Sustainability of CV Care Todd Anderson Mar 2017 Disclosures - PowerPoint PPT Presentation

Sustainability of CV Care Todd Anderson Mar 2017

Disclosures • Todd Anderson – Dept Head and Institute Director

Quality Dimensions

US Burden of CV disease Mozaffarian Circ 2015;131:e29-

Canadian Burden of CV disease • About 2 million people have CVD or stroke • About 16 % of total health care costs • About 15% of admissions to hospital • $25 billion dollars with about $8B in direct costs • 2 nd only to MSK • 10% of all out-patient visits – 40 million • 75 million Rx for CVD drugs • By 2030 80% of provincial budgets will be needed for health care • CHF costs almost $3B • 2% of population living with CHF PHAC

Sustainable? Clinical Area Inpatient Costs ED + UC Physician Services Total Addictions and Mental Health $194,898,187 $11,499,681 $219,134,001 $425,531,869 Bone and Joint $149,284,168 $21,615,954 $161,930,594 $332,830,715 Cancer $116,225,723 $9,655,216 $68,344,711 $194,225,649 Cardiac and Stroke $202,145,065 $21,811,328 $149,068,838 $373,025,231 Diabetes Nutrition Obesity $37,766,695 $2,559,936 $63,247,102 $103,573,733 Seniors Health TBD TBD TBD TBD Alberta Health

Sustainable? 34.2 M people 23.4M people 1975 to 2010 • Expenditure increases = 3.5 fold • Population increases = 1.5 fold CIHI website

Mozaffarian Circ 2015;131:e29-

The Burning Platform 10

Current State • Total budget for AHS $14.3 billion, 2.6% increase from last year

“The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.” IOM, Crossing the Quality Chasm: A new Health System for the 21 st Century 2001

Cost Drivers • Driver

Models to Explore

• Embed quality literacy • Transform culture • Empower local improvement and innovation • Optimize processes

The Intermountain Healthcare Way • Apply the rigorous measurement tools developed for clinical research to routinely measure clinical variation in routine care performance • Examine quality, utilization and efficiency • Learning Approach ; not a judgmental approach • Focus on the process ; not on the persons

Intermountain Health care approach to protocols • Build evidence-based best practice protocols results (memory-based medicine gets it right 50% of the time!) • Incorporate them into clinical workflow • Embed data systems to track protocol variations and short- and long- term • Demand that clinicians vary care based upon patient need • Feed the data back in a “ Learning Loop ” • Consistently update and improve protocols

Unwarranted/Unexplained CPV

Distribution of Ontario hospitals by ratio of PCI:CABG procedures Tu, J et al. CMAJ 2012. DOI:10.1503/cmaj.111072

www.consumerhealthchoices.org

How else can we “Choose Wisely”?

Reduce Lab Costs Test Cost CBC $7.00 Chemistry Panel 7 $35.00 Liver Panel $33.00 PT/PTT $16.00 Troponin T $15.00 D-Dimer $44.00 Venous Blood Gases $40.00 Type and Screen $36.00 ESR $6.00 CRP $6.00 Urinalysis $5.00 Urine Culture $10.00 Blood Culture $32.00 Plasma Lactate $5.00

Reduce Lab Costs • Reduce Unnecessary Labs – Daily Labs? $40/pt/day x 70 pts x 365 days =>$1 million http://www.choosingwiselycanada.org/recommendations/internal-medicine/

Reduce Lab Costs How much does an ECG cost? – $30

DI Cost per Service % Census % Cost Hospitalist Hospitalist IM IM Gen Surg Gen Surg Ortho Ortho Neuro Neuro Other Other

Cardiac Imaging • Huge costs • Tests often repeated or multiple tests done • Try to do less invasive, lower cost tests • Access to out-patient cardiac imaging is readily available

Length of Stay • Focus on standardized admissions • STEMI and CHF pathways • Expand the number of same day discharges • Use team approach to expedite discharges – NPs and pharmacy

Out-patient • Long wait times generates costs • Annual visits and testing is not cost effective • Tele-health could replace face to face visits • Clinics with allied health professionals • Prevention is cost effective with high ROI

Innovation • Always will be newer, better and more expensive technology • Need to eliminate tests and interventions of lower value to allow for growth in other areas – TAVI – New drugs – Advanced imaging

Summary • Start asking/thinking about how much things cost • Educate colleagues • Opportunities: – Order Sets – Unnecessary/Redundant Exams – Supply Carts • Best approach is a blend of Appropriateness Guidelines and awareness of Fiscal Responsibility

What is the Future State? • Priority must be on quality and not cost • Quality is a balance of competing factors • Appropriateness is the responsibility of all • Standardized pathways decrease practice variation and waste • Choosing Wisely must become part of the culture • Costing knowledge needs to start during training • Innovation is a reality and also needs to be embraced