Overuse in Clinical Care: Too Much of a Good Thing? Wendy Everett, - - PowerPoint PPT Presentation

Overuse in Clinical Care: Too Much of a Good Thing? Wendy Everett, ScD President, NEHI National Quality Forum March 26, 2009

Fostering Innovation Through Collaboration

Strong Reputation as a Trusted Source Reputation as a Trusted Source

Disease Prevention & Wellness Medical Innovation HIT Innovation Waste & Inefficiency

Cross Cutting Issues

Indicators Report

II

Fostering Innovation Through Policy Action Fostering Innovation Through Policy Action

Waste: Where & How Much? Waste: Where & How Much?

50%? 30%?

Demand for Data Is Everywhere Demand for Data Is Everywhere

The Call to Action

2. We must create a roadmap for progress.

• 1. We must find the evidence and

understand root causes to solve the problem. 3. We must pull the right policy levers to enable the health care system to reduce waste.

Major Phases of the Policy Process Major Phases of the Policy Process

Phase I

• What is Waste?
• Where is it?
• How much is

there?

Definition, Identification, and Quantification

Phase II

• Why does it

exist?

• Who wins

and loses?

Identification of Policy Issues

Phase III

• How can we

reduce it?

• How do we

reallocate the savings?

Policy Action Plan

What/Where? Why? How?

Focus on Clinical Care Focus on Clinical Care

Waste Across the System

Basic Research Clinical Development Prototype Design/ Discovery Preclinical Development Approval, Scale-up, and Manufacturing Marketing and Evaluation Prevention Acute Care Treatment Screening Chronic Care Treatment Diagnosis End of Life Care Enrollment Utilization / Disease Management Price / Fee Setting Claims Processing

Development Payment & Finance Clinical Care

Piecing Together the Puzzle of Waste Piecing Together the Puzzle of Waste

NEHI Goal: Select 3 – 5 areas for policy action 3,000 Studies 1,500 Studies 460 Studies

NEHI’s Evidence: Quantifying the Problem

Compendium

• f Evidence

2008

Overview of Findings

2008

Waste Evidence Waste Evidence – – in a Few Clicks in a Few Clicks

Searchable by:

1. Type of Waste (overuse, underuse, misuse) 2. Service type 3. Diagnostic category 4. Condition 5. Region

www.nehi.net

The $700 Billion Health Care Wasteland

= Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving

$600 b $100 b $10 b $1 b $100 m

Cost Saving Cost Effective (But Not Cost Saving) Strength of Evidence

Unexplained Variation Adverse Events Non Urgent ED Use Antibiotic Overuse Antihypertensive Misuse Beta Blocker Underuse DM Underuse Antidepressant Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse Antihypertensive Underuse Statin Underuse Back Imaging Overuse Asthma Medication Underuse Back Surgery Overuse CABG/PTCA Overuse

Low High Potential Opportunities

$682 Billion Opportunity $682 Billion Opportunity

Unexplained variation: $500 Billion Adverse events: $ 52 Billion Non-urgent ED use: $ 32 Billion

Top Three Contenders Top Three Contenders

Unexplained variation Adverse events Non-urgent ED use

NEHI and NQF: NPP Intersections NEHI and NQF: NPP Intersections

NEHI Opportunities NQF Opportunities

Adverse Events Asthma Medication Underuse Antihypertensive Misuse Back Imaging Overuse

Antibiotic Overuse Non Urgent ED Use Practice Variation: CABG/PTCA Overuse Back Surgery Overuse

Harmful preventive services with no benefit Maternity care interventions Diagnostic Procedures Inappropriate non-palliative services at end of life Lab tests

The $700 Billion Health Care Wasteland

= Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving

$600 b $100 b $10 b $1 b $100 m

Cost Saving Cost Effective (But Not Cost Saving) Strength of Evidence

Unexplained Variation Adverse Events Non Urgent ED Use Antibiotic Overuse Antihypertensive Misuse Beta Blocker Underuse DM Underuse Antidepressant Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse Antihypertensive Underuse Statin Underuse Back Imaging Overuse Asthma Medication Underuse Back Surgery Overuse CABG/PTCA Overuse

Low High Potential Opportunities

Practice Variation: Key Driver of Waste Practice Variation: Key Driver of Waste

• The largest source of wasteful spending is unexplained

practice variation in patterns of care that are not associated with differences in clinical outcomes.

• This variation represents a potential cost savings of up to

$500 billion annually.

• Overuse of three procedures contribute significantly to
• verall practice variation:

– Back surgery – Coronary artery bypass grafts (CABG) – Percutaneous coronary interventions (PCI)

Root Causes and Strategies for Change

What can we do? Reform guideline development process and use Encourage IT innovations to advance clinical decision support Train physicians on guideline use and IT Pay for performance and adherence

Reducing Overuse/Practice Variation

13% 15% 32% 49% 4% 36%

20% 9% 2%

Money Matters Money Matters

Likelihood of Compliance with Guidelines by Bonus Level

Bonus Bonus Bonus

Somewhat or much more likely to comply 19% 51% 81%

The $700 Billion Health Care Wasteland

= Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving

$600 b $100 b $10 b $1 b $100 m

Cost Saving Cost Effective (But Not Cost Saving) Strength of Evidence

Unexplained Variation Adverse Events Non Urgent ED Use Antibiotic Overuse Antihypertensive Misuse Beta Blocker Underuse DM Underuse Antidepressant Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse Antihypertensive Underuse Statin Underuse Back Imaging Overuse Asthma Medication Underuse Back Surgery Overuse CABG/PTCA Overuse

Low High Potential Opportunities

Combined Preventable Adverse Drug Events: 10.4% of All Admissions Preventable Adverse Drug Events 8.8% of total adult admissions Preventable Renal Dosing Errors 1.6% of all admissions with renal ADE

Adverse Events: Medication Errors Adverse Events: Medication Errors

With CPOE: 55,000 medication errors eliminated annually $170 million in annual savings to hospitals and payers

Adverse Events: Policy Change Adverse Events: Policy Change

February 2008: Massachusetts payers to require hospitals to adopt CPOE by 2012 for participation in quality incentive programs SECTION 36 – Health Reform Bill, August 2008: “…the department of public health shall adopt regulations requiring hospitals and community health centers, as a standard of eligibility for

• riginal licensure and

renewal of licensure, to implement computerized physician order entry systems….”

The $700 Billion Health Care Wasteland

= Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving

$600 b $100 b $10 b $1 b $100 m

Cost Saving Cost Effective (But Not Cost Saving) Strength of Evidence

Unexplained Variation Adverse Events Non Urgent ED Use Antibiotic Overuse Antihypertensive Misuse Beta Blocker Underuse DM Underuse Antidepressant Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse Antihypertensive Underuse Statin Underuse Back Imaging Overuse Asthma Medication Underuse Back Surgery Overuse CABG/PTCA Overuse

Low High Potential Opportunities

40% of all ED visits 40% of all ED visits could be treated or avoided with could be treated or avoided with timely primary care. timely primary care.

ED Overuse: a $32 Billion Problem

13.9% 9% 9.7% 10.7% 9.1% 10% 13% 12.5% 9%

0% 2% 4% 6% 8% 10% 12% 14% 16% 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year Non-urgent ED Visits as Percent of Overall Visits Source: CDC

Who Overuses Who Overuses EDs EDs? ?

An elderly nursing home patient is taken to the ED with dehydration as his facility did not have a physician on site at the time. A new mother cannot get her baby to stop crying - her doctor’s office is closed and the ED is the best place to get immediate reassurance. A college student thinks she has strep throat and decides that a few hours at the ED on a Sunday is better than waiting until the student health clinic re-opens on Monday.

Estimated Non-urgent and Preventable/Avoidable ED Visits in 2006

5,000,000 10,000,000 15,000,000 20,000,000 25,000,000

Private Medicaid Uninsured Medicare Total Number of ED Visits

Preventable/Avoidable Non-urgent

Source: CDC and MADHCFP

It It’ ’s Not Just the Uninsured s Not Just the Uninsured

Reducing Emergency Department Overuse

Perceived True Emergency Convenience of the ED Limited Access to Primary Care

Telemedicine Improved Chronic Disease Management Worksite Wellness Programs Co-location of Urgent Care at the ED Online Access to Healthwise After hours Telephone Triage

Root Causes Solutions

Innovations to Reduce Overuse Innovations to Reduce Overuse

Reducing Emergency Department Overuse

Perceived True Emergency Convenience of the ED Limited Access to Primary Care

Telemedicine Improved Chronic Disease Management Worksite Wellness Programs Co-location of Urgent Care at the ED Online Access to Healthwise After hours Telephone Triage

Root Causes Solutions

A unique partnership and opportunity A unique partnership and opportunity… …

Evidence-based research Convene multiple stakeholders Policy action and change Canvass network for new solutions Rapid assessment Health care improvement

C H A N G E

We We’ ’re Beating the Drum re Beating the Drum… …and People are Listening and People are Listening