As the value of care has become a growing concern of payers and administrators, it's also become a larger focus of attention at medical conferences, including Hospital Medicine 2017, the annual meeting of the Society of Hospital Medicine.
The conference, held in Las Vegas in May, featured numerous speakers offering advice on providing high-value care, from how to talk about the concept with patients to which tests and screens to give and which drugs to stop.
Talking about value
When it comes to their own care, getting patients to join the high-value movement is tricky, but not impossible, according to Emily Gottenborg, MD.
With a few tips and tricks, “You can have these conversations about high-value care with your patients effectively and feel better about it,” said Dr. Gottenborg, an assistant professor of medicine at the University of Colorado in Denver.
The process starts with sitting down with the patient and family and accepting that it will take some extra time to explain why you're not recommending a low-value test or treatment, she said.
On the bright side, the conversation might go more smoothly than you expect. “When they ask us questions—’Why can't I have that CT?’ ‘When can I get those antibiotics?’—we make the assumption that they want them and are demanding them from us. But actually they might not be,” said Dr. Gottenborg. “We're not good at predicting this, so let's not make those assumptions as we're sitting down to embark on these conversations.”
Here's another thing not to do: “Don't tell her that a head CT would be a waste of money. She does not want to hear that,” Dr. Gottenborg said. Instead, explain the potential harms to the patient from low-value care, whether it's radiation from a CT scan or Clostridium difficile from antibiotics.
Patients and families may respond with more questions. “‘But, really, doc, what is the downside of testing? Why can't I just get that CT? It would make me feel so much better,’” said Dr. Gottenborg. “Here's where you need to have your anecdotes ready. We've all had the CT or the head imaging that shows the incidentaloma that leads us down a rabbit hole of unnecessary further testing, anxiety, and stress for the patient.”
If you don't have your own anecdote appropriate to the situation, consider borrowing someone else's. Dr. Gottenborg recommended the JAMA series “A Teachable Moment” as a source. “Trainees from the front lines are writing these stories of harm that happens when you do low-value care,” she said.
Some patient-centered written materials are also available to help with discussions about high-value care. Dr. Gottenborg recommended pamphlets developed by the Choosing Wisely campaign and Consumer Reports that explain issues like overtreatment of urinary tract infections in the elderly.
“It's clearly labeled ‘Consumer Reports' so patients know it's for them, it's not coming from us as a way to change their behavior. It gives them quick tips that they can tuck away,” she said.
The benefits of these pamphlets were proven in a study that distributed them to patients filling benzodiazepine prescriptions, she reported. The pamphlet warned of the drugs' risks and offered advice on de-escalating. A third of the patients discontinued or reduced their use of the drug.
Physicians can also provide resources to help patients deal with the cost of health care. The solutions may be websites, such as Healthcare Blue Book and GoodRx, or other health care professionals, such as social workers.
“If you can integrate this into your daily language of every patient encounter—’What's it like paying for your health care? Have you had any trouble paying for those copays? Are you worried about the cost of this hospitalization?’—you might get some answers that you don't expect,” she said.
Of course, all of this conversation takes time, for which clinicians are currently not paid, Dr. Gottenborg noted. “In the future, I do hope and expect that we will have innovative reimbursement models that will help support value-based care conversations and practicing high-value care,” she concluded.
There's a definitive resource for determining what imaging test will provide the highest-value care, according to Timothy P. Kasprzak, MD, MBA, director of abdominopelvic and oncologic imaging at Case Western MetroHealth in Cleveland.
It's the American College of Radiology (ACR) appropriateness criteria, which give clinical scenarios and evidence on which scan will be most effective. “There are some studies that are better for certain things than others. Computed tomography may be really good to look at things like free air, but it's really bad at looking at hepatobiliary, it's really bad at looking at prostate,” Dr. Kasprzak said. “You're getting all the evidence of why the committee came up with this recommendation.”
If that sounds like too much work, there's another option. “If you're not going to dig into the appropriateness criteria, ask a radiologist,” said Dr. Kasprzak. “If you have a complex case … you're not quite sure what studies would be the best, just ask a radiologist.”
Routinely sharing case details with the radiologist can improve the clarity of imaging results. “I've actually seen ‘rule out pain’ as a history,” he said. “It's OK if you're fishing, that's all right, but just kind of own it and say that: ‘I don't know what's going on. Vague nonspecific abdominal pain.’”
Selection of an imaging test also often involves decisions about contrast. Contrast adds some risks to both CT and MRI, but it is also often necessary for the interpretation of images, explained Dr. Kasprzak. “Each contrast medium administration should be considered a risk-benefit analysis,” he said. “When possible, when the ACR appropriateness criteria advocates for it, let's use contrast.”
In addition to the potential for accurate diagnosis, use of the criteria is about to be financially encouraged. “CMS has established guidelines about appropriate use criteria,” he said. “What'll be happening in the future is there will be a software program superimposed on your [electronic medical record] and basically if you go to order a foot MRI to exclude [pulmonary embolism], the software is going to say, ‘No, you can't do that.’”
That “no” will either be a hard stop, which absolutely prevents the ordering of the test, or a soft stop, which can be overridden with a justification, but the involvement of CMS will make it difficult to order any test that isn't judged appropriate, predicted Dr. Kasprzak. “The hospital is not going to get paid, so they're not going to allow you to order these studies,” he said.
That's only the first step in computers guiding radiology practice, Dr. Kasprzak predicted. “On the diagnostic end, artificial intelligence or big data is going to make a big impact when it comes to pattern recognition,” he said. “I think the role of radiologist will go back to what I envision it should be, which is truly a consultant. I may be rounding with you or doing studies with you, doing things in a very different way than you're used to having a radiologist interact.”
Physicians don't have to wait for artificial intelligence to make their geriatric care higher value. Existing data have revealed a number of common clinical practices that may offer no benefit to acutely ill older patients, according to Melissa L. Mattison, MD, FACP, chief of the hospital medicine unit at Massachusetts General Hospital in Boston.
Take, for example, the prescription of antipsychotics for delirium. For a meta-analysis published in the April 2016 Journal of the American Geriatrics Society, researchers reviewed 19 studies on the use of antipsychotics for prevention and treatment of delirium and found that the drugs had no significant effects on preventing delirium and did not decrease the duration or severity of delirium, mortality, or length of stay in the hospital or ICU.
“What they found was striking … since we use this class of medications regularly to treat patients with delirium,” said Dr. Mattison.
Another study, published in the August 2016 Journal of Hospital Medicine, retrospectively followed about 260 older patients given antipsychotics during a hospitalization with no psychiatric indication. A year later, 41% had been readmitted at least once and 29% had died. “The 41% who were readmitted: Two-thirds of those patients were still taking the antipsychotic they had been started on during their hospitalization,” Dr. Mattison noted. “I sure as heck hope they weren't still delirious up to a year later.”
There were some particular markers of risk: The odds ratio of death was 2.28 for those discharged to a postacute care facility and 3.41 for those with baseline QT prolongation, she noted.
Instead of using antipsychotics to try to treat the symptoms of delirium, identify and treat the cause, Dr. Mattison advised. “Essentially, antipsychotics are chemical restraints,” she said. “They're not the answer for delirium, they're not the answer for dementia, and I would say you should really only use them when you're absolutely pushed to do so for patient safety or comfort.”
In addition to avoiding new drugs, internists can also help elderly patients by de-prescribing certain drugs, that is, tapering or discontinuing them to minimize the risk of adverse drug events. Docusate is one example. An August 2016 editorial in JAMA Internal Medicine noted significant evidence of its ineffectiveness. “And yet, when they looked at this, 64% of laxatives prescribed were docusate,” Dr. Mattison said.
The authors considered the costs, both to patients and to the health care system, associated with docusate. “They actually talk about how disgusting liquid docusate is, evidently. I thankfully have never tasted it, and now that I know it doesn't work, I don't think I ever will,” Dr. Mattison said. “They basically say we're flushing hundreds of millions of dollars per year down the toilet, and we are delaying more effective interventions to relieve constipation.”
An entire class to target for de-prescribing is proton-pump inhibitors (PPIs). “PPIs are associated with increased risk of [Clostridium difficile] infection, especially when used in conjunction with fluoroquinolones,” said Dr. Mattison. She added that a useful Canadian website provides evidence-based algorithms for de-prescribing PPIs, benzodiazepines, antipsychotics, and antihyperglycemic agents.
Another resource she recommended to help clinicians treat elderly patients and better target interventions is the Clinical Frailty Scale. It scores patients from 1 to 9 and has been shown to be a valuable tool in assessing and addressing frailty, Dr. Mattison noted. “If you're a 1, you're very fit, you're robust, you're energetic,” she said. “If you're a 9, you're terminally ill.”
In a study published in the June 2016 BMC Geriatrics, researchers found that residents could reliably use the tool to predict patients' functional decline and mortality. Another study, published in the June 2016 Canadian Geriatrics Journal, showed that scores correlated with length of stay on an acute medicine unit.
Researchers divided patients into three groups based on score: 1 to 4 (non-frail, n=21), 5 to 6 (moderately frail, n=38), and 7 to 9 (severely frail, n=64). They found that length of stay was 4.1 days for non-frail patients but jumped to 11.2 and 12.6 days, respectively, for moderately and severely frail patients.
“When we know what our patients' Clinical Frailty Scale score is when they walk in the door or roll in the door, we can help target therapies to the highest-risk patients and certainly consider advance directive discussions,” said Dr. Mattison.
The frailest patients may benefit from palliative care consultations, according to a study published in the September 2016 Journal of the American Geriatrics Society that found reduced use of acute care services with targeted consults of nursing home patients.
“Now, I know most of us don't set foot in nursing homes, but when we get a patient [who is] severely frail … you know he's got limited improvement that's even possible,” said Dr. Mattison. If palliative care and advance directives for future hospitalizations cannot be discussed during the admission, she said, “It may be worth mentioning to your colleague on that transition, either [when] discharging someone or maybe just picking up the phone.”