COMMISSIONING DIAGNOSTICS: System Biases & How to … August 17th...Of primary care visits result in...
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COMMISSIONING DIAGNOSTICS: System Biases & How to Influence Dr Imran Sajid | MBBS BSc AICSM MRCGP DipSEM DPMSA DCP CMCBT DipFIPT GENERALIST | HEALTHCARE COMMISSIONER LONDON, UNITED KINGDOM @imransajid
Transcript of COMMISSIONING DIAGNOSTICS: System Biases & How to … August 17th...Of primary care visits result in...
COMMISSIONING DIAGNOSTICS:System Biases & How to Influence
Dr Imran Sajid | MBBS BSc AICSM MRCGP DipSEM DPMSA DCP CMCBT DipFIPT
GENERALIST | HEALTHCARE COMMISSIONER
LONDON, UNITED KINGDOM
@imransajid
Academics Clinician Leaders
Policy MakersCare Providers
Patients
THE NEED FOR SPEED
DIAGNOSTICS can be
a CASH COW
PROFIT or
LOSS
Of primary care visits
result in blood test
requests
Of blood tests are
unnecessary / inappropriate
PATHOLOGY KEY INFO
Cadoga, Brown, Bradley 2015
Fryer, Smellie 2016
PRE-
ANALYTIC
ANALYTICEg Reflex Testing,
Add Ons etc
POST-ANALYTICEg Sensitivities,
Suppression of certain
results etc
LOW UNITCOST
HIGH VOLUME
- CHANGING DEFAULTS
- MINIMUM RETEST INTERVALS
- DECISION TREES
(COMPUTER SAYS NO)
CHOICE ARCHITECTURE
*NUDGES DON’T ALWAYS WORK*
↑60-90%
↓20-30%
Zaat et al 1992
Shalev et al 2008
Kahan et al 2009
PROFILES for key indications, eg a group of tests for tiredness
COST INDICATORS?
Horn et al 2014
MUSCULO-SKELETAL IMAGING
Age + 10
=
Prevalence of
Incidental Disc
Protrusion
Knee X-rays Shoulder
USS
Back MRI
Brinjinki et al 2014
Over Age 40:
90+% have
‘something’ on USS
Girish et al 2011Bedson 2008
PERSISTENT PAIN TISSUE DAMAGE
80% of Patients would want imaging for low back pain
Findings should be expected and are
often normal age-related changes
unrelated to harm or pain.
Kendrick 2001
LOCAL AUDIT: 156 Musculoskeletal MRI Scans in Primary Care
10%
Clinically
indicated
68%
Incorrectly
interpreted:
False Positives
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Unnecessary
Surgical Referrals
(0% conversion
rate)
52% of Results
discussed with
different GP
43%
Psychological
Yellow Flags
31 Days
Median
Delay to
action*NOCEBIC LANGUAGE*
GP ENGAGEMENT & SURVEY• Cognitive Dissonance
• Dunning-Kruger Effect
• Availability Bias / Impact Bias /
Uncertainty Bias
• Patient Expectations: 85% of GPs said
‘sometimes’, ‘often’, or ‘always’ their
imaging is influenced by patient
pressure
Limitations:
1) PRACTICE-LEVEL DATA, NOT
INDIVIDUAL DATA
2) LOWER REFERRERS DID NOT
SHOW IMPROVED QUALITY OF
REFERRAL OR INTERPRETATION
3) FOCUSING ON OUTLIERS CAN
HAVE AN OPPORTUNITY COST
BENCHMARKING
Yay or Nay?
Rogers Diffusion Curve
WHAT TO DO?BENCHMARKING & EDUCATION
Starts the conversation; that’s all.Limited detail of data. Less imaging doesn’t equal better clinical value of imaging. Limited reach of education. Don’t focus only on the ‘outliers’
AMEND REPORTS Limited impact (McCullough 2012)
POLICE REQUESTS (ieREFERRAL MANAGEMENT CENTRES)
High cost; limited return on investmentIllegitimate learning develops to bypass barrier
ELECTRONIC ORDER COMMS (EG DECISION AIDS)
Up against strong pre-held beliefs.No benefit on post-analytic errors
SWITCH OFF MSK IMAGING (ENSURE ‘RED FLAG’ PATHWAYS IN PLACE)
Risks de-skilling primary care, but harm > benefitSaves unethical resource spend / iatrogenic harm
EFFECTS OF PAYMENT MODELS
‘Unbundling’ EffectActivity-Based Billing for Diagnostics: ECG
HOW UNETHICAL?
• EXPLICIT (’Cross-Subsidising’)
• IMPLICIT (Unintentional Bias)600% increase in
ECGs after
introduction of
activity-based /
fee-for-service
invoicing
How to COMMISSIONING the SYSTEM
■ ACTIVITY-BASED TARIFFS – AVOID!!!
■ BLOCK CONTRACTS – Quality may suffer
■ TRANSPARENT ACCOUNTING – Need Honest Conversations
■ RISK/GAIN SHARES – to kickstart the right culture?
■ ACCOUNTABLE CARE ORGANISATIONS??
TAKE HOME MESSAGES
1) Era of Excess Diagnostic Complexity:
(CAREFULLY) ADJUST (REDUCE) THE CHOICE ARCHITECTURE
2) Financial Influences:
YOUR PAYMENT SYSTEM MUST MATCH YOUR STRATEGY
