Cost-Effective Care Strategies in
Emergency Medicine
February 18, 2014
Cost-Effective Care Strategies
in Emergency Medicine
Myles Riner, MD
Prentice Tom, MD
Objectives
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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
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Cost-effective Care Task Force
Membership survey
Reconsideration of CW Campaign Participation
Delphi Panel
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Concerns about Choosing Wisely
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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
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Do not do CT of the head in adult patients with syncope, insignificant trauma and a normal neurological
evaluation.
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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.
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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).
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Do not admit low risk patients after appropriate troponin testing, and ECGs, are negative).
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Do not prescribe antibiotics for uncomplicated sinusitis.
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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.
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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
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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
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Pros
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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
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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
Alignment
Selection
Buy-in
Tools
Monitoring
Incentives
Mentoring and Feedback
Closing the Loop
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Tools
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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
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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
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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
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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
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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 decisionmaking
• CEC can even reduce malpractice risk by improving ED
efficiency
• CEC can change, and improve, perceptions of ED care
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