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 of 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 of 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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