized patients1

A Common Inpatient Diagnosis: PE

Thompson et al, “Overview of Acute Pulmonary Embolism., accessed 11/11/11

Cartoon by Dan Pirraro


The overall economic burden of PE in the U.S. is estimated to be over $1.5B per year in healthcare costs

Some estimates suggest that PE results in healthcare costs of more than $30,000 per incident2

Several studies have determined that prevention of PE in hospitalized patients is cost-effective, costing just $3,000 per pulmonary embolism event avoided3

The Economic Burden of PE

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

Steps Toward High-Value, Cost-Conscious Care4

What is your work-up for pulmonary embolism?

What factors lead us to make orders or recommendations for our patients?

Which labs or initial studies do you want to order?

How much does this cost?

Step 1: Benefits, Harms, CostsInitial Work-up for PE

Cartoon by T. McCracken

Benefits, Harms, Costs

After getting TTE that showed RV dysfunction and +McConnell’s sign, our patient had the following studies performed:

CT-PE protocol  +bilateral subsegmental PEs




Troponin x 4 : 0.5  1.6  1.3  0.6


LE Doppler U/S  Negative for DVT

Patient Presentation - Update

NOTE: This is an actual case and charges are directly from a copy of her hospital bill

TTE ($2,917)

CT-PE protocol ($3,558 + $462 contrast + risk of contrast reaction + radiation exposure)

D-dimer ($410)

Fibrinogen ($100)

BNP ($338)

Step 1: Know the benefits, harms and costs of the interventions that you offer patients


Troponin x4 ($116 x 4 = $464 + risk of repeated phlebotomy)

ABG ($110 + risk of arterial stick)

LE Doppler U/S ($1,397)

Hypercoagulable panel ($2,250 - $3,050)

Cost of diagnostic work-up (not including all of the routine labs, etc. obtained): > $12,756

Step 1: Know the benefits, harms and costs of the interventions that you offer patients

Which tests had the potential to change management?

CT-PE protocol




Troponin x 4

Hypercoagulable panel

Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful


The prices listed are estimates based on actual hospital bills

There are a lot of complexities to how things are priced and how much a specific patient is charged

The goal is to give an idea of magnitude

Costs reported here are hospital charges (found on a bill)

Clinical reasoning and individualized care are very important

Cost-conscious care is not about discouraging appropriate care, nor denying beneficial services


Value, Cost and Health Care

Cost ≠ Value

Cost ≠ Cost of Test

  • Cost includes cost of test and downstream costs, benefits and harms

  • High-cost interventions may provide good value because they are highly beneficial

  • Low-cost interventions may have little or no value if they provide little benefit or increase downstream costs

Management of DVT

Two patients in an ambulatory setting were found to have a DVT

One of the patients was sent to the Emergency Department and hospitalized for management of the DVT

The other patient was started on LMWH and managed as an outpatient

Split into two groups to review the two cases, with the associated healthcare bills

Use the five-step model for each patient to identify what to eliminate and what would be the best approach

Case #2

Hospitalized patient

What costs surprised you?

What can be eliminated?

What would be the most elegant approach to work-up and management?


What costs surprised you?

What can be eliminated?

What would be the most elegant approach to work-up and management?

EBM Update: Younger patients with calf DVTs, without incapacitating pain have equal outcomes for $1,402/pt compared to hospitalized patients at $5,465 (1999 dollars)5



To use validated clinical scores (Wells Criteria, Revised Geneva Score) and follow diagnostic algorithms to avoid overuse of tests

To ask yourself before you order the test if the results will change what you do for the patient


Do NOT routinely obtain LE U/S studies and hypercoagulable panel in patients with acute PE

Stop routinely sending patients with suspected DVT to the ED




  • Thompson et al, “Overview of Acute Pulmonary Embolism.”, accessed 11/11/11

  • MacDougall DA, et al. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 2006;63(suppl 6)

  • McGarry LJ, et al. Cost effectiveness of thromboprophylaxis with a low-molecular-weight heparin versus unfractionated heparin in acutely ill medical inpatients. Am J Manag Care 2004;10:632–642

  • Adapted from Owens, D. Ann Intern Med. 2011;154:174-180

  • Pearson S, Blair R, Halper A, Eddy E, McKean S. An outpatient program to treat deep venous thrombosis with low-molecular weight heparin. Effective Clinical Practice. 1999; 2:210-7

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