February 18, 2014 Cost-Effective Care Strategies in Emergency - - PowerPoint PPT Presentation

Cost-Effective Care Strategies in Emergency Medicine February 18, 2014

Cost-Effective Care Strategies in Emergency Medicine

Myles Riner, MD Prentice Tom, MD

Objectives

• Discuss how CEC strategies are developed
• Review ACEP participation in Choosing Wisely
• Discuss implementation of CEC strategies in the ED
• Discuss the broader implications of CEC in the ED

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The Impetus for Cost-effective Care

• Decades of growth in health spending
• NPA’s ‘Promoting Good Stewardship in Clinical

Practice’ project, inspired by the ABIM Foundation’s Physician Charter on Professionalism

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What does cost-effective care mean?

• Cost:

– charges, payments, cost-plus, immediate vs. longer term – patient, insurance plan, provider, combination

• Effective:

– outcome, patient satisfaction, QALY, risk-avoidance, work productivity The severed digit example: complete amputation and revision

• vs. reimplantation

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Evidence base for cost-effective care

• National Guideline Clearinghouse - Agency for

Healthcare Research and Quality

• Center for Reviews and Dissemination – CRD

Database – UK NIHR

• CEA Registry - Tufts
• Appropriateness Criteria Search – ACR search

engine for radiology services

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Developing Cost-effective Care Strategies

Potential cost savings Care benefits Actionability Risk Considerations Targets

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Most expensive vs. Most costly

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Most expensive vs. Most costly

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Most expensive vs. Most costly

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ACEP’s Approach

• Cost-effective Care Task Force
• Membership survey
• Reconsideration of CW Campaign Participation
• Delphi Panel

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Concerns about Choosing Wisely

• Denial of payment or coverage
• Benefit Design
• Medical Necessity
• Pre-authorization
• Too dogmatic
• Liability exposure

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Considerations for CEC Strategies

Contribution to Cost Savings expense of action frequency in EM performance “gap” Risk / Benefit to patients of proposed strategy effect on quality of care unintended consequences Actionability by EM providers use decided by emergency providers Usability Strength of evidence base

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Do This / Don’t Do That vs Consider

• Avoid computed tomography (CT) scans of the head in

emergency department patients with minor head injury who are at low risk based on validated decision rules

• Don't do computed tomography (CT) scans of the head in

emergency department patients with minor head injury who are at low risk based on validated decision rules

• Computed tomography (CT) scans of the head are not generally

indicated in emergency department patients with minor head injury who are at low risk based on validated decision rules

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ACEP’s (First) Five Strategies

• 1. Avoid computed tomography (CT) scans of the head in emergency department

patients with minor head injury who are at low risk based on validated decision rules

• 2. Avoid placing indwelling urinary catheters in the emergency department for either

urine output monitoring in stable patients who can void, or for patient or staff convenience

• 3. Don’t delay engaging available palliative and hospice care services in the

emergency department for patients likely to benefit

• 4. Avoid antibiotics and wound cultures in emergency department patients with

uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up

• 5. Avoid instituting intravenous (IV) fluids before doing a trial of oral rehydration

therapy in uncomplicated emergency department cases of mild to moderate dehydration in children

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Other strategies considered

• Do not do CT of the head in adult patients with syncope, insignificant trauma and a normal neurological

evaluation.

• Do not order CT pulmonary angiography in patients with a low-pretest probability of pulmonary embolism

and either a negative Pulmonary Embolism Rule-Out Criteria (PERC) or a negative D-dimer.

• Do not order any imaging for adults in the ED with atraumatic back pain unless the patient has severe or

progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis).

• Do not admit low risk patients after appropriate troponin testing, and ECGs, are negative).
• Do not prescribe antibiotics for uncomplicated sinusitis.
• Do not order CT of the abdomen and pelvis in young ED patients (age <50) with known histories of

ureterolithiasis presenting with symptoms consistent with uncomplicated renal colic.

• Futile resuscitative efforts should not be initiated, or continued, in the pre-hospital setting or in the

Emergency Department.

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Pertinent CW Strategies from other specialties

• Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for

uncomplicated acute rhinosinusitis (AAAAI)

• Don’t prescribe antibiotics for otitis media in children aged 2–12 years with non-severe

symptoms where the observation (deferred treatment) option is reasonable (AAFP)

• Avoid the routine use of “whole-body” diagnostic computed tomography (CT) scanning

in patients with minor or single system trauma (ACS)

• Don’t recommend bed rest for more than 48 hours when treating low back pain (ANSS)
• Don’t use coronary computed tomography angiography in high risk emergency

department patients presenting with acute chest pain (SCCT)

• Don’t place, or leave in place, peripherally inserted central catheters for patient or

provider convenience (SGIM)

• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds

and in the absence of symptoms of active coronary disease, heart failure or stroke (AABB)

• Don’t routinely use bronchodilators in children with bronchiolitis (SHMPHM)
• Don’t do work up for clotting disorder (order hypercoagulable testing) for patients who

develop first episode of deep vein thrombosis (DVT) in the setting of a known cause (SVM) http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf

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Shared Decision-making

• Pros

– May enhance the physician-patient relationship – Often encourages patients to express their concerns – Usually improves the matching of patient and care plan – Meets patient’s expectations for more information and greater participation

• Cons

– Some patients do not want to participate in decisions – Revealing the uncertainties inherent in medical care could be harmful – It’s not feasible to provide information about the potential risks and benefits of all treatment options – Increasing patient involvement could lead to greater demand for unnecessary, costly or harmful services

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Likely admitted vs. Likely discharged

• vs. Questionable

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Epidemiologic considerations in cost-effective care

• Kidney stones affect one in 11 adults in the United States, and their prevalence has

increased 40 percent in the past decade. Renal colic accounts for more than 700,000 emergency-department visits annually

• Only 1 in 8 CT scans of renal colic patients result in a change in ED management, yet

between 1996 and 2007 there was a 10-fold increase in CT imaging of patients with suspected kidney stone, with little added benefit.

• Ureteral stones have a recurrence rate of approximately 50%. A 25% reduction in the use
• f CT scans in patients with symptoms of recurrent ureteral stone could save upwards of

200 million dollars a year in costs http://www.acepnow.com/article/cost-effective-way-evaluate-patients-recurrent-renal-colic/

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Implementing Cost-effective Care Strategies in the ED

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Alignment Selection Buy-in Tools Monitoring Incentives Mentoring and Feedback Closing the Loop

Tools

• Scripts
• Physician Education Materials
• Patient Education Materials
• Hand-held References
• Discharge Instructions
• Follow-up Coordination

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Tools

• Scripts

“It looks like you are having another kidney

• stone. It should pass within a week. If it

doesn't, or the pain gets worse, or you get a fever, then it may be necessary to get a CT

• scan. At this time, it doesn't appear necessary

to expose you to the radiation or cost. We should be able to help relieve your pain. You will need to follow-up as referred. Does this sound OK?”

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Tools

• Physician Education Materials

http://www.choosingwisely.org/resources/modules/

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Tools

• Patient Education Materials

http://www.choosingwisely.org/resources/modules/

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Tools

• Discharge Instructions

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Tools

• Follow-up Coordination

– Direct physician to physician communication – Faxed discharge instructions – Instructions to make follow-up appointment – Make an appointment for the patient – Post-discharge follow-up call to patient

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Monitoring Utilization and Performance

• Benchmarks and Targets
• Individual vs Group
• Dashboards
• Validity

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Monitoring Utilization and Performance

• QI Process Loop
• Outcomes and Adverse Events

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Liability considerations in Cost-effective Care Strategies

• Incentives to withhold needed care
• Uncertain liability risk exposure
• Dependence on uncertain followup
• Clinical inertia
• However: CEC can reduce liability exposure by improving ED

inefficiency; and by picking the low handing fruit first, any potential liability risk is minimized.

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Shared-savings and Other Provider Incentives

• Achieving the Proper Balance
• Utilization Risk Pools, Shared Savings Models
• Contractual considerations
• Anti-trust and Regulatory concerns

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Implementing CEC Moves the ED from a Cost-Center to a Good Steward of Costly Acute Care Continuum Resources

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Moving Foward

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• The momentum for CEC
• An opportunity for EPs to take a lead role
• Changing the ED care paradigm
• If the time is right, and the stars are aligned, move

forward

Review

• There is a process to developing CEC strategies
• Go for the low hanging fruit
• Implementing CEC is not much different than

implementing any QI process in the ED

• Hurdles: Inertia, lack of data, patient expectations, fears
• f malpractice, and stakeholder alignment
• Key to CEC is the approach to patients in shared decision-

making

• CEC can even reduce malpractice risk by improving ED

efficiency

• CEC can change, and improve, perceptions of ED care

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