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Clinical Reasoning Utilizing a Cost-
Conscious Framework
Kim Tartaglia, MDMarch 2012
A Case-ED Presentation
O 60yo woman w/ DM2 (10yr) and RAO LUQ and L flank pain x3 daysO Subjective feversO Fatigue, L sharp chest pain and
productive cough x1 dayO Meds: Metformin, Prednisone, MTXO Fam Hx: Sister with lung cancerO h/o tobacco abuse, born in Central
America; lived in US x20y
Modified from MedEd Portal
ED ExamO VS: 36.2, 130, 40, 129/76, 92% on 2L NCO Gen: Agitated, tachypneicO Lungs: bibasilar crackles, nontender ribsO CV: tachy, nml S1/S2, no murmurs/rubsO Abd: diffusely tender in LUQO Ext: warm, well-perfused, no edema
Modified from MedEd Portal
What are you thinking?O Differential Diagnosis
O What is your PlanO To DiagnoseO To Treat
ResultsO Chem7: Na-129, Bicarb-18, Cr-1.4, AG-5O CBC: WBC: 13.9, Hb-14, Plt-252O CXR: Obscured L. hemidiaphragm, ill-
defined density in right mid-lung: atelectasis vs infxn
O EKG: Sinus tach, otw nml
O How would you modify differential diagnosis?
O Any other tests you want to order?
Modified from MedEd Portal
Other TestsO Would you order D-dimer?
O Sent twice in ED, elevated both timesO Any other labs or imaging?
O CT abd/pelvis: Multifocal pna, no other abnormality
O Fibrinogen sent twice, both nml
O Does diagnosis explain symptoms and labs?
O Are you worried about anything else?
Day 1 ICUO Chest CT w/o contrast
O Eval effusions/infiltrate. Result: pneumonia
O Later, Chest CT: PE protocolO Negative for PE.
O CT Imaging ChargesO $3200 (Abd/Pelvis), $2000 (non-contrast),
$2400 (PE study) = $7600O Benefits/Potential Harms of CTs
Modified from MedEd Portal
Day 2 ICU O S: Feels better although abd pain persistsO VS: T-38.9, P-113, 114/65, 92% on 3LO Pulm: Crackles L>R at basesO CV: Tachy, regular, no murmursO Neuro: alert/oriented, nonfocal
O Sputum gram stain: Many PMN and GNRO Does this change your diagnosis or make
you more comfortable?
Modified from MedEd Portal
Day 3 ICUO Develops hypotension, atrial fibrillation,
progressive resp failure, and acute kidney injury (Cr 1.6 from 1.1)
O Intubated and BAL shows H. fluO Started on levophed (NE) for
hypotension
O What’s the explanation? Ddx?O What role did CTs play in kidney injury?
Modified from MedEd Portal
Day 4-13 ICUO Slowly weaned off pressorsO Extubated and weaned off O2O Hb dropped to 8.2 (over 3 d) and
rec’d 2uPRBCs on day 6O Creatinine improved to nml by day 6O LFTs increased with hypotensive
episode on day 3, nml by day 12
Modified from MedEd Portal
Day 14-18 FloorO Off abx and O2O Discharged on day 18 to rehab.O Discharge diagnoses: resolving
pneumonia with sepsis, resolved shock liver, resolved acute kidney injury, severe deconditioning
O 12 days in rehab; discharged home on day 30.
Modified from MedEd Portal
Labs
O Chem7: checked 44 times in 30 daysO All values nml on day 14 when xferred to
floorO Checked 12 times before d/c on day 30O $274/test = $12,000
O Mg: Checked 34 times in 30 daysO Slightly elevated 9 times; no interventions O $52/test = $1768
O Phos: Checked 32 times in 27d (after AKI)O Slightly low twice; no interventionO $39/test = $1248
Modified from MedEd Portal
LabsO CBC: Checked 30 times in 30 days
O Rec’d blood on HD 6.O Hb 10.5-12 for next 24 daysO $119/test ($142 if diff) = $3570
O What are reasons for ordering a lab?O When should you check it regularly?O When could you stop?
Modified from MedEd Portal
Summary of Patient’s Labs
O Micro (Blood cx-8, urine cx-2, Sputum cx)….$ 2600
O CBC X 30……………………………………….$ 3570O Chem7 X 44……………………………………$12000O Mg X 34, Phos X 32……………………………$ 3016O Lactate X17……………………………………..$ 2635O Trop X14 (all nml)………………………………$ 628O LFTs X 5…………………………………………$ 1770 O D-dimer X2………………………………………$ 968O Total lab costs…………………………………..$27187
Modified from MedEd Portal
Summary of Hospital Costs
O Hospital Services for ICU (14d) and Floor (4d): $62,200
O Inpatient rehab services (12d): $19,680O Physician charges (38 visits): $16, 131O Total charge of 30-day stay approx
$148,000
O This patient had no health insurance
Modified from MedEd Portal, 2012 charges
Costs vs ChargesO Costs – What it costs the institutionO Charges – What the institution charges
a patient. Includes profit marginO Examples
O Blood cx: Cost-$65, Charge-$258O CT abd/pelvis: Cost-$405, Charge-$3900
(does not include professional fees to read study)
ObjectivesO Review the cost of healthcare in the USO Discuss a framework for evaluating the
value of an interventionO Address strategies for avoiding low-value
care
The Cost of HealthcareO Rising to unsustainable levelO In 2008, more than $2.2 trillion,
accounting for more than 16% of GDPO Major contributing factor to
approximately 50% of all bankruptcy filings in US
The Cost of Healthcare
O Physicians direct as much as 87% of all healthcare spending
O Care delivered in context of medical education is 20-60% higher than care in non-teaching environments.
O Physicians have poor knowledge regarding costs of medical care
How is the “Value” of an Intervention Defined
O In healthcare, value is the assessment of benefit of an intervention relative to expenditures.
O High cost interventions may be a good value if highly beneficial.
O Interventions with minimal to no health benefit are low-value, regardless of cost. (ex: routine imaging in low back pain.)
O 30% of medical decisions in US are of no value to patients
Avoiding Low-Value Care
O Do not order a test if results do not change management (ex. CXR 4wks after pna)
O If pretest probability of dz is low, likelihood of false-positive test is higher than true-positiveO False-positives lead to additional tests that
add cost, may introduce harm, and may lead to inappropriate treatment
O True cost of test includes downstream costs of additional testing, treatment, and follow-up
ACP’s Wasteful TestsO Ad hoc workgroup, convened 2011 to
identify overused screening and diagnostic tests.
O Members collected suggestions of low-value care and required unanimous agreement among workgroup members
O 37 situations/tests identified
Clinical Situations in Which a Test Does Not Reflect High-Value Care.
Qaseem A et al. Ann Intern Med 2012;156:147-149©2012 by American College of Physicians
ACP Wasteful Tests-Hospital
O Echo in asymptomatic patients w/ innocent-sounding heart murmurs (grade I-II/VI short, systolic, murmurs at LLSB)
O ECG to screen for cardiac disease in patients with low to average risk
O Measuring BNP in initial evaluation of patients with typical findings of heart failure
ACP Wasteful Tests-Hospital
O Brain imaging (CT or MRI) in patients with syncope who have normal neuro exams
O Routine echo in evaluation of syncope, unless the history, exam, & ECG do not provide an explanation
O Pre-discharge CXR for patients with pneumonia who are making satisfactory clinical recovery
O Chest CT for pneumonia confirmed by CXR in absence of complicating features
ACP Wasteful Tests-Hospital
O Performing imaging, rather than D-dimer, as initial test for pts w/ low probability of VTE
O Measuring D-dimer, rather than appropriate diagnostic imaging, in patients with intermediate or high probability of VTE
O Routine preoperative CXR
Cost-effectiveness
O Interventions of no benefit are of no value and therefore are NOT cost-effective
O But what about interventions that are beneficial? O How do you determine if they are cost-
effective?
Evaluating Beneficial Interventions
O Requires cost-effectiveness analysis (ie. quantitative assessment of benefit and cost)
O Cost-effectiveness ≠ RationingO Definition of Rationing: Restricting
interventions regardless of benefitO Cost-effectiveness analysis can help
AVOID rationing
Incremental Cost-effectiveness Ratio
O Def: Difference in costs divided by difference in health benefit when 2 strategies are compared
OCE ratio = Costnew strategy – Costcurrent practice
Effectnew strategy – Effectcurrent practice
Incremental Cost-effectiveness Ratio
O Health benefit measured by quality-adjusted life-years (QALYs) gained
O Cost effectiveness ratio expressed in dollars per life-year gained.
O Lower ratios imply better cost-effectivenessO Used by decision-makers to determine
whether and how a new intervention should be used
Utilizing Cost-effectiveness Ratios
O Compare CER with well-accepted medical practice using league-table
O Interventions with CER <$100,000 per QALY gained is generally acceptable in US
O WHO: O Interventions <3 times GDP per capita are cost-
effectiveO Those <GDP per capita ($48K in US) are “very
cost-effective”O Historical standard: Hemodialysis (incremental
CER of $60-128K per QALY gained)
Examples
O MADIT: randomized controlled study of asx pts at high risk for sudden cardiac death
O AICD pts with significant reductions in all-cause, cardiac, and arrythmic deaths
O ICD group: Avg survival 3.46yrs, cost $97, 560
O Conventional group: Avg survival 2.66yrs, cost $75,980
O Incremental CER: $27,000 per life-yr saved
SummaryO We (Physicians) direct the vast
majority of healthcare spendingO Low-value tests are NEVER cost-
effectiveO Cost of “routine labs” adds up
quicklyO Beneficial tests require quantitative
analysis to determine if they are cost-effective (<$100K/QALY gained)
