Dec. 13, 2012

Disinvestment in 

Implementation Resear

what are we talking abo

Patsi Sinnott PT PhD MPH Patsi Sinnott, PT, PhD, MPH

Health Economics Resource Center
Outline

 High and Low Value Health Care  Waste  Investment and disinvestment Investment and disinvestment  The QUERI Program  QUERI disinvestment strategy (ie Resources  Challenges and next steps Challenges and next steps 
High Value Care 

 Effective  Cos

t-effective 

 Net benefits justify the costs Net benefits justify the costs
High Value Health Car

 Examples? 
Low Value Health Car

 Makes the patient worse  No benefit at same cost  Little benefit at same cost Little benefit at same cost  Some benefit but benefit small rel

cost 
Low Value Health Car

 Examples? 
Ove use

Waste 

 Definition: 

– U dn eruse – Overuse – Misuse 
Waste - Examples 

 Underuse  Overuse Misuse 
How 
QUERI Program

 to generate new knowledge about 

imp

lemen

t evid encebase

d researc

findin

gs in clinical 

practice, and to 

facilitate systematic, continuous 

implementation into routine clinicimplementation into routine clinic

practice in several specific disease 
QUERI Program

 Six steps (plus two foundational) 

– Step M: Develop Measures, Methods, and Da– Step C: Develop Clinical Evidence – Step 

1: 

S

e

lec

t Diseases/Conditi ons/P

atient Po

– Step 2: Identify Evidence-Based Guidelines/ 

Recommendations

– Step 3: Measure and Diagnose Quality/Perfor

Gaps 

– 

Step 

4: 

Imp

lement 

Improvement 

Programs 

– Step 5/6: Evaluate Improvement Programs 
QUERI Program Primar

QUERI Program Primar

Focused....

 Underuse 
Implementation/Investm

 Evidence-based treatments or serv Enhance use of guidelines  Identify gaps in care Identify gaps in care  Im

plement and evaluate im

provem

programs 
Disinvestment 

 Identify and eliminate waste  Identify and eliminate low-value c
Work with communities to wide use of best 

National Priorities Partner

Summary of NPP’s Proposed Goals and Measure Conc• Work with communities to promote wide use of best prac

rac

enable healthy living and well-being. • Promote the most effective prevention, treatment, and int

practices for the leading causes of mortality, starting with 

cardiovascular disease. 

• Ensure person- and f il d family-cent d ere care. 

• Make care safer. 

• P t ff ti i ti d di ti Promote effective communication and care coordination. 

• Make quality care affordable for people, families, employ

governments. 
- —

-

National Priorities PartnerNational Priorities Partner

PRIORITY Make care safer. Goals Reduce preventable hospital 

admissions and readmissions. 

Reduce the incidence of adverse healthcare-associated conditions. 

Reduinappcare. 

Illustrative Measuresi Illustrative Measuresi Hospital admissions for Hospital admissions for 

ambulato-ry-sensitive conditions, including congestive heart failure, diabetes, pediatric asthma28† All-cause readmission index*29 Medicare hospital 30-day readmis-sion rates30 

Hospital acquired conditions acquired conditions all-cause harm31 Hospital-acquired conditions: 32 - Adverse drug events - Catheter-associated urinary tract infections - Central line blood stream infections - Injuries from falls and immobility - Obstetrical adverse events 

Pressure ulcers Pressure ulcers 

- Surgical site infections - Venous thromboembolism - Ventilator-associated pneumonia 

AdultAdult

potenmediElect

compcomp

Cardpreopfor no

surgesurge

Imagwith n
†

National Priorities PartnerNational Priorities Partner

Make quality care affordable for people, families, employers, and Make quality care affordable for people, families, employers, and 

Goals Ensure affordable and acces-sible 

high-quality healthcare for people, 

families, employers, and 

governments governments. 

Reduce total national healthcare costs per capita by 5 percent and 

limit the increase in healthcare costs to no more than 1 percent costs to no more than 1 percent above the consumer price index, without compromising quality or access. 

Supporensure 

while r

Illustrative Measuresi Percentage of people under 65 with 

out-of-pock di l d i ket medical and premium 

expenses greater than 10 percent of income47† Percentage of households with-out 

an ad t b d t f dequate budget for 

healthcare48 Adults under 65 insured all year and not under-insured49 People unable to get or delayed getting needed medical care, dental care, prescription medications50† 

Access p roblems due to cost51†

Annual national and state h l h di health-care expenditures per 

capita52 Annual healthcare expenditures as a percentage of gross domestic and 

gross st t d t tate product53 Average annual percentage growth in national and state healthcare expenditures54 

Menu o

vari ti 

iatio

- Unwamedica- Inapp

serviceservice- Cesarwomen- Preve
suse

QUERI Next steps....

 Address areas of waste and low-v

– Overuse – Misuse 
Disinvestment strategy (i

 Review work to date (Resources) 
Resources

 http://www nice org uk/usingguidance/dono

http://www.nice.org.uk/usingguidance/donomendations/index.jsp 

 http://www.nehi bli.net/publications/30/how_m

e_studies_will_it_take 

 http://www.qualityforum.org/Setting_Priorit

nput_into_the_National_Quality_Strategy.as

 http://www.iom.edu/Global/Perspectives/20

hecklist.aspx 

 http://www.abimfoundation.org/Initiatives/C

Wisely.aspx Wisely.aspx 
–

Resources

 Choosing Wisely partners include: 

– American Academy of Allergy, Asthma & Immunology 

– American Academy of Family Physicians American Academy of Family Physicians – American College of Cardiology – American College of Physicians 

American College of Radiology American College of Radiology 

– American Gastroenterological Association – American Society of Clinical Oncology – American Society of N ephrology – American Society of Nuclear Cardiology – National Physicians Alliance 

http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx 
Resources

 Consumer Reports and the medical societies developed summaries of the lis

Consumer Reports and the medical societies developed summaries of the lis

– Allergy tests: When you need them and when you don’t (American Academ

Allergy and Immunology) 

– Bone-density tests: When you need them and when you don't (American Ac

Physicians)

– Chest X-rays before surgery: When you need them – and when you don’t (A

Radiology) 

– Chronic kidney disease: Making hard choices (American Society of Nephro– EKGs and exercise stress tests: When you need them for heart disease -- and 

(American Academy of Family Physicians) 

– Hard decisions about cancer: 5 tests and treatments to question (American S

Oncology) 

– How should you treat heartburn and GERD? (American Gastroenterological – When do you need an imaging test for a headache? (American College of Ra– When do you need antibiotics for sinusitis? (American Academy of Asthma

Immunology) 

– When do you need antibiotics for sinusitis? (American Academy of Family P– When do you need a Pap test? (American Academy of Family Physicians) – When do you need imaging tests for lower back pain? (American Academy 

Physicians) 
Disinvestment strategy (i

 Review work to date  Identify unwarranted variation in 
Disinvestment strategy (i

 Review work to date  Identify unwarranted variation in 

– Identify overuse Identify overuse – Identify misuse 
Challenges 

 Identify low value services and 

subgroups 

 Politics Politics  Unintended consequences?  Framework/theories for disinvestm
Where to start?

 HERC Website  http://vaww herc research va gov/

http://vaww.herc.research.va.gov/es/faq_a09.asp 
Questions
 

1. Qaseem, A., et al., Appropriate use of screening and diagnostic tests to foster highvalue, cost-conscious care. Ann Intern Med, 2012. 156(2): p. 147-9. 

2.	 Neumann, P.J., et al., Low-value services in value-based insurance design. Am J Manag 

Care, 2010. 16(4): p. 280-6. 

3.	 New England Healthcare Institute – How many more studies will it take: A collection of 

evidence that our healthcare system can do better. (1998-2006). 

http://www.nehi.net/publications/30/how_many_more_studies_will_it_take 

4.	 QUERI Implementation Guide, Part 1, Section 3: Methods Used in Translating Research 

Into Practice. [cited 2012 Dec. 13, 2012]; Available from: 

http://www.queri.research.va.gov/implementation/guide-part1.pdf. 

5.	 National Quality Forum, Input to the Secretary of Health and Human Services: Priorities 

for the National Quality Strategy, 2011, National Quality Forum: Washington, DC. 

http://www.qualityforum.org/Setting_Priorities/NPP/Input_into_the_National_Quality_Stra 

tegy.aspx 

6.	 Institute of Medicine. CEO Checklist for High-Value Health Care. 2012 [cited 2012 

12/13/2012]; Available from: 

http://www.iom.edu/Global/Perspectives/2012/CEOChecklist.aspx. 

6.	 Institute of Medicine. CEO Checklist for High-Value Health Care. 2012 [cited 2012 

12/13/2012]; Available from: 

http://www.iom.edu/Global/Perspectives/2012/CEOChecklist.aspx.