Reduce Waste and Improve
Outcomes
Darilyn V. Moyer, MD, FACP
Chair, ACP Board of Governors
Disclosures
Elected Chair of BOG
Not specifically asked to speak about MOC…
Learning Objectives
• Define High Value Care
• Utilize the High Value Care Curriculum and Cases
• Balance benefits with harms and costs when caring
for patients
• Set expectations for the provision of high value care
to patients, learners, and other providers
Outline
•
•
•
•
•
Introduce the HVC Initiative and the curriculum
Demonstrate several HVC Cases
Review pilot feedback
Introduce Choosing Wisely
Future
High Value Care Definition
Care that balances clinical
benefit with cost and
harms with the goal of
improving patient
outcomes
What is the problem?
• We spend too much on
healthcare – 17% of U.S. GDP
• Healthcare spending is the
largest driver of budget
deficits
• Despite spending twice as
much on healthcare as other
developed nations, we have
lower life expectancy
1
Healthcare Waste
• Estimated $700 Billion of
“Healthcare waste” annually
• $250-325B in “Unwarranted use”
• $75-100B in “Provider
inefficiency and errors”
• $25-50B in “Lack of care
coordination”
2
Ordering more services …
3
Tests
Imaging
• Two areas of greatest expenditures and most
rapid growth: imaging and tests
Can you think of specific examples?
Improved Outcome
High Cost
Low Cost
No Improved Outcome
Shifting focus
More care is better care
High value, customized
care is better care
The Educational Gap
• Cross sectional survey from 18,102 IM
residents (2012 IM-ITE survey)
• Response rate 84%
• Resident self-reported knowledge and practice
of high value care and high value care
teaching
I know the benefits and harms associated with
common tests and treatments
85%
I know where to find estimated costs of tests and
treatments
26%
0%
20%
40%
60%
80%
Percent of IM Residents who
Somewhat/Strongly Agree
100%
I share estimated costs of tests and treatments with
patients
24%
I incorporate the cost of tests and treatments into clinical
decisions
46%
I reduce health care waste within my hospital and/or
clinic
59%
I avoid ordering unnecessary tests and treatments for
patients
72%
I offer patients alternatives of care, considering benefits,
harms and costs
81%
I incorporate patients' values and concerns into clinical
decisions
88%
0%
20%
40%
60%
Percent of IM Residents who
Somewhat/Strongly Agree
80%
100%
7%
Every day
15%
16%
Few times a week
How often are issues of
balancing benefits and harms
with costs the subject of
teaching conferences or rounds?
25%
29%
33%
Few times a month
How often do you and your
faculty discuss balancing
benefits and harms with cost
when caring for patients?
40%
Few times a year
23%
8%
4%
Never
0%
20%
40%
60%
80%
100%
•
•
•
•
IM Resident Curriculum Overview
FREE, off-the-shelf curriculum
Based on a simple, step-wise framework
Six, one-hour sessions
Small group activities involving actual
cases and bills to engage learners
• Facilitator’s guide accompanies each
session to help faculty prepare
• Program Director’s toolbox
Steps Toward High Value Care4
• Step one: Understand the benefits, harms, and relative costs of the
interventions that you are considering
• Step two: Decrease or eliminate the use of interventions that provide no
benefits and/or may be harmful
• Step three: Choose interventions and care settings that maximize benefits,
minimize harms, and reduce costs (using comparative-effectiveness and
cost-effectiveness data)
• Step four: Customize a care plan with the patient that incorporates their
values and addresses their concerns
• Step five: Identify system level opportunities to improve outcomes,
minimize harms, and reduce healthcare waste
Curriculum Topics and Cases
1. Eliminating Healthcare Waste and
Over ordering of Tests
2. Healthcare Costs and Payment
Models
3. Utilizing Biostatistics in Diagnosis,
Screening and Prevention
4. High Value Medication Prescribing
5. Overcoming Barriers to High Value
Care
6. (Local) High Value Quality
Improvement Projects
• Headache, heart failure, deep
venous thrombosis
• Appendicitis, sports injury,
osteomyelitis
• Chest pain, periodic health
examination, chemoprevention
• Seasonal allergies, discharge
medication reconciliation
• Low back pain, URI, septic joint
Program Director’s Toolbox
• Resident survey to measure curricular effectiveness
• Tools to help faculty and program directors assess resident
competence in high value care milestones
• Sample local high value care quality improvement projectsreports, abstracts, posters, and slide decks for oral
presentations
Curriculum Dissemination
• The curriculum has been
downloaded over 27,000 times since
July 2012
• Over 138 IM programs have
implemented some component of
the curriculum as of 2/14
• 122 programs report the initiation of
local high value quality improvement
projects from the curriculum
Online High Value Care Cases
• Web-optimized cases with
questions
• Based on actual patients
and their hospital bills
• Free to all practicing
physicians
• CME and MOC credit (inc
patient safety)
Online High Value Care Cases
• Introductory video
• Five modules (30-60 minutes
each)
• Take home tools with each
module to help provider
incorporate modules into practice
1. Avoid Unnecessary Testing
2. Use Emergency and Hospital
Level Care Judiciously
3. Improve Outcomes with Health
Promotion and Prevention
4. Prescribe Medications Safely and
Cost Effectively
5. Overcome Barriers to High Value
Care
Format
• Short clinical vignette
• Multiple choice question based on the case
(audience participation preferred)
• Questions are designed to engage learners and
promote discussion- some may require guessing and
some may require synthesizing information
• Discussion of the answer and key points
Topic 5: Overcome Barriers to High Value Care
• Understand the barriers to high value care in clinical
practice
• Explore ways to overcome some barriers to high value
care
• Communicate clear expectations to patients and other
members of the healthcare team
• Negotiate a care plan with patients that incorporates
their values and addresses their concerns
Michael Thompson
45-year-old man who is evaluated for low back pain.
• He has had the pain for 2 weeks
• The pain has not remitted and is affecting his work.
• He does not have fever, radiation of the pain to the legs,
weakness, numbness, bowel or bladder incontinence,
or any other neurologic symptoms.
He is requesting an MRI scan to look for a “slipped disk.”
Michael Thompson cont …
• He has taken acetaminophen with some relief.
• His medical history is unremarkable.
• He has a sedentary job, occasionally uses
alcohol, and does not use illicit drugs.
• He has no family history of cancer.
Physical exam including a neuro exam are normal.
Question #1
What is the probability that an MRI of the lumbar spine
will change how you manage Mr. Thompson's back
pain?
A.
B.
C.
D.
Very low
Medium
High
Very high
Question #1 - Answer
What is the probability that an MRI of the lumbar spine
will change how you manage Mr. Thompson's back
pain?
A.
B.
C.
D.
Very low
Medium
High
Very high
Question #1 Key Point
• Back imaging in patients with acute-onset, nonspecific
low back pain is unlikely to change management.
• Most patients with low back pain feel better within a
month whether they get an imaging test or not.
• An MRI done in the setting of acute nonspecific low
back pain can lead to incidental findings and
additional procedures that may increase cost, delay
recovery, and decrease sense of well-being.
Who needs back imaging?
• Imaging is indicated in patients with:
• presence of rapidly progressing neurologic symptoms
• evidence of cord compression, or cauda equina syndrome
• Suspected infection or malignancy as a possible cause of
the symptoms and examination findings.
• Mr. Thompson has none of these red flag signs or
symptoms that would increase the probability that
imaging would change management.
Recovery from Back Pain
• The overall prognosis for acute musculoskeletal low
back pain is excellent.
• Most patients without sciatica show substantial
improvement within 2 weeks, and 3/4 of those with
sciatica are substantially better after 3 months.
• Therapeutic interventions should focus on relieving
symptoms and maintaining function while the patient
recovers.
Michael Thompson cont …
• You ask Mr. Thompson what he is concerned about and
why he wants an MRI.
• He is worried that his back pain could lead to
permanent nerve damage.
• You tell him that his back pain is caused by muscle
spasm and there is no evidence of nerve damage.
• You tell him you wish more testing would help him feel
better but it could actually make him feel worse.
Michael Thompson cont …
• Empathize with his pain and treat his pain with antiinflammatory medicine and heat.
• Encourage him to continue walking every day and avoid
heavy lifting.
• Ask him to call you if the pain start to radiate down to his
leg and if he develops any weakness in his foot or leg.
• Schedule a follow-up appointment with him in 2 weeks to
see how he is doing.
Question #2
What would you estimate the probability of Mr.
Thompson leaving your office satisfied with his care
after having the above conversation?
A.
B.
C.
D.
Very low
Medium
High
Very high
Question #2 - Answer
What would you estimate the probability of Mr.
Thompson leaving your office satisfied with his care
after having the above conversation?
A.
B.
C.
D.
Very low
Medium
High
Very high
Question #2 Key Point
• Patient-centered discussions that include asking
patients what they are concerned about,
explaining your reasons, providing empathy, and
providing a clear follow-up plan improve patient
satisfaction more than doing unnecessary
diagnostic testing because the patient requested
it.
Principles of patient-centered discussions
1. Find out where the patient is coming from: “What are you
afraid we will find?” “What do you think is going on and what are
you worried about?”
2. Explain your reasons: “The good news is that you don't have any
worrisome symptoms.”
3. Make it clear that you are on the patient's side: “I wish more
testing would help you, but it could actually make things worse.”
4. Contract for a clear follow-up plan and review red flag signs
and symptoms: “I want to see you in 2 weeks, but call sooner if you
have leg weakness.”
Noel Kenmore
27-year-old woman who is evaluated for 3 days of sore
throat, cough, congestion, and sneezing.
• No fever or myalgia.
• No significant medical history, No medications, No
allergies.
• Ms. Kenmore has no exposure to young children.
• She asks for a prescription for antibiotics.
Noel Kenmore cont…
On exam:
• Afebrile with normal vital signs.
• Her oropharynx reveals slight erythema and a single 2mm patch of exudate on her right tonsil.
• She has no cervical adenopathy, and her tympanic
membranes are normal bilaterally. Her lungs are clear.
Question #3
Which of the following is the most appropriate next step
in management?
A.
B.
C.
D.
Start antibiotics now
Give a prescription for antibiotics to fill in case
she worsens
Do not prescribe antibiotics
Rapid antigen detection test for streptococcus
Question #3 - Answer
Which of the following is the most appropriate
next step in management?
A.
Start antibiotics now
B.
Give a prescription for antibiotics to fill in case
she worsens
C.
Do not prescribe antibiotics
D.
Rapid antigen detection test for streptococcus
Question #3 Key Point
Patients with only one of four Centor criteria (tonsillar
exudates, tender anterior cervical adenopathy, fever by
history, absence of cough) do not require antibiotics or
further testing.
Centor Criteria
• Criteria widely used and validated as a predictor of the likelihood of
Group A Streptococcus bacterial infection causing pharyngitis.
• These criteria are:
•
•
•
•
Tonsillar exudates
Tender anterior cervical adenopathy
Fever by history (> 38 C or 100.4 F)
Absence of cough
• The absence of three or four of these criteria has a negative
predictive value of 80% to 88%. This makes the Centor criteria most
useful for identifying patients in whom neither microbiologic testing
nor antibiotic treatment are necessary.
Modified Centor Criteria
• The Modified Centor Criteria add the patient's age to the
criteria:
• Age <15 add 1 point
• Age >44 subtract 1 point
• 0 or 1 points - No antibiotic or throat culture necessary (Risk
of strep. infection <10%)
• 2 or 3 points - Should receive a throat culture and treat with
an antibiotic if culture is positive (Risk of strep. infection 32%
if 3 criteria, 15% if 2)
• 4 or 5 points - Treat empirically with an antibiotic (Risk of
strep. infection 56%)
Ms. Kenmore cont…
• You ask Ms. Kenmore why she wants
antibiotics, and she tells you that she is
getting on an airplane the next day to go to a
series of important meetings. She is worried
about strep throat.
• She asks you, “How will I get antibiotics if I
get sicker?”
Question #4
What would be your next steps in communicating with Ms.
Kenmore about not prescribing antibiotics?
A.
Describe the epidemiologic problem of antibiotic resistance
worldwide
B. Explain why antibiotics will not help her, empathize, and provide a
clear follow-up plan
C. Scare her with warnings about antibiotic-associated diarrhea and
allergic reactions
D. Tell her that the antibiotics will cost the health system too much money
Question #4 - Answer
What would be your next steps in communicating with Ms.
Kenmore about not prescribing antibiotics?
A.
Describe the epidemiologic problem of antibiotic resistance
worldwide
B. Explain why antibiotics will not help her, empathize, and provide a
clear follow-up plan
C. Scare her with warnings about antibiotic-associated diarrhea and
allergic reactions
D. Tell her that the antibiotics will cost the health system too much money
Question #4 Key Point
• Clear and concise communications focused
around the patient's concerns can overcome
some potential barriers to high value care.
Patient-Centered Discussions
1.
2.
3.
4.
Find out where the patient is coming from: “Why do you want antibiotics and
what are you concerned about?”
Explain your reasons: “The good news is that based on your history and
physical exam, it is extremely unlikely that you have an infection that would
respond to antibiotics.”
Make it clear that you are on the patient's side: “I wish antibiotics or more
testing would help you feel better, but they actually may make things worse by
placing you at risk for harm with little or no chance of benefit.”
Contract for a clear follow-up plan and review red flags: “Let's talk by
telephone in 2 days. I want to be sure that you are feeling better by then.
Please call me sooner if you develop a high fever, tender lumps in your neck,
or difficulty swallowing.”
Potential Barriers
•
•
•
•
Patient/family requests
Lack of guidelines
Poor familiarity with guidelines
Lack of knowledge of costs,
including the impact of setting on
cost
• Defensive medicine (fear of
litigation)
• Time pressure
• Explaining to patients why
tests/treatments are not
indicated also takes time.
• Discomfort with diagnostic
uncertainty
• Local standards of care
• Misaligned financial incentives
• Lack of appreciation of harms
Maria
Hernandez
70-year-old woman admitted for presumed CAP.
•
She has a history of a right TKA with a titanium implant one year
ago.
• During her evaluation, Mrs. Hernandez complains of a swollen
right knee.
On exam:
• Knee is warm, erythematous, tender, and there is a large effusion.
She has pain with palpation and limited range of motion. Her
surgical scar is well-healed.
• You are concerned about septic arthritis in her prosthetic knee.
You call the orthopedic surgeon and ask for a consult for “knee
pain.” He says, “order an MRI and we will see her tomorrow.” You
have some concerns about this management plan.
Question #5
What should you do next for Mrs. Hernandez?
A.
Call the surgeon's supervisor to complain about his recommendation
B.
Document the orthopedic surgeon's recommendations in the chart and clearly state that you
disagree with him
C.
Order the MRI and wait because he is the specialist and that is what he recommended
D.
Reframe your question to the consultant in order to clearly communicate what you are
concerned about and why
Question #5 - Answer
What should you do next for Mrs. Hernandez?
A.
Call the surgeon's supervisor to complain about his recommendation
B.
Document the orthopedic surgeon's recommendations in the chart and clearly state that you
disagree with him
C.
Order the MRI and wait because he is the specialist and that is what he recommended
D.
Reframe your question to the consultant in order to clearly communicate what you are
concerned about and why
Question #5 Key Point
• A well-framed clinical question prior to
consultation includes what you are specifically
concerned about, why you are concerned,
relevant findings on examination or diagnostic
studies, testing and treatment that has been
done to date, and your expected time frame for
the consultation.
Communicating with Consultants
•
•
•
•
An analysis of inter-physician communications in consultations found that physicians
commonly requested consultations to get advice on diagnosis (56%), advice on
management (37%), or assistance in arranging or performing a procedure or test
(20%).
The requesting physician and the consultant completely disagreed on both the reason
for the consultation and the principal clinical issue in 22 (14%) of 156 consultations.
Consultations that were initiated with a clear and concise clinical question were more
likely to be valued by both the requesting and consulting physician.
Breakdowns in communication were not uncommon in the consultation process and
may adversely affect patient care, cost effectiveness, and education.
Maria Hernandez cont …
• You call the orthopedic surgeon back and explain the key
aspects of Mrs. Hernandez's history and that you are
specifically worried about a septic joint.
• Your consultation question is: “I have a patient with a
history of a right total knee replacement with a titanium
implant 1 year ago who presents with pneumonia, fever,
and a painful, swollen prosthetic knee. I am worried about
septic arthritis. Can you evaluate her urgently to help us
rule this out?”
• The orthopedic surgeon agrees to come by in an hour and
evaluate the patient and you want to do everything you can
to improve the patient's care coordination.
Question #6
Which of the following things do you tell Mrs. Hernandez to prepare her for the consultation?
A.
“A specialist is going to come by to take some fluid out of the knee with a needle to check for
infection. You will also get an MRI of your knee.”
B.
“I want to be sure your knee is not infected so I have asked a specialist to come by to take a look at
your knee. He will discuss his recommendations with me directly after he sees you. He may need to
put a small needle in your knee and extract some fluid to look for infection and may order an x-ray or
other imaging studies.”
C.
“I am not sure why your knee is sore, so I asked a specialist to come by and examine you.”
D.
The patient does not need to be informed of the consultation.
Question #6 - Answer
Which of the following things do you tell Mrs. Hernandez to prepare her for the
consultation?
A.
“A specialist is going to come by to take some fluid out of the knee with a needle to check for
infection. You will also get an MRI of your knee.”
B.
“I want to be sure your knee is not infected so I have asked a specialist to come by to take a look at
your knee. He will discuss his recommendations with me directly after he sees you. He may need to
put a small needle in your knee and extract some fluid to look for infection and may order an x-ray
or other imaging studies.”
C.
“I am not sure why your knee is sore, so I asked a specialist to come by and examine you.”
D.
The patient does not need to be informed of the consultation.
Question #6 Key Points
• Setting patient expectations for consultations and
referrals includes:
• Explaining your reason for requesting the consultation
• Estimating the time frame
• Reassuring the patient that you will communicate
directly with the consultant
• Discussing the possibility of further testing.
Discussing Consults with Patients
A discussion with a patient regarding a planned consultation or referral
should include the following:
1.
2.
3.
4.
Clearly explain the reason for the consultation or referral.
Estimate the time frame of when the consultation will take place.
Reassure the patient that you will be in direct communication with
the consultant and will include the patient/family in any major
decisions that need to be made.
Provide a list of potential tests the specialist might order,
emphasizing that they may not order any additional tests and may
just provide a clinical evaluation.
Richard Hanson
68-year-old man admitted for a recent exacerbation of
systolic heart failure.
• He has been diuresed aggressively and has new acute
kidney injury.
• His urine output is good but his serum creatinine
concentration has doubled. The nurse tells you his postvoid residual volume is minimal.
• You would like to request a nephrology consultation
because you are worried that Mr. Hanson may need
dialysis.
Question 7
Before calling the nephrologist to see Mr. Hanson, you make sure your
patient has an appropriate workup.
Which of the following represents the essential tests that should be
performed prior to nephrology consultation in this case?
A. ANCA serology testing and venous mapping for
hemodialysis access
B. Complete metabolic profile and stone protocol CT scan
C. Urinalysis and basic metabolic profile, including blood
urea nitrogen and creatinine
D. Urine eosinophils and renal ultrasonography
Question 7 - Answer
Before calling the nephrologist to see Mr. Hanson, you make sure your
patient has an appropriate workup.
Which of the following represents the essential tests that should be
performed prior to nephrology consultation in this case?
A. ANCA serology testing and venous mapping for
hemodialysis access
B. Complete metabolic profile and stone protocol CT scan
C. Urinalysis and basic metabolic profile, including blood urea
nitrogen and creatinine
D. Urine eosinophils and renal ultrasonography
Question #7 Key Points
• Limit pre-consultation and referral testing to basic, essential
investigations.
• Use your initial conversation with the consultant to drive any additional
testing.
• Subspecialty consultations and referrals are a huge driver of waste within
our current healthcare system. The numerous unnecessary consultations
and referrals may be driven by patient requests or fear of malpractice
lawsuits or missing something.
• Much of the waste occurs prior to the consultation, when the attending
physician of record orders every test he or she can think of so that
consultants have as much information as possible to make their
recommendations.
Richard Hanson cont…
The nephrologist comes to see Mr. Hanson and tells you to withhold the
diuresis for a couple of days and to follow the patient's kidney function,
serum electrolytes, and urine output carefully.
He also recommends that you order several additional tests to be sure
every possible cause of this patient's kidney failure has been ruled out:
• Antinuclear antibodies (ANA), anti–double-stranded DNA, complement
levels (C3 and C4),
• HIV, Hepatitis B and C serologies Rapid Plasma Reagin (RPR),
• ANCA, anti–glomerular basement membrane antibodies, cryoglobulin
levels, and a streptozyme test
Question 8
When you ask the nephrologist about these recommendations because you feel these diagnoses are
unlikely in Mr. Hanson, he agrees, but says that from a medico-legal standpoint, he feels obligated to order
these tests on every patient to protect himself from a lawsuit.
Which of the following should you take into account before adopting this strategy to limit malpractice
lawsuits?
A. Defensive medicine protects against lawsuits
B. Forty percent of malpractice claims do not involve medical errors
C. More testing results in fewer lawsuits
D. You are more likely to be sued for not ordering a test than for an adverse event that resulted from a test
you ordered
Question 8 - Answer
When you ask the nephrologist about these recommendations because you feel these diagnoses are
unlikely in Mr. Hanson, he agrees, but says that from a medico-legal standpoint, he feels obligated to order
these tests on every patient to protect himself from a lawsuit.
Which of the following should you take into account before adopting this strategy to limit malpractice
lawsuits?
A. Defensive medicine protects against lawsuits
B. Forty percent of malpractice claims do not involve medical errors
C. More testing results in fewer lawsuits
D. You are more likely to be sued for not ordering a test than for an adverse event that resulted from a test
you ordered
Question #8 Key Points
• Defensive medicine has never been proven to protect physicians
from lawsuits.
• Clear, patient-centered communication about potential benefits
and risks of an intervention coupled with documentation of these
discussions are more likely to protect physicians from malpractice
litigation.
• It is well documented that patients are not likely to sue physicians
they like and trust. This observation tends to hold true even when
patients have experienced considerable injury as a result of a
“medical mistake” or misjudgment.
Communication Deters Lawsuits!
• Studies exploring what prompts patients and families to file malpractice
lawsuits found a common theme of breakdown in physician-patient
relationships manifested by unsatisfactory communication.
• Common perceived communication problems include:
• Physicians would not listen, would not talk openly, delivered information poorly
• Perception physicians attempted to mislead them, did not warn them of long-term
problems,
• Physicians were not available
• Physicians devalued patient or family views or failed to understand the patient's
perspective.
Tips to Avoid Malpractice
1. Listen to your patients.
2. Carefully document decision making.
3. Discuss and document potential side effects
and risks of all tests and treatments.
4. Manage patient expectations.
Framework for High Value Care
1. Understand the benefits, harms, and relative costs of the
interventions that you are considering
2. Decrease or eliminate the use of interventions that provide no
benefits and/or may be harmful
3. Choose interventions and care settings that maximize benefits,
minimize harms, and reduce costs (using comparative-effectiveness
and cost-effectiveness data)
4. Customize a care plan with the patient that incorporates their
values and addresses their concerns
5. Identify system level opportunities to improve outcomes,
minimize harms, and reduce healthcare waste
The HVC Cases significantly impacted
physicians’ reported behavior
•
•
•
•
•
Increased frequency of discussing the risks and benefits of tests and treatments
with patients.
Increased frequency of discussing relative costs of tests and treatments with
patients when generating a plan.
Decreased frequency of ordering unnecessary tests and treatments because
they were requested by patients.
Increased frequency of offering patients alternatives to tests and treatments
that consider the risks, benefits, patient preference and costs.
Decreased frequency of ordering tests and treatments out of fear of
malpractice.
Confidence in One’s Ability to Communicate with
Patients as to Why Tests are Not Necessary
Impact on Motivation to Incorporate
Principles into Daily Practice
Patient Education Materials
• Partnerships with Consumer Reports and AHRQ- to provide
patient educational materials
• New ACP center for patient partnership and engagement,
materials on website as they are developed
• Consistent message between provider and patient
educational materials
• Resident Curriculum and Online Cases include patient
education materials you can start using now!
Expansion
• Beyond IM: adapt curriculum to other specialties
including Ob-gyn, surgery, pediatrics and family
medicine
• MedU Editorial Board to adapt on-line student cases
for Peds, FM, Radiology (led by Heather Harrell)
• Encourage GME programs to work together on
projects to improve outcomes and control costs
Future Challenges
•
•
•
•
•
Faculty development
Validated HVC assessment tools
Learning environment that “celebrates restraint”
Cross-departmental collaboration on high value care
New topics : end of life care, price transparency,
defensive medicine, and misaligned financial
incentives
In Summary: What can we do?
• Eliminate unnecessary tests and treatments and teach our
students and residents to do the same
• Individualize care by asking patients about their concerns,
incorporating their values into the care plan and managing
their expectations
• Use the FREE tools from the ACP and Choosing Wisely
Campaign http://hvc.acponline.org/index.html
References
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.
Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009.
Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012.
Adapted from Owens, D. Ann Intern Med. 2011;154:174-180.
Detsky ME, et al. JAMA. 2006; 296:1274-1283
Baras JD, Baker LC. Magnetic resonance imaging and low back pain care for Medicare patients. Health Aff (Millwood).
2009;28(6):w1133-40
Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med.
1983;74(1):106-12
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and
perceived medical need for investigations, referral, and prescribing in primary care: nested observational study. BMJ.
2004;328(7437):444.
Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role
and effect on outcome. Radiology. 2005;237(2):597-604