Reduce Waste and Improve Outcomes

Darilyn V. Moyer, MD, FACPChair, ACP Board of Governors

DisclosuresElected Chair of BOGNot specifically asked to speak about MOC…

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

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

High Value Care Definition

Care that balances clinical benefit with cost and harms with the goal of improving patient outcomes

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

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”

Ordering more services3…

• Two areas of greatest expenditures and mostrapid growth: imaging and tests

TestsImaging

Can you think of specific examples?Improved Outcome No Improved Outcome

High Cost

Low Cost

Shifting focusMore care is better care High value,

customized care is better care

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

Percent of IM Residents who Somewhat/Strongly Agree

I know where to find estimated costs of tests and treatments

I know the benefits and harms associated with common tests and treatments

0% 20% 40% 60% 80% 100%

26%

85%

Percent of IM Residents who Somewhat/Strongly Agree

I incorporate patients' values and concerns into clinical decisions

I offer patients alternatives of care, considering benefits, harms and costs

I avoid ordering unnecessary tests and treatments for patients

I reduce health care waste within my hospital and/or clinic

I incorporate the cost of tests and treatments into clinical decisions

I share estimated costs of tests and treatments with patients

0% 20% 40% 60% 80% 100%

88%

81%

72%

59%

46%

24%

Never

Few times a year

Few times a month

Few times a week

Every day

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

4%

23%

33%

25%

15%

8%

40%

29%

16%

7%

How often are issues of balanc-ing benefits and harms with costs the subject of teaching conferences or rounds? How often do you and your faculty discuss balancing bene-fits and harms with cost when caring for patients?

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

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

Curriculum Topics and Cases1. Eliminating Healthcare Waste and

Over ordering of Tests2. Healthcare Costs and Payment

Models3. Utilizing Biostatistics in Diagnosis,

Screening and Prevention4. High Value Medication Prescribing5. Overcoming Barriers to High Value

Care6. (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

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

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

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)

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

1. Avoid Unnecessary Testing2. Use Emergency and Hospital

Level Care Judiciously3. Improve Outcomes with Health

Promotion and Prevention4. Prescribe Medications Safely and

Cost Effectively5. Overcome Barriers to High Value

Care

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

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

Michael Thompson45-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.”

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.

Question #1What 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

Question #1 - AnswerWhat 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

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.

Who needs back imaging?• Imaging is indicated in patients with:• presence of rapidly progressing neurologic symptoms• evidence of cord compression, or cauda equina syndrome• 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.

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.

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.

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.

Question #2What 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

Question #2 - AnswerWhat 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

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.

Principles of patient-centered discussions 1. 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.”

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.

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.

Question #3Which 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

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

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.

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.

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%)

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?”

Question #4What 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

Question #4 - AnswerWhat 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

Question #4 Key Point• Clear and concise communications focused

around the patient's concerns can overcome some potential barriers to high value care.

1. Find out where the patient is coming from: “Why do you want antibiotics and what are you concerned about?”

2. 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.”

3. 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.”

4. 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.”

Patient-Centered Discussions

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

Maria Hernandez70-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.

Question #5What should you do next for Mrs. Hernandez?

A. Call the surgeon's supervisor to complain about his recommendation

B. Document the orthopedic surgeon's recommendations in the chart and clearly state that you disagree with him

C. Order the MRI and wait because he is the specialist and that is what he recommended

D. Reframe your question to the consultant in order to clearly communicate what you are concerned about and why

Question #5 - AnswerWhat should you do next for Mrs. Hernandez?

A. Call the surgeon's supervisor to complain about his recommendation

B. Document the orthopedic surgeon's recommendations in the chart and clearly state that you disagree with him

C. Order the MRI and wait because he is the specialist and that is what he recommended

D. Reframe your question to the consultant in order to clearly communicate what you are concerned about and why

Question #5 Key Point• A well-framed clinical question prior to

consultation includes what you are specifically concerned about, why you are concerned, relevant findings on examination or diagnostic studies, testing and treatment that has been done to date, and your expected time frame for the consultation.

Communicating with Consultants• An analysis of inter-physician communications in consultations found that physicians

commonly requested consultations to get advice on diagnosis (56%), advice on management (37%), or assistance in arranging or performing a procedure or test (20%).

• The requesting physician and the consultant completely disagreed on both the reason for the consultation and the principal clinical issue in 22 (14%) of 156 consultations.

• Consultations that were initiated with a clear and concise clinical question were more likely to be valued by both the requesting and consulting physician.

• Breakdowns in communication were not uncommon in the consultation process and may adversely affect patient care, cost effectiveness, and education.

Maria Hernandez cont …• You call the orthopedic surgeon back and explain the key aspects

of Mrs. Hernandez's history and that you are specifically worried about a septic joint.

• Your consultation question is: “I have a patient with a history of a right total knee replacement with a titanium implant 1 year ago who presents with pneumonia, fever, and a painful, swollen prosthetic knee. I am worried about septic arthritis. Can you evaluate her urgently to help us rule this out?”

• The orthopedic surgeon agrees to come by in an hour and evaluate the patient and you want to do everything you can to improve the patient's care coordination.

Question #6Which of the following things do you tell Mrs. Hernandez to prepare her for the consultation?

A. “A specialist is going to come by to take some fluid out of the knee with a needle to check for infection. You will also get an MRI of your knee.”

B. “I want to be sure your knee is not infected so I have asked a specialist to come by to take a look at your knee. He will discuss his recommendations with me directly after he sees you. He may need to put a small needle in your knee and extract some fluid to look for infection and may order an x-ray or other imaging studies.”

C. “I am not sure why your knee is sore, so I asked a specialist to come by and examine you.”

D. The patient does not need to be informed of the consultation.

Question #6 - AnswerWhich of the following things do you tell Mrs. Hernandez to prepare her for the consultation?

A. “A specialist is going to come by to take some fluid out of the knee with a needle to check for infection. You will also get an MRI of your knee.”

B. “I want to be sure your knee is not infected so I have asked a specialist to come by to take a look at your knee. He will discuss his recommendations with me directly after he sees you. He may need to put a small needle in your knee and extract some fluid to look for infection and may order an x-ray or other imaging studies.”

C. “I am not sure why your knee is sore, so I asked a specialist to come by and examine you.”

D. The patient does not need to be informed of the consultation.

Question #6 Key Points• Setting patient expectations for consultations and

referrals includes:• Explaining your reason for requesting the consultation• Estimating the time frame• Reassuring the patient that you will communicate directly

with the consultant• Discussing the possibility of further testing.

Discussing Consults with PatientsA discussion with a patient regarding a planned consultation or referral should include the following:

1. Clearly explain the reason for the consultation or referral. 2. Estimate the time frame of when the consultation will take place. 3. Reassure the patient that you will be in direct communication with the

consultant and will include the patient/family in any major decisions that need to be made.

4. Provide a list of potential tests the specialist might order, emphasizing that they may not order any additional tests and may just provide a clinical evaluation.

Richard Hanson68-year-old man admitted for a recent exacerbation of systolic heart failure. • He has been diuresed aggressively and has new acute

kidney injury. • His urine output is good but his serum creatinine

concentration has doubled. The nurse tells you his post-void residual volume is minimal.

• You would like to request a nephrology consultation because you are worried that Mr. Hanson may need dialysis.

Question 7Before calling the nephrologist to see Mr. Hanson, you make sure your patient has an appropriate workup.Which of the following represents the essential tests that should be performed prior to nephrology consultation in this case?

A. ANCA serology testing and venous mapping for hemodialysis access B. Complete metabolic profile and stone protocol CT scan C. Urinalysis and basic metabolic profile, including blood urea nitrogen and creatinine D. Urine eosinophils and renal ultrasonography

Question 7 - AnswerBefore calling the nephrologist to see Mr. Hanson, you make sure your patient has an appropriate workup.Which of the following represents the essential tests that should be performed prior to nephrology consultation in this case?

A. ANCA serology testing and venous mapping for hemodialysis access B. Complete metabolic profile and stone protocol CT scan C. Urinalysis and basic metabolic profile, including blood urea nitrogen and creatinine D. Urine eosinophils and renal ultrasonography

Question #7 Key Points• Limit pre-consultation and referral testing to basic, essential investigations.• Use your initial conversation with the consultant to drive any additional testing.• Subspecialty consultations and referrals are a huge driver of waste within our

current healthcare system. The numerous unnecessary consultations and referrals may be driven by patient requests or fear of malpractice lawsuits or missing something.

• Much of the waste occurs prior to the consultation, when the attending physician of record orders every test he or she can think of so that consultants have as much information as possible to make their recommendations.

Richard Hanson cont…The nephrologist comes to see Mr. Hanson and tells you to withhold the diuresis for a couple of days and to follow the patient's kidney function, serum electrolytes, and urine output carefully.

He also recommends that you order several additional tests to be sure every possible cause of this patient's kidney failure has been ruled out:• Antinuclear antibodies (ANA), anti–double-stranded DNA,

complement levels (C3 and C4), • HIV, Hepatitis B and C serologies Rapid Plasma Reagin (RPR), • ANCA, anti–glomerular basement membrane antibodies, cryoglobulin

levels, and a streptozyme test

Question 8When you ask the nephrologist about these recommendations because you feel these diagnoses are unlikely in Mr. Hanson, he agrees, but says that from a medico-legal standpoint, he feels obligated to order these tests on every patient to protect himself from a lawsuit.

Which of the following should you take into account before adopting this strategy to limit malpractice lawsuits?

A. Defensive medicine protects against lawsuits B. Forty percent of malpractice claims do not involve medical errors C. More testing results in fewer lawsuits D. You are more likely to be sued for not ordering a test than for an adverse event that resulted from a test you ordered

Question 8 - AnswerWhen you ask the nephrologist about these recommendations because you feel these diagnoses are unlikely in Mr. Hanson, he agrees, but says that from a medico-legal standpoint, he feels obligated to order these tests on every patient to protect himself from a lawsuit.

Which of the following should you take into account before adopting this strategy to limit malpractice lawsuits?

A. Defensive medicine protects against lawsuits B. Forty percent of malpractice claims do not involve medical errors C. More testing results in fewer lawsuits D. You are more likely to be sued for not ordering a test than for an adverse event that resulted from a test you ordered

Question #8 Key Points• Defensive medicine has never been proven to protect physicians from

lawsuits.• Clear, patient-centered communication about potential benefits and risks

of an intervention coupled with documentation of these discussions are more likely to protect physicians from malpractice litigation.

• It is well documented that patients are not likely to sue physicians they like and trust. This observation tends to hold true even when patients have experienced considerable injury as a result of a “medical mistake” or misjudgment.

Communication Deters Lawsuits!• Studies exploring what prompts patients and families to file malpractice

lawsuits found a common theme of breakdown in physician-patient relationships manifested by unsatisfactory communication.

• Common perceived communication problems include: • Physicians would not listen, would not talk openly, delivered information poorly• Perception physicians attempted to mislead them, did not warn them of long-term

problems, • Physicians were not available• Physicians devalued patient or family views or failed to understand the patient's

perspective.

Tips to Avoid Malpractice1. Listen to your patients.2. Carefully document decision making.3. Discuss and document potential side effects

and risks of all tests and treatments.4. Manage patient expectations.

Framework for High Value Care1. Understand the benefits, harms, and relative costs of the interventions that you are considering 2. Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful 3. Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) 4. Customize a care plan with the patient that incorporates their values and addresses their concerns 5. Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste

The HVC Cases significantly impacted physicians’ reported behavior

• Increased frequency of discussing the risks and benefits of tests and treatments with patients.

• Increased frequency of discussing relative costs of tests and treatments with patients when generating a plan.

• Decreased frequency of ordering unnecessary tests and treatments because they were requested by patients.

• Increased frequency of offering patients alternatives to tests and treatments that consider the risks, benefits, patient preference and costs.

• Decreased frequency of ordering tests and treatments out of fear of malpractice.

Confidence in One’s Ability to Communicate with Patients as to Why Tests are Not Necessary

Impact on Motivation to Incorporate Principles into Daily Practice

Patient Education Materials• Partnerships with Consumer Reports and AHRQ- to provide

patient educational materials• New ACP center for patient partnership and engagement,

materials on website as they are developed• Consistent message between provider and patient educational

materials• Resident Curriculum and Online Cases include patient

education materials you can start using now!

Expansion• Beyond IM: adapt curriculum to other specialties

including Ob-gyn, surgery, pediatrics and family medicine

• MedU Editorial Board to adapt on-line student cases for Peds, FM, Radiology (led by Heather Harrell)

• Encourage GME programs to work together on projects to improve outcomes and control costs

Future Challenges• Faculty development• Validated HVC assessment tools• Learning environment that “celebrates restraint”• Cross-departmental collaboration on high value care• New topics : end of life care, price transparency,

defensive medicine, and misaligned financial incentives

In Summary: What can we do?• Eliminate unnecessary tests and treatments and teach our

students and residents to do the same• Individualize care by asking patients about their concerns,

incorporating their values into the care plan and managing their expectations

• Use the FREE tools from the ACP and Choosing Wisely Campaign http://hvc.acponline.org/index.html

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