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9/21/2015 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 1

9/21/2015 Outline • The cost of doing nothing—big picture • Definition of health services research • Cataract surgery example 3 4 International Comparison of Spending on Health, 1980–2012 Average spending on health Total expenditures on health per capita ($US PPP) as percent of GDP AUS US 10000 20 NOR SWIZ UK NOR 18 9000 SWE 17.6% $8,745 NETH NZ GER 8000 16 CAN CAN SWIZ FRA GER 14 7000 SWE FRA NETH AUS 12 6000 UK US NZ 10 5000 8.9% 8 4000 $3,182 6 3000 4 2000 2 1000 0 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12 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. 2

9/21/2015 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? Health Services Research 6 3

9/21/2015 • 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. http://www.nlm.nih.gov/nichsr/ihcm/01whatis/whatis07.html 7 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? http://www.academyhealth.org/About/content.cfm?ItemNumber=831 8 4

9/21/2015 Where does HSR fit into the traditional research paradigm? Anaesthesia 2013,68,121–135 9 Health services research in anesthesia 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 of anaesthetic clinical practice and the development and validation of the measures to fill this unmet need are important research priorities within our profession . 10 5

9/21/2015 But the future is bright… 11 12 6

9/21/2015 UCSF Laurel Heights 13 Philip R. Lee Institute for Health Policy Studies 14 7

9/21/2015 UCSF Center for Healthcare Value 15 IHPS Mentor: Adams Dudley 16 8

9/21/2015 Why now? • UCSF is a powerhouse of innovation but focusing on the costs of healthcare has been out 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 17 Cataract surgery example 18 9

9/21/2015 Why focus on cataract surgery? http://www.nei.nih.gov/eyedata/cataract.asp 20 10

9/21/2015 Specific Aim • To determine the prevalence, cost and factors associated with routine preoperative testing prior to cataract surgery in Medicare patients 21 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 occurred within 30 days of index surgery 22 11

9/21/2015 Increase in preop testing compared to baseline Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press). 23 Increase in preop testing compared to baseline Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press). 24 12

9/21/2015 Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press). 25 ROC curves comparing models predicting preop testing Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. (in press). 26 13

9/21/2015 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. 27 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 28 14

9/21/2015 What’s the harm? • Does routine preoperative testing actually hurt patients? 30 15

9/21/2015 31 • Can we figure out, using claims data, whether routine preoperative testing occurred in the months leading up to cataract surgery that led to delay in previously ‐ scheduled surgery? 32 16

9/21/2015 • Is there something different about the ophthalmologic work ‐ up that can help us distinguish cataract surgery patients who were originally scheduled for surgery, but had a delay for whatever reason? 33 Biometry • 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 34 17

9/21/2015 Time between biometry and surgery 7 6 5 4 3 2 1 0 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 Chen et al. Unpublished data. 35 Is there additional preop testing that occurs around the time of biometry? 12 months between biometry and surgery Surgery Biometry 70 60 50 40 PreopTst 30 20 10 0 ‐ 2 ‐ 1 0 1 2 3 4 5 ‐ 6 ‐ 5 ‐ 4 ‐ 3 ‐ 2 ‐ 1 1 2 Chen et al. Unpublished data. 36 18

9/21/2015 Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. 2015. 37 Effect of provider behavior 12 months between biometry and surgery Surgery 100 Biometry 80 60 >75% 40 <75% 20 0 ‐ 2 ‐ 1 0 1 2 3 4 5 ‐ 6 ‐ 5 ‐ 4 ‐ 3 ‐ 2 ‐ 1 1 2 3 Chen et al. Unpublished data. 38 19

9/21/2015 Difference between providers in time from biometry to surgery 8 7 6 High-testing providers 5 4 3 2 1 0 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 Chen et al. Unpublished data. 39 Variation among ophthalmologists in the prevalence of preop testing or office visits in their patients Chen et al. Preoperative Medical Testing Prior to Cataract Surgery in Medicare Patients. NEJM. 2015. 40 20

9/21/2015 % of patients experiencing >30 days between biometry and surgery 35 30 25 Percent 20 15 10 5 0 1 2 3 4 Quartile % of patients experiencing >90 days between biometry and surgery 8 7 6 5 Percent 4 3 2 1 0 1 2 3 4 Quartile Chen et al. Unpublished data. 41 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 21

9/21/2015 Future Directions • Identify other areas of overutilization associated with cataract surgery – Routine use of anesthesiologists for sedation during cataract surgery 43 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 outcomes 44 22

9/21/2015 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 23