Choosing Wisely when Ordering
Tests: When less is more…
Sapna Patel Kuehl, MD FACP
Program Director, Internal Medicine
St.Agnes Hospital
Conflicts of Interest
None
Special thank you to:
Dr. Cynthia “Daisy” Smith
Senior Medical Associate for Content
Development
Medical Education Division
American College of Physicians
DSmith@mail.acponline.org
Learning Objectives
• Recognize the urgent need for
eliminating waste in US Health Care.
• Understand Choosing Wisely® Campaign
of the ABIM Foundation and it’s
goals.
• Understand the concept of High Value
Cost Conscious Care.
• Motivate to eliminate medical tests
that provide no benefit and may be
harmful.
Clinical Case
• 35 year-old woman presents
to clinic complaining of
headaches every 1-2 weeks
for the past few months
• Headaches preceded by
“seeing spots” and
associated with nausea
• R-sided, pulsatile, lasts
approximately 4-8 hours
• Cannot identify any
“triggers”
No Red Flags
 Onset of headache after
age 50 years
 Change/progression of
headache pattern
 Acute onset of “worst”
severe headache
 Headache in a patient
with cancer,
immunosuppression or HIV
infection
 Headache with fever (or
in context of systemic
illness)
 Headache with an abnormal




neurologic examination
Migraine and epilepsy
Associated with
personality change
Symptoms of increased
intracranial pressure
(early AM headache, worse
with valsalva, exertion,
or sex)
Neurological symptoms
lasting more than 1 hr
Migraine Headaches
Likelihood Ratio for
migraine by number of
POUNDING criteria met1:
“POUND”
• Pulsating
• Duration of 4-72
• 4 of 5 criteria – LR 24
hours
• 3 of 5 criteria – LR 3.5
• Unilateral
• 2 or fewer criteria – LR
• Nausea
0.41
• Disabling
Should she get head
imaging? Is it needed?
How much does it cost?
U.S. HEALTHCARE COSTS ARE
UNSUSTAINABLE !
•$2,6000,000,000,000 ($2.6 trillion)
•10x cost in 1980
•Employer-sponsored health coverage for
family premiums 97% in last 10 years!
•17.9% of the nation’s Gross Domestic
Product (GDP) in 2010.
Centers for Medicare and Medicaid Services, Office of the Actuary, National Health
Statistics Group, National Health Care Expenditures Data, January 2012 Martin, A.B.
et al. January 2012. Growth in US health spending remained slow in 2010; Health share
of gross domestic product was unchanged from 2009. Health Affairs 31(1): 208-219
$8233
$5250
Why care about the costs?
Medical Professionalism in the New
Millennium
• Improving access to high-quality
health care,
• Advocating for a just and costeffective distribution of finite
resources, and
• Maintaining trust by managing
conflicts of interest.
http://www.abimfoundation.org/Professionalism/~/media
/Files/Physician%20Charter.ashx
Why care about the costs?
• Decisions are being made related
to costs
• Affordable Care Act
• Lower payments, fewer services
covered
• 30% ($750-765 billion) per year
have been identified as
potentially avoidable
Excess Cost Estimates
Cost in Billions of $$$
$75
$210
$55
$105
$130
$190
Institute of Medicine.
2010.
Unnecessary Services
($210 B)
Inefficiently Delivered
Services ($130 B)
Excess Administrative
Costs ($190 B)
Excessive Pricing ($105 B)
Missed Prevention
Opportunities ($55 B)
Fraud ($75 B)
The Healthcare Imperative,
750 Billion!
• Buy out of all ad
spots from
SuperBowl 3061
times over
• Over 74 days of
ads
http://www.pbs.org/newshour/multimedia/health-750b/
Growth in Volume of Physician Services Per Medicare
beneficiary 2000-2009
From Reinhardt blog, NY Times, 12/24/2010
Physician Controlled
Costs
• Unnecessary testing
and treatment=210B
• Inefficiently
delivered care=130B
• Missed prevention
opportunities=55B
395 Billion
Are We Willing (and Able) to
Address the Problem?
Physicians Agree That
Healthcare is Overused
Survey of primary care physicians
• 42% believe patients in their own practice are
receiving too much care (vs. 6% who say “too
little”)
• Perceived factors leading to overuse
– Malpractice concerns: 76%
– Clinical performance measures: 52%
– Inadequate time to spend with patients: 40%
Arch Intern Med. 2011; 171:1582-1585
ACP High Value Needs Assessment
Survey
Unpublished Data: 427 respondents; courtesy of Dr. Cynthia Daisy Smith
Challenges to High
Value Needs Assessment
A practicing physician knowledge
gap:
– costs of services in healthcare 93%
– balancing benefits with harms and
costs 85%
Unpublished Data: courtesy of Dr. Cynthia Daisy Smith
Reasons for overuse
• Diagnostic uncertainty 74%
• Malpractice fear 65%
• Inadequate patient follow-up or
access 59%
• Time savings 50%
• Patient request 47%
Data: ACP High Value Needs Assessment Survey
courtesy of Dr. Cynthia Daisy Smith
Drivers of the shortfalls
"2 Unnecessary Services." The Healthcare Imperative:
Lowering Costs and Improving Outcomes
• Scientific uncertainty
• Perverse economic and practice
incentives
• System fragmentation
• Opacity as to cost, quality, outcomes
• Changes in the population’s health
status
• Lack of patient engagement in decisions
• Underinvestment in population health
Young, Pierre L., Olsen, LeighAnne, Roundtable on Evidence-Based Medicine, Institute of
Medicine. "2 Unnecessary Services." The Healthcare Imperative: Lowering Costs and Improving
Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press, 2010.
Recommendations for
change-slide 1/2
• Streamlined and harmonized health insurance
regulation
• Administrative simplification and consistency
• Payment redesign to focus incentives on results
and value
• Quality and consistency in treatment, with a
focus on the medically complex
• Evidence that is timely, independent, and
understandable
Young, Pierre L., Olsen, LeighAnne, Roundtable on Evidence-Based Medicine, Institute of
Medicine. "2 Unnecessary Services." The Healthcare Imperative: Lowering Costs and Improving
Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press, 2010.
Recommendations for
change-2/2
• Transparency requirements as to cost, quality,
and outcomes
• Clinical records that are reliable, sharable,
and secure
• Data that are protected but accessible for
continuous learning
• Culture and activities framed by patient
perspective
• Medical liability reform
• Prevention at the personal and population
levels
Young, Pierre L., Olsen, LeighAnne, Roundtable on Evidence-Based Medicine, Institute of
Medicine. "2 Unnecessary Services." The Healthcare Imperative: Lowering Costs and Improving
Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press, 2010.
Back to Case
• 35 year-old woman with
headaches
• “POUND” criteria
• 4 of 5 criteria – LR
24
• Cost of head imaging??
– CT Head
– MRI Brain
Cost of Head Imaging
CT Head
US Minimum Price
$ 750
US Average Price
$ 1,150
US Maximum Price
$ 4,200
MRI Brain
U.S. Minimum Price
$ 1,650
U.S. Average Price
$ 2,550
U.S. Maximum Price
$ 7,300
http://healthcarebluebook.com/ and
http://clearhealthcosts.com/
National Initiatives
• Archives of Internal Medicine: “Less is
More” series 2010
• National Physicians Alliance: “Promoting
Good Stewardship in Medicine :Top 5” Campaign
Less Is More: How Less Health Care Can Result in Better
Health Deborah Grady, MD, MPH; Rita F. Redberg, MD, MSc
May 10, 2010
National Initiatives
• ABIM Foundation 2011: Choosing Wisely
Campaign
• High Value, Cost-Conscious Health Care
Initiative ACP 2011
• Avoiding Avoidable Care Conference April
2012 www.avoidablecare.org
Less Is More: How Less Health Care Can Result in Better
Health Deborah Grady, MD, MPH; Rita F. Redberg, MD, MSc
May 10, 2010
Choosing Wisely
Campaign
• Promote conversations between
physicians and patients
• Help patients choose care that is:
– Supported by evidence
– Not duplicative of other tests or
procedures already received
– Free from harm
– Truly necessary
Choosing Wisely
Campaign
• American Academy of Allergy, Asthma &
Immunology
• American Academy of Family Physicians
• American College of Cardiology
• American College of Physicians
• American College of Radiology
• American Gastroenterological Association
• American Society of Clinical Oncology
• American Society of Nephrology
• American Society of Nuclear Cardiology
• National Physicians Alliance
Choosing Wisely New
Partners- Feb 2013
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American Academy of Hospice and
Palliative Medicine
American Academy of Neurology
American Academy of
Ophthalmology
American Academy of
Otolaryngology–Head and Neck
Surgery
American Academy of Pediatrics
American College of
Obstetricians and Gynecologists
American College of
Rheumatology
•
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American Geriatrics Society
American Society for Clinical
Pathology
American Society of
Echocardiography
American Urological
Association
Society of Cardiovascular
Computed Tomography
Society of Hospital Medicine
Society of Nuclear Medicine
and Molecular Imaging
Society of Thoracic Surgeons
Society for Vascular Medicine
• AARP
•
Choosing Wisely
Consumer Organization
Partners
Alliance Health Networks
• Leapfrog Group
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Midwest Business Group on Health
Minnesota Health Action Group
National Business Coalition on Health
National Business Group on Health
National Center for Farmworker Health
National Hospice and Palliative Care Organization
National Partnership for Women and Families
Pacific Business Group on Health
•
Service Employees International
• Union Plus
• Wikipedia Community
residence)
Union
(SEIU)
(through a dedicated Wikipedian in
Patient Materials
When you need them and when you don’t
•Allergy tests: When you need them and when you
don’t
•Bone Density Tests
•Chest Xrays before surgery
•EKGs and exercise stress tests
•Chronic Kidney Disease: Making Hard Choices
•Hard decisions about cancer: 5 tests and
treatments to question
•When do you need antibiotics for sinusitis?
•How should you treat heartburn and GERD?
•When do you need an imaging test for a headache?
1. Don’t obtain screening exercise electrocardiogram testing in
individuals who are asymptomatic and at low risk for
coronary heart disease.
2. Don’t obtain imaging studies in patients with non-specific
low back pain.
3. In the evaluation of simple syncope and a normal
neurological examination, don’t obtain brain imaging studies
(CT or MRI).
4. In patients with low pretest probability of venous
thromboembolism (VTE), obtain a high-sensitive D-dimer
measurement as the initial diagnostic test; don’t obtain
imaging studies as the initial diagnostic test.
5. Don’t obtain preoperative chest radiography in the absence
of a clinical suspicion for intrathoracic pathology.
Current Philosophy at ACP
• Focus now on the “low-hanging fruit”:
interventions with low or no benefit,
independent of cost
• Goal: reduce inappropriate care that does
not help (or even harms) patients
• Ultimate outcomes:
reduced cost
better patient care,
ACP Slides: courtesy of Dr. Cynthia Daisy Smith,
ACP
ACP’s High-Value, CostConscious Care Initiative
• Eliminate health care spending on
interventions that do not improve health
outcomes
• ACP is not proposing that care be rationed
• Rational care: assuring that care is
clinically effective, thus avoiding overuse
or misuse of care that is inappropriate
• Rationing: decisions are made about the
allocation of scarce medical resources and
who receives them, leading to underuse of
potentially appropriate care
Owens DK et al for Clinical Guidelines Committee of ACP. High Value Cost-conscious
Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of
Medical Interventions. Ann Intern Med. 2011; 154: 174-180
Shifting focus: More ≠ Better
Health Outcomes
C
A
A
B
A to B = higher cost for better
outcome
A to C = more value
Health Care Costs
Owens DK et al for Clinical Guidelines Committee of ACP. High Value Cost-conscious Health
Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical
Interventions. Ann Intern Med. 2011; 154: 174-180
Value, Cost and
Healthcare
Cost ≠ Value
Cost ≠ Cost of Test
• Cost = cost of test + downstream
costs, benefits and harms
• Low-cost interventions may have
little or no value if they provide
little benefit or SIGNIFICANTLY
increase downstream costs.
Owens DK et al for Clinical Guidelines Committee of ACP. High Value Cost-conscious
Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs
of Medical Interventions. Ann Intern Med. 2011; 154: 174-180
Benefit, Cost, and Value
High Benefit
High
Cost
Anti-retroviral
therapy for HIV
Value: high
Low
Cost
HIV screening
Value:
highest
Low Benefit
Routine MRI for low back
pain
Value: lowest
Annual pap smears
Value: low
Value Measurement: Quality
Adjusted Life Years (QALYs)
• An important metric for measuring health
benefits by taking into account both length
and quality of life
• Allows for comparison of interventions
between different specialities (compare
cancer treatments with cardiovascular
treatments)
Cost-Effectiveness Threshold:
How Much is Health Worth?
• Threshold depends on who is making the
decision and their willingness to pay for
better health outcomes
• National Health Service in UK $30,000$50,000/ QALY
• No consensus in US - citizens have been
willing to pay up to $109,000/QALY, most US
decision makers consider interventions that
cost less than $50,000-$60,000/QALY high
value
Prevention Measures
Cost-Effectiveness Ratio
QALY Examples
One time colonoscopy screening for
ca
Cost-Saving
High intensity smoking prevention
$190/QALY
Screening 60 y o for Diabetes
$25,738/QALY
Treatments for existing conditions
ART for HIV
$29,000/QALY
Implantation of defibrillators
$52,000/QALY
Surgery in 70 y o male with
prostate ca
Increased cost and worsens health
M 2008:358:661-663
Steps Toward High-Value, CostConscious Care
1
• Understand the benefits, harms, and relative
costs of the interventions that you are
considering
• Decrease or eliminate the use of
interventions that provide no benefits and/or
may be harmful
• Choose interventions and care settings that
maximize benefits, minimize harms, and
reduce costs (using comparativeeffectiveness and cost-effectiveness data)
1Owens,
D. Ann Intern Med. 2011;154:174-180
Steps Toward High-Value, CostConscious Care
1
• Customize a care plan with the patient
that incorporates their values and
addresses their concerns
• Identify system level opportunities to
improve outcomes, minimize harms, and
reduce healthcare waste
1Owens,
D. Ann Intern Med. 2011;154:174-180
Education of Target
Audiences
1. Practicing physicians
2. Trainees (students, residents,
and fellows)
3. Patients
Targeting Practicing
Physicians
• High value care recommendations in MKSAP
16, Annual live ACP meeting
• ACP Waxman Clinical Skills Center:
provide more cost effective and
comprehensive care
• New Maintenance of Certification (MOC)
activities: eliminating misuse and
overuse
• Smartmedicine (free for ACP members)
• Guidelines, guidance statements,
position papers
Education of Trainees
- AAIM-ACP Curriculum is available for
free download at
www.highvaluecarecurriculum.org
– SIMPLE and other interactive cases
Educating Patients
• High quality patient information
materials to accompany physician
education materials
• ABIM Collaboration with Consumer
Reports
• Patient fair at annual ACP
meeting in April in San
Francisco
• ACP collaboration with AHRQ’s
Effective Healthcare Program
Future Challenges in
Eliminating Waste
• End of life care
• Appropriate use of subspecialty
consultation and referral
• Decreasing hospitalization and ER
utilization
• Over-pricing
• Price transparency
• Defensive medicine
• Improved reimbursement for care
coordination
• Alignment of financial incentives
• Physician financial conflict of interest
Paradigm Shift
•National Health Care
Debate
•“Doc fix”
•Medical Malpractice
Reform
•Active role of
Physicians
•Reconstruct health
care industry
•Patient Expectations
Are we merely postponing the
reckoning?
Medical costs typically increase by
a few to several percent per year
(after adjustment for inflation).
• “Costs will resume their rise unless
we start saying no to some
beneficial care.”
• “Eliminating only ineffective care
would shift the cost curve down but
wouldn't change its slope.”
Beyond the “R Word”? Medicine's New Frugality
M. Gregg Bloche, M.D., J.D. NEJM 2012; 366:1951-1953May 24, 2012DOI: 10.1056/NEJMp1203521
Reasons Residents OverOrder Tests9
1. Duplicating role
modeled behavior
2. Desire to be complete
3. Pre-emptive
ordering/rushing an
evaluation/unnecessary
duplication of tests
4. Discomfort with
Diagnostic Uncertainty
5. Curiosity
6. Lack of knowledge of
the costs and harms
7. Defensive medicine
8. Patient requests
9. Faculty demand
10.No training in
weighing benefit
relative to cost and
harm
11.Ease of access to
services when patient
is hospitalized
Strategy Questions to Ask
Before Ordering a Test
8
• Did the patient have this test previously?
• Will the result of this test change the
care of the patient?
• What are the probability and potential
adverse consequences of a false positive
result?
• Is the patient in potential danger in the
short term if I do not perform this test?
• Am I ordering the test primarily because
the patient wants it or to reassure the
patient?
Conclusions
• 365 billion of dollars annually are
considered “healthcare waste”
• The highest percent of waste occurs
in Unnecessary Services category.
• Review Choosing Wisely Campaign
Recommendations.
• Comprehensive Societal Discussion
• Medical Malpractice Reform
What can we do?
• Eliminate unnecessary tests and
treatments and teach our students
and residents to do the same
• Tolerate some diagnostic
uncertainty- close follow up and
care coordination can help assuage
anxiety
• Manage patient expectations by
talking to them about their values
and concerns
References
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Detsky ME, et al. Does this patient with headache have a migraine or need
neuroimaging. JAMA 2006;296:1274-1283.
ABIM Foundation, Choosing Wisely Campaign. www.choosingwisely.org (accessed
5/1/12).
Kaniecki R. Headache assessment and management. JAMA.2003;289:1430-1433.
Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth,
2000-2005. Boston: Health Reform Program, Boston University School of
Public Health; 2005.
Cooke M. Cost consciousness in patient care--what is medical education’s
responsibility? NEJM. 2010;362:1253-1255.
Thomas Reuters. Where can $700 billion in waste be cut annually from the
U.S Health Care system? October, 2009.
Uwe E. Reinhardt blog, NY Times, 12/24/2010.
Laine C. High-value testing begins with a few simple questions. Ann Intern
Med. 2012;156:162-163.
Adapted from Neel Shah. Commonhealth. Accessed 10/2011.
Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster
High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149
Any Questions or
comments?
Notable Books
•
•
•
•
•
•
Overdiagnosed: Making People Sick in the Pursuit of Health
Author: H. Gilbert Welch, MD
My Mother, Your Mother: Embracing “Slow Medicine,” the
Compassionate Approach to Caring for Your Aging Loved Ones
Author: Dennis McCullough, MD
How We Do Harm: A Doctor Breaks Ranks About Being Sick in
America
Author: Otis Webb Brawley, MD
Hope or Hype: The Obsession with Medical Advances and the
High Cost of False Promises
Authors: Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD,
MSPH
Money-Driven Medicine
Author: Maggie Mahar
Overtreated
Author: Shannon Brownlee, MsC
Case #2
• 62 y/o man with ischemic cardiomyopathy
presents to the emergency department with
increasing dyspnea and orthopnea
• Last echo 2 months ago showed LVEF 35%
• Returned from cruise yesterday where he
was non-compliant with dietary
restrictions and missed several doses of
his medications
• Denies chest pain
• Vitals are normal, exam shows volume
overload
• Further Evaluation?
Approximate Costs
 1 night in the hospital
$1,400
 Physician fees (per day):
$200
 Consulting physician fee (per
day): $300
 EKG: $60
 CXR: $100
 Transthoracic echocardiogram:
$1,000
 CT angiogram of the chest:
$1,200
 Coronary angiography: $8,000
 ECG stress test: $500
 Echo/nuclear stress test:
$2,000
 Electrolyte panel: $50
 CBC: $50
 Troponin: $75
 BNP: $75
 Oral medications: $5 per pill
 IV medications: $80 ($50 for
med and $30 for
administration)
http://www.imaginghealthcare.com/procedures/
Expansion of the High Value Care
Initiative
• Beyond internal medicine
• current work underway with ACOG
and CREOG; family medicine,
pediatrics and psychiatry also
interested;
• Collaboration with ACGME
Resident/Fellow Council to
expand beyond IM