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9/21/2015 1

Anesthesia Health Services Research—an Opportunity to Lead the Cost Conversation

Changing Practice of Anesthesia 2015

Catherine L. Chen

Clinical Instructor, T32 Trainee Department of Anesthesia and Perioperative Care Friday, September 25, 2015

Disclosures

• No financial relationship with pharmaceutical or

device manufacturing companies

• Research funding provided by the Foundation

for Anesthesia Education and Research and the UCSF Department of Anesthesia

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Outline

• The cost of doing nothing—big picture
• Definition of health services research
• Cataract surgery example

3

4

1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12

US SWIZ NOR NETH GER CAN FRA SWE AUS UK NZ

2 4 6 8 10 12 14 16 18 20

80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12

AUS NOR UK SWE NZ CAN SWIZ GER FRA NETH US

International Comparison of Spending on Health, 1980–2012

Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, November 2013). US data from National Health Expenditure Accounts, adjusted to match OECD definitions.

Total expenditures on health as percent of GDP

$8,745 $3,182 17.6% 8.9%

Average spending on health per capita ($US PPP)

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No matter what your policy goals, the conclusion is inescapable:

• US health care costs are hurting the

economy, workers, employers, shareholders, taxpayers…everyone. And they are hurting them a lot Research Interest

• How to lower healthcare costs while

maintaining the quality of care delivered?

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Health Services Research

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• In a nutshell, health services

researchers investigate three major aspects of health care: access to care, the quality of the care, and its cost. Health services researchers attempt to evaluate the effects and outcomes of the health care "system" on people's health.

7 http://www.nlm.nih.gov/nichsr/ihcm/01whatis/whatis07.html

In the simplest terms, health services research (HSR) is the science/field of study that asks:

• What works?
• For whom?
• At what cost?
• Under what circumstances?

8 http://www.academyhealth.org/About/content.cfm?ItemNumber=831

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Where does HSR fit into the traditional research paradigm?

9 Anaesthesia 2013,68,121–135

Health services research in anesthesia

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Large, high-quality datasets are the foundations on which much of HSR is built… In anaesthesia, these clinical measures are in their infancy: there are limitations in both the breadth and depth of coverage. We have major deficiencies in case mix/risk and outcomes measures in several areas

• f anaesthetic clinical practice and the development

and validation of the measures to fill this unmet need are important research priorities within our profession.

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But the future is bright…

11 12

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UCSF Laurel Heights

13

Philip R. Lee Institute for Health Policy Studies

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UCSF Center for Healthcare Value

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IHPS Mentor: Adams Dudley

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Why now?

• UCSF is a powerhouse of innovation but

focusing on the costs of healthcare has been

• ut of bounds. This is partly due to a lack of

funding for research and demonstration projects in this area but is also due to deep ambivalence about whether attention to costs draws us away from a primary focus on doing the best thing for patients. A lack of attention to costs, however, is now a major barrier to providing great healthcare. The CHV is trying to bring together the right people to enable faculty and staff to innovate in reducing costs of healthcare while improving quality or at least leaving it unchanged.

– Clay Johnston, MD, PhD, Former Director of CHV

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Cataract surgery example

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Why focus on cataract surgery?

http://www.nei.nih.gov/eyedata/cataract.asp

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Specific Aim

• To determine the prevalence, cost and

factors associated with routine preoperative testing prior to cataract surgery in Medicare patients

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Methods

• Data source

– Medicare research identifiable files 2010- 2011

• Study cohort

– 440,857 Medicare beneficiaries who had index cataract surgery in the year 2011

• Definition of preop test

– CBC, chem panels, coags, U/A, EKG, TTE, cardiac stress test, CXR, PFT’s, if test

• ccurred within 30 days of index surgery

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9/21/2015 12 Increase in preop testing compared to baseline

23

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press).

Increase in preop testing compared to baseline

24

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press).

9/21/2015 13 Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients

25

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press).

ROC curves comparing models predicting preop testing

26

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press).

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Conclusions

• Preoperative medical testing prior to

cataract surgery still occurs frequently, despite clear guidelines recommending against it.

• Testing rates are primarily determined by

the practice pattern of the care team.

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Policy implications

• We can identify and target high-use

providers for intervention

– Decrease inappropriate utilization – Reduce patient and provider inconvenience – Result in substantial cost savings for Medicare

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What’s the harm?

• Does routine preoperative testing

actually hurt patients?

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• Can we figure out, using claims data,

whether routine preoperative testing

• ccurred in the months leading up to

cataract surgery that led to delay in previously‐scheduled surgery?

32

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• Is there something different about the
• phthalmologic work‐up that can help

us distinguish cataract surgery patients who were originally scheduled for surgery, but had a delay for whatever reason?

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Biometry

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• A way for ophthalmologists to measure

the required intraocular lens power of the replacement lens

• Only performed in patients who are

about to get cataract surgery

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Time between biometry and surgery

1 2 3 4 5 6 7 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 103 109 115 121 127 133 139 145 151 157 163 169 175 181 187 193 199 205 211 217 223 229

35

Chen et al. Unpublished data.

Is there additional preop testing that occurs around the time of biometry?

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10 20 30 40 50 60 70 ‐2 ‐1 0 1 2 3 4 5 ‐6 ‐5 ‐4 ‐3 ‐2 ‐1 1 2

12 months between biometry and surgery

PreopTst

Biometry Surgery

Chen et al. Unpublished data.

9/21/2015 19 Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients

37

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. 2015.

Effect of provider behavior

38

20 40 60 80 100 ‐2 ‐1 0 1 2 3 4 5 ‐6 ‐5 ‐4 ‐3 ‐2 ‐1 1 2 3

12 months between biometry and surgery

>75% <75%

Biometry Surgery

Chen et al. Unpublished data.

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Difference between providers in time from biometry to surgery

1 2 3 4 5 6 7 8 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 103 106 109 112 115

39 High-testing providers

Chen et al. Unpublished data.

Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients

40

Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. 2015.

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5 10 15 20 25 30 35 1 2 3 4 Percent Quartile

% of patients experiencing >30 days between biometry and surgery

1 2 3 4 5 6 7 8 1 2 3 4 Percent Quartile

% of patients experiencing >90 days between biometry and surgery 41

Chen et al. Unpublished data.

Conclusions

• Preoperative medical testing prior to

cataract surgery still occurs frequently, despite clear guidelines recommending against it.

• Testing rates are primarily determined by

the practice pattern of the care team.

• The use of routine preoperative

testing appears to delay cataract surgery and may actually harm patients as a result.

42

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Future Directions

• Identify other areas of overutilization

associated with cataract surgery

– Routine use of anesthesiologists for sedation during cataract surgery

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Rationale

• Payers may decide that anesthesiologists

are not necessary for cataract surgery and stop reimbursing our services

• We as a specialty should define indications

for anesthesiologist involvement in cataract surgery, not have it defined for us

• As clinicians, we can take the first step to

streamline perioperative expenditures without affecting quality of care or patient

• utcomes

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Acknowledgments

IHPS: Adams Dudley, Grace Lin, Naomi Bardach, John Boscardin, Ted Clay, Claire Brindis, Beth Thew, Mitzi Dean

• Dept. of Anesthesia:

Judith Hellman, the late Bill Young, Adrian Gelb, Mervyn Maze, Michael Gropper, Sonali Joshi, Paul Riegelhaupt