Sustainability of CV Care Todd Anderson Mar 2017 Disclosures - - PowerPoint PPT Presentation

Sustainability of CV Care

Todd Anderson Mar 2017

Disclosures

• Todd Anderson

– Dept Head and Institute Director

Quality Dimensions

Mozaffarian Circ 2015;131:e29-

US Burden of CV disease

• About 2 million people have CVD or stroke
• About 16 % of total health care costs
• About 15% of admissions to hospital
• $25 billion dollars with about $8B in direct costs
• 2nd only to MSK
• 10% of all out-patient visits – 40 million
• 75 million Rx for CVD drugs
• By 2030 80% of provincial budgets will be needed for health care
• CHF costs almost $3B
• 2% of population living with CHF

PHAC

Canadian Burden of CV disease

Clinical Area Inpatient Costs ED + UC Physician Services Total Addictions and Mental Health $194,898,187 $11,499,681 $219,134,001 $425,531,869 Bone and Joint $149,284,168 $21,615,954 $161,930,594 $332,830,715 Cancer $116,225,723 $9,655,216 $68,344,711 $194,225,649 Cardiac and Stroke $202,145,065 $21,811,328 $149,068,838 $373,025,231 Diabetes Nutrition Obesity $37,766,695 $2,559,936 $63,247,102 $103,573,733 Seniors Health TBD TBD TBD TBD

Sustainable?

Alberta Health

1975 to 2010

• Expenditure increases = 3.5 fold
• Population increases = 1.5 fold

23.4M people 34.2 M people CIHI website

Sustainable?

Mozaffarian Circ 2015;131:e29-

10

The Burning Platform

Current State

• Total budget for AHS $14.3 billion, 2.6%

increase from last year

“The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

IOM, Crossing the Quality Chasm: A new Health System for the 21st Century 2001

Cost Drivers

• Driver

Models to Explore

• Embed quality literacy
• Transform culture
• Empower local improvement

and innovation

• Optimize processes

The Intermountain Healthcare Way

• Apply the rigorous measurement tools

developed for clinical research to routinely measure clinical variation in routine care performance

• Examine quality, utilization and efficiency
• Learning Approach; not a judgmental approach
• Focus on the process; not on the persons

Intermountain Health care approach to protocols

• Build evidence-based best practice protocols results

(memory-based medicine gets it right 50% of the time!)

• Incorporate them into clinical workflow
• Embed data systems to track protocol variations and

short- and long- term

• Demand that clinicians vary care based upon patient

need

• Feed the data back in a “Learning Loop”
• Consistently update and improve protocols

Unwarranted/Unexplained CPV

Distribution of Ontario hospitals by ratio of PCI:CABG procedures

Tu, J et al. CMAJ 2012. DOI:10.1503/cmaj.111072

www.consumerhealthchoices.org

How else can we “Choose Wisely”?

Test Cost CBC $7.00 Chemistry Panel 7 $35.00 Liver Panel $33.00 PT/PTT $16.00 Troponin T $15.00 D-Dimer $44.00 Venous Blood Gases $40.00 Type and Screen $36.00 ESR $6.00 CRP $6.00 Urinalysis $5.00 Urine Culture $10.00 Blood Culture $32.00 Plasma Lactate $5.00

Reduce Lab Costs

Reduce Lab Costs

http://www.choosingwiselycanada.org/recommendations/internal-medicine/

• Reduce Unnecessary Labs

– Daily Labs? $40/pt/day x 70 pts x 365 days =>$1 million

How much does an ECG cost?

– $30

Reduce Lab Costs

DI Cost per Service

% Census

Hospitalist IM Gen Surg Ortho Neuro Other

% Cost

Hospitalist IM Gen Surg Ortho Neuro Other

Cardiac Imaging

• Huge costs
• Tests often repeated or multiple tests done
• Try to do less invasive, lower cost tests
• Access to out-patient cardiac imaging is

readily available

Length of Stay

• Focus on standardized admissions
• STEMI and CHF pathways
• Expand the number of same day discharges
• Use team approach to expedite discharges – NPs and pharmacy

Out-patient

• Long wait times generates costs
• Annual visits and testing is not cost effective
• Tele-health could replace face to face visits
• Clinics with allied health professionals
• Prevention is cost effective with high ROI

Innovation

• Always will be newer, better and more expensive technology
• Need to eliminate tests and interventions of lower value to allow for

growth in other areas – TAVI – New drugs – Advanced imaging

Summary

• Start asking/thinking about how much things cost
• Educate colleagues
• Opportunities:

– Order Sets – Unnecessary/Redundant Exams – Supply Carts

• Best approach is a blend of Appropriateness

Guidelines and awareness of Fiscal Responsibility

What is the Future State?

• Priority must be on quality and not cost
• Quality is a balance of competing factors
• Appropriateness is the responsibility of all
• Standardized pathways decrease practice variation and waste
• Choosing Wisely must become part of the culture
• Costing knowledge needs to start during training
• Innovation is a reality and also needs to be embraced