A Systemic Approach to Containing Health Care Spending

Emanuel, Ezekiel J.; Tanden, Neera; Altman, Stuart H.; Armstrong, Scott; Berwick, Donald M.; Brantes, François de; Calsyn, Maura; Chernew, Michael E.; Colmers, John M.; Cutler, David M.; Daschle, Tom; Egerman, Paul; Kocher, B; Milstein, Arnold; Lee, Emily Oshima; Podesta, John D.; Reinhardt, Uwe E.; Rosenthal, Meredith B.; Sharfstein, Joshua; Shortell, Stephen M.; Stern, Andrew; Orszag, Peter R.; Spiro, Topher

doi:10.1056/nejmsb1205901

Cited by 161 publications

(77 citation statements)

References 13 publications

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“…Defensive medicine due to perceived medicolegal liability is widespread 17,45 and has been linked with higher imaging use and health care costs. 16,17,[45][46][47][48] While some have advocated that tort reform should be central to policies aimed at reducing excessive medical spending, 45,49 studies evaluating the effect of actual reform efforts have demonstrated a limited effect on cost reduction and physician behavior. 46,[49][50][51][52][53][54] However, given the high malpractice concern among physicians in our sample and others, 17,45,51 we believe that although tort reform would not be sufficient to eliminate overuse, 54 it may be a necessary initial step.…”

Section: Discussionmentioning

confidence: 99%

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Kanzaria

Hoffman

Probst

et al. 2015

Academic Emergency Medicine

175

146

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Objectives: The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.Methods: As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.Results: In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Conclusions:Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.ACADEMIC EMERGENCY MEDICINE 2015;22:390-398

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Section: Discussionmentioning

confidence: 99%

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Kanzaria

Hoffman

Probst

et al. 2015

Academic Emergency Medicine

175

146

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“…16,19,28 This is not a new concept. Around 100 years ago, Harvey Cushing, one of the pioneers of neurosurgery, thoroughly documented his patients' complications.…”

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confidence: 99%

Predicting functional impairment in brain tumor surgery: the Big Five and the Milan Complexity Scale

Ferroli¹,

Broggi²,

Schiavolin³

et al. 2015

FOC

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OBJECT The Milan Complexity Scale—a new practical grading scale designed to estimate the risk of neurological clinical worsening after performing surgery for tumor removal—is presented. METHODS A retrospective study was conducted on all elective consecutive surgical procedures for tumor resection between January 2012 and December 2014 at the Second Division of Neurosurgery at Fondazione IRCCS Istituto Neurologico Carlo Besta of Milan. A prospective database dedicated to reporting complications and all clinical and radiological data was retrospectively reviewed. The Karnofsky Performance Scale (KPS) was used to classify each patient’s health status. Complications were divided into major and minor and recorded based on etiology and required treatment. A logistic regression model was used to identify possible predictors of clinical worsening after surgery in terms of changes between the preoperative and discharge KPS scores. Statistically significant predictors were rated based on their odds ratios in order to build an ad hoc complexity scale. For each patient, a corresponding total score was calculated, and ANOVA was performed to compare the mean total scores between the improved/unchanged and worsened patients. Relative risk (RR) and chi-square statistics were employed to provide the risk of worsening after surgery for each total score. RESULTS The case series was composed of 746 patients (53.2% female; mean age 51.3 ± 17.1). The most common tumors were meningiomas (28.6%) and glioblastomas (24.1%). The mortality rate was 0.94%, the major complication rate was 9.1%, and the minor complication rate was 32.6%. Of 746 patients, 523 (70.1%) patients improved or remained unchanged, and 223 (29.9%) patients worsened. The following factors were found to be statistically significant predictors of the change in KPS scores: tumor size larger than 4 cm, cranial nerve manipulation, major brain vessel manipulation, posterior fossa location, and eloquent area involvement (Nagelkerke R2 = 0.286). A grading scale was obtained with scores ranging between 0 and 8. Worsened patients showed mean total scores that were significantly higher than the improved/unchanged scores (3.24 ± 1.55 vs 1.47 ± 1.58; p < 0.001). Finally, a grid was developed to show the risk of worsening after surgery for each total score: scores higher than 3 are suggestive of worse clinical outcome. CONCLUSIONS Through the evaluation of the 5 aforementioned parameters—the Big Five—the Milan Complexity Scale enables neurosurgeons to estimate the risk of a negative clinical course after brain tumor surgery and share these data with the patient. Furthermore, the Milan Complexity Scale could be used for research and educational purposes and better health system management.

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“…Nevertheless, only clinicians and their professional organisations can enact the above set of interdependent strategies for improving value, because ultimately value is determined by how medicine is practiced. Although system-level remedies for cost containment proposed by organisational analysts are not without merit, 102 clinicians must lead efforts to maximise high-value care. If they fail to do so, then looming insolvency of the healthcare system amidst grid-locked professional self-interest and conservatism may cause governments to consider severe cost-cutting measures, rationing of services, cumbersome remuneration formulas and major limits to professional autonomy that could inflict serious harm on the populations they serve.…”

Section: Resultsmentioning

confidence: 99%

Ten clinician-driven strategies for maximising value of Australian health care

Scott¹

2014

Aust. Health Review

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Objective. To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable.Methods. Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy.Results. Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low-or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings.Conclusions. Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia.What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low-to highvalue care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.

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A Systemic Approach to Containing Health Care Spending

Cited by 161 publications

References 13 publications

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Predicting functional impairment in brain tumor surgery: the Big Five and the Milan Complexity Scale

Ten clinician-driven strategies for maximising value of Australian health care

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