Darilyn V Moyer MD FACP Chair ACP Board of Governors Disclosures Elected Chair of BOG Not specifically asked to speak about MOC Learning Objectives Define High Value Care Utilize the High Value Care Curriculum and Cases ID: 719167
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Slide1
Reduce Waste and Improve Outcomes
Darilyn V. Moyer, MD, FACP
Chair, ACP Board of GovernorsSlide2
DisclosuresElected Chair of BOG
Not specifically asked to speak about MOC…Slide3
Learning ObjectivesDefine 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 providersSlide4
OutlineIntroduce the HVC Initiative and the curriculumDemonstrate several HVC Cases
Review pilot feedback
Introduce Choosing Wisely
FutureSlide5
High Value Care Definition
Care that balances clinical benefit with cost and harms with the goal of improving patient outcomesSlide6
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 expectancySlide7
Healthcare
Waste
2
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
”Slide8
Ordering more services3
…
Two areas of greatest expenditures and most
rapid growth: imaging and tests
Tests
ImagingSlide9
Can you think of specific examples?
Improved Outcome
No Improved Outcome
High Cost
Low CostSlide10
Shifting focus
More care is better care High value, customized care is better careSlide11
The Educational GapCross 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 teachingSlide12
Percent of IM Residents who Somewhat/Strongly AgreeSlide13
Percent of IM Residents who Somewhat/Strongly AgreeSlide14
Slide15
IM Resident Curriculum Overview
FREE, o
ff-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 toolboxSlide16
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
wasteSlide17
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 jointSlide18
Program Director’s ToolboxResident survey to measure curricular effectivenessTools 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 presentationsSlide19
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 curriculumSlide20
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)Slide21
Online High Value Care CasesIntroductory 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 CareSlide22
FormatShort 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 pointsSlide23
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
concernsSlide24
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.” Slide25
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.Slide26
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
highSlide27
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
highSlide28
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. Slide29
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.Slide30
Recovery from Back PainThe overall prognosis for acute musculoskeletal low back pain is excellent.
M
ost
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.Slide31
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.Slide32
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.
A
sk
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.Slide33
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
highSlide34
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
highSlide35
Question #2 Key PointPatient-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.Slide36
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.”
Slide37
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
.Slide38
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.Slide39
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
streptococcusSlide40
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
streptococcusSlide41
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.Slide42
Centor Criteria
Criteria widely used and validated as a predictor of the likelihood of G
roup
A S
treptococcus 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.Slide43
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
%)Slide44
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?”Slide45
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 moneySlide46
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 moneySlide47
Question #4 Key PointClear and concise communications focused around the patient's concerns can overcome some potential barriers to high value care.Slide48
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.”
Patient-Centered DiscussionsSlide49
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 harmsSlide50
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:
K
nee
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.Slide51
Question #5
What should you do
next for Mrs. Hernandez?
Call
the surgeon's supervisor to complain about his recommendation
Document
the orthopedic surgeon's recommendations in the chart and clearly state that you disagree with him
Order
the MRI and wait because he is the specialist and that is what he recommended
Reframe
your question to the consultant in order to clearly communicate what you are concerned about and
whySlide52
Question #5 - Answer
What should you do
next for Mrs. Hernandez?
Call
the surgeon's supervisor to complain about his recommendation
Document
the orthopedic surgeon's recommendations in the chart and clearly state that you disagree with him
Order
the MRI and wait because he is the specialist and that is what he recommended
Reframe
your question to the consultant in order to clearly communicate what you are concerned about and
whySlide53
Question #5 Key PointA 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.Slide54
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.Slide55
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.Slide56
Question #6
Which of the following things do you tell Mrs. Hernandez to prepare her for the consultation
?
“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.”
“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.”
“I
am not sure why your knee is sore, so I asked a specialist to come by and examine you.”
The
patient does not need to be informed of the consultation
.Slide57
Question #6 - Answer
Which of the following things do you tell Mrs. Hernandez to prepare her for the consultation
?
“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.”
“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.”
“I
am not sure why your knee is sore, so I asked a specialist to come by and examine you.”
The
patient does not need to be informed of the consultation
.Slide58
Question #6 Key Points
Setting patient expectations for consultations and referrals
includes:
E
xplaining
your reason for requesting the
consultation
E
stimating
the time
frame
Reassuring the patient that you will communicate directly with the
consultant
D
iscussing
the possibility of further testing.Slide59
Discussing Consults with Patients
A discussion with a patient regarding a planned consultation or referral should include the following:
Clearly explain the reason for the consultation or referral.
Estimate the time frame of when the consultation will take place.
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.
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.Slide60
Richard Hanson
68-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.Slide61
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 ultrasonographySlide62
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 ultrasonographySlide63
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.Slide64
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
:
A
ntinuclear
antibodies (ANA),
anti–double-stranded DNA, complement
levels (C3 and C4),
HIV
,
Hepatitis
B and C
serologies
R
apid Plasma
Reagin
(RPR),
ANCA, anti–glomerular basement membrane antibodies, cryoglobulin levels, and a streptozyme testSlide65
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 orderedSlide66
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 orderedSlide67
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.Slide68
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:
P
hysicians
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. Slide69
Tips to Avoid Malpractice
Listen
to your
patients.
Carefully document decision
making.
Discuss and document potential side effects and risks of all tests and
treatments.
Manage patient
expectations.Slide70
Framework for High Value Care
1. 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 wasteSlide71
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.Slide72
Confidence in One’s Ability to Communicate with Patients as to Why Tests are Not NecessarySlide73
Impact on Motivation to Incorporate Principles into Daily PracticeSlide74
Patient Education MaterialsPartnerships 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!Slide75
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 costsSlide76
Future Challenges
Faculty development
Validated HVC
a
ssessment 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 incentivesSlide77
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.htmlSlide78
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