**Transcript of Cyberseminar**

**QUERI Implementation Research**

**Disinvestment in Implementation Research. What are we talking about?**

**Presenter: Patsi Sinnott, PT, PhD, MPH**

**December 13, 2012**

**Disinvestment in Implementation Research. What are we talking about?**

**December 13, 2012**

Molly:Once again I would like to welcome you to today’s QUERI Implementation Research Seminar. The topic is disinvestment in implementation research. What are we talking about? We will begin the presentation. Actually, we are at the top of the hour, so we will go ahead and get started. I would like to introduce our speaker for today. We have Dr. Patsi Sinnott, and she is a health economist at the Health Economics Resource Center in VA Palo Alto Health Care System. So at this time I would like to turn it over. Patsi, are you ready to share your screen? 

Patsi:Sure.

Molly:Excellent. You will see a popup that says “show my screen,” just click on that. 

Patsi:Good morning or afternoon depending on where you are. This is Patsi, and we are going to talk today about implementation research and the correlates to investment, which is getting people to do what they are supposed to do in implementation research. The alternative is to get people to stop doing what they should not be doing in implementation research. So I would like you to think for a minute about coming to the decision that your car is not what it used to be and, in fact, maybe it is costing you more to provide...to continue to operate it than it might cost you to buy a new car. That is really what we are talking about here in a general or global sense. It is figuring out when to stop using something and training people to stop doing it. 

So we are going to talk today about what is considered high- and low-value healthcare, how to define waste and how to identify it and then investment and disinvestment, what the QUERI program has been to date and then to outline some disinvestment strategies and provide you with some resources for disinvestment and then to review some of the challenges and next steps. So high-value care is care that is effective and cost-effective...excuse me a second. And the net benefits justify the cost. So that means that whatever you have spent in trying to adopt it is worth the outcome. So I wonder if you can think of some examples of high-value care and put them in the question screen so that we can get some conversation as well as we can in this. And, Molly, if you can read them to me, that would be great. So for example, we might be talking about high-value care that is antiretroviral therapy for patients with HIV. Are there other examples of high-value care you can think of?

Molly:  None have come in yet, but I will remind—oh, Telehealth for rural veterans, one that has come in. So attendees, you can simply open the question section of your GoToWebinar dashboard and type in examples of high-value healthcare. And, Patsi, I will let you know. 

Patsi:I think this question of value is a challenge for all of us, which is why it is hard for people to come up with this...examples of high-value healthcare. We may also include implantable cardioverter defibrillator for patients who meet the clinical criteria and have a reasonable expectation of one-year survival, so that is a lot of caveats to the question of what is high value. So then...     

Molly:We have a few more responses that have come in. Would you like me to read those?

Patsi:Sure. 

Molly:Cardiac rehab post procedure, colorectal cancer screening, MST screening program, population-based outreach using EMRs and registries, and CABG surgery versus meds. 

Patsi:Well, those are all potentially examples of high-value care, and I am going to provide you with some examples and some resources to actually confirm those suggestions. So really the alternative is low-value healthcare, and as we would assume, it makes the patient worse or it has no benefits. Or it has little benefit at the same cost, or it has some benefit but the benefits are very small relative to the cost. So can you think of low-value healthcare services? And again, if you go to the answer panel...and if, Molly, you can read them out, that would be terrific. 

Molly:Happy to do so. So far we have low-value healthcare is most MRIs or prostate cancer screening. 

Patsi:Very good, um-hmm. Preoperative chest x-rays in asymptomatic healthy patients prior to surgery, annual Pap smears as compared to every three years. These are examples. So what I am going to show you here is a table that came from an article by Qaseem on the appropriate use of screening, and this is a long, long list of elements or tests and screenings that are used often but are low-value healthcare. So for example, imaging stress test, this is number eight as the initial diagnostic test in patients with known or suspected CAD who are able to exercise and have no resting electrocardiographic abnormalities, et cetera. Most of these in the first set are coronary or cardiac testing. Excuse me while I zoom down. Here is screening for cervical cancer in low risk women 65 and older. Number 20, performing imaging studies in patients with nonspecific low back pain. I apologize again because I am...so this is a list of 30 tests or screening devices, screening measures that are used that are considered low-value, in other words that the cost does not...the benefits do not warrant the cost. 

And then I am going to show you another list of low-value services in, this is called, value-based insurance design. You see on the right-hand side the cost-effectiveness ratios or the cost per QALY that have been estimated for these kinds of surgeries or procedures. And just as a reminder that, in general, if a QALY is gained at $50,000 or less, it is considered cost-effective, where you see all of these elements in this first table have a QALY cost greater than $100,000. And then if you go down to the bottom of the screen, the PET test in Alzheimer’s disease, you see it actually increases cost and results in a worse health outcome. And then down below on table two, these are technologies that have been rejected by the National Institute for Clinical Effectiveness in England, again, on the grounds of poor cost-effectiveness. And these are treatments that were rejected to be included or excluded from the treatment authorized by NICE or approved by NICE. So these are examples of low-value care that are out there that continue to be used. 

So then the next question is: What is waste? And waste is...I am sorry, we talked about low-value healthcare. And what is waste? Waste is healthcare that can be eliminated completely without reducing the quality of care. And for example, waste is underuse of services that should be used, so that the failure to use...underuse of something is failure to use it when using it would have produced a favorable outcome. Overuse is when the potential for harm outweighs the potential benefit, or the flat of the curve, and misuse is the third element of waste and that is when you use something and it causes harm. So can you think of examples of underuse, overuse, and misuse that we should be looking at as wasteful in healthcare today? And again, going to the...let us start with underuse, for example, inhaled corticosteroids for patients with asthma or use of generic antihypertensives. Are there other underuse elements that we should be thinking about? And this should be at the tip of everyone’s tongue. 

Molly:We have a few responses coming in. The MOVE Program is underused. Underused is, again, cardiac rehab for patients post cardiac procedure/cardiac events. And an example for overuse is opioids in chronic pain, waste and frankly dangerous. And CBT is underused. 

Patsi:Um-hmm. Any other overuse items? For example, overuse of antibiotics or going to the ED when the problem is not urgent. And misuse, other than using the wrong drug, can you think of other items of misuse? From my background, most familiarly, my experience is the operation on the wrong leg for a total hip replacement or a hip fracture or a knee surgery to repair a ligament or meniscus. I want to show you a table from the New England Institute of...I am sorry, the New England Healthcare Institute, and this is a table extracted from their resources at NEHI. And all of these links will be in the...at the end of the presentation. You see that what they have done on this first table is identified the kind of problem or waste that needs to be attended to on the left-hand side. Then they describe what kind of a procedure or visit or type of service, where it occurs or what it is, what system it involves, and what treatments it is supposed to treat. 

Molly:We have some more examples that have come in from the audience. 

Patsi:Okay. 

Molly:Misuse would be sending excessive consults for pain patients to get them out of primary care visits, and taking over-the-counter drugs while also taking prescription drugs.

Patsi:Right, right. So...exactly. So again, what we have here is a registry of articles that describe the evidence and how this might be reflective of overuse or underuse. And so this is a list. This first page is a list of all the articles the NEHI has accumulated or synthesized. This is the type and accounts of articles by service overuse by type of service and by diagnostic category. The count summary, the drugs and what kinds of problems there are. Imaging, again, is it overuse or underuse? Lab tests, visits. Over here...and you can see as I scroll along the bottom, here is the summary table gives us a count of all the conditions and variations, underuse and overuse totals. So this is a terrific resource for looking at the kinds of problems that have been identified as overuse, underuse, or waste. And then I want to show you another element...another resource that NEHI has produced, which gives you an idea of where these activities sit on the scale or the range of evidence and cost. 

So you can see, for example, the underuse of antihypertensives is cost saving. So if more people or the population was more completely treated with antihypertensives, it would be a cost savings in the billions of dollars. And this is not in VA but in the United States. The back-imaging overuse is a cost savings. Statin underuse is cost-effective but not cost-saving. And you understand that some things are cost-effective but they are not going to reduce costs. They are actually going to increase cost. And also the colon, cervical, and breast cancer screening underuse are cost-effective, but not cost-saving. This comes from a paper or a report called, *How Many More Studies Will It Take? A Collection of Evidence That Our Health Care System Can Do Better,*and this is a synthesis of the evidence, 1998 to 2006. So in the QUERI program we know that our goal here is to generate new knowledge, to implement evidence-based research in clinical practice—this is straight from the QUERI resource pages—and to facilitate systematic continuous implementation into routine practice. 

And so that means that we are familiar with the six steps in the QUERI program and the two foundational steps to develop measures in clinical evidence and then to go through the six steps to use guidelines, measure gaps, and then to identify quality improvement programs, implement them, and evaluate them. And so what we have here is an example from the QUERI resource page of the steps that they describe...that are described in the QUERI process and the kinds of measures and kinds of activities that are expected in the QUERI process. I am sorry, I am scrolling rather quickly, but I think mostly people are familiar with these resources. So if you think again about what the QUERI program is about, it is really about underuse. It is really about finding clinical evidence where there are gaps in care and to enhance the use of guidelines and to identify gaps and to implement and evaluate improvement programs. 

So generally, the QUERI program is focused on underuse services and treatments but not [inaudible] with regard to the cost or the cost-effectiveness of these things, although generally that is a background to the...adopting a clinical guideline but not always. So then this is about what investment is, which is enhancing underuse, and that is the core of implementation research so far. But this investment is about identifying and eliminating waste and identifying and eliminating low-value care. And I want to show you some examples of the kinds of things that are happening out there to identify and eliminate waste and low-value care. So this program, the National Priorities Partnership, is a partnership convened by NQF, the National Quality Forum, to provide input to the Secretary of Health and Human Services and to provide priorities for the National Quality Strategy. And you see that these are the primary goals for the National Priorities Partnership, which all make perfect sense, but most importantly, I want you to consider the goal to make care safer and to make it affordable for people, families, employers, and governments. 

And so as part of their strategy that has been proposed and, I believe, adopted by the Health and Human Services, is to take these goals and then to develop measures for measuring whether or not we are accomplishing this, we are making care safer, for example. And you can see across the top, the goals. This is an overuse factor. This is a misuse factor, in other words reducing the incidence of adverse healthcare-associated conditions, and this is an overuse problem. And so what we see here in the National Priorities Partnership are proposed measures of performance that can be used to make care safer. So for example, the adverse healthcare-associated conditions, you can see that catheter-associated UTIs, central line blood stream infections, all of these are quality performance measures currently in use. So the question then is, what is really going to be next? Here, again, are the affordability measures. And you see in particular over here, you have unwanted diagnostic procedures, inappropriate non-palliative services at the end of life, C-section among low-risk women, preventable ED visits. These are all potential measures of overuse and waste. For QUERI then, what do we do, and how do we go about addressing these areas of waste and low-value care? 

And I am proposing that we take on the following agenda. The first thing is to review the resources to date, and I have provided you with a couple of items. Here are resources for...many, many resources. This first one is the UK National Institute for Clinical Effectiveness. In the UK, all new technologies and new drugs are reviewed before they are approved for adoption. The NICE recommendations are not the only criteria on which new drugs and new treatments are adopted, but they are a key element of the adoption at a national level. The national—I am sorry, the New England Healthcare Initiative is the resource with the big table that I showed you. The National Quality Forum, National Priorities Partnership. And then there is another resource, and I am going to show you this. This is an Institute of Medicine report on...let me see if I can make this go up. You can see that Jonathan Perlin was involved. This is a CEO checklist for high-value healthcare. It is a resource for executives to develop value-based insurance design and self-insurance programs. Again, it provides a list of many of the elements that we have talked about before about high-value and low-value care, primarily to focus on taking care of the things that are easy targets for elimination or reduction in care. 

We also have a program here, Choosing Wisely. This is from the American Board of Internal Medicine, and this is a challenge from ABIM Foundation to several other associations to identify at least five items within their specialty areas to eliminate. So again, what I am talking about in terms of identifying things for QUERI, is to go back...to start here and see whether any of the items that have been identified so far are appropriate for a QUERI study for disinvestment. If we go here, here are the various partners in the Choosing Wisely program and for various specialty areas in VA to identify your appropriate contact or conditions and treatments that might be eliminated or considered wasteful. This would be a great place to start. This ABIM, or the American Board of Internal Medicine, and the other boards of medical societies have produced in collaboration with Consumer Reports various resources for patients and providers in various treatments. And again, this is a place to start as a resource to identifying things that should or could be eliminated. 

If we then look at the next step, we review the work to date, and then the best way to...let us say there is nothing out there that meets your QUERI center’s condition criteria, the way to see if there is something out there that warrants disinvestment is to look at unwanted variation in practice. And this really is using administrative observational and natural experiment data to identify where in particular geographically or by patient severity or by practice site or specialty care where is there unwanted variation? First, where is there variation in practice, and then trying to infer or generate hypotheses about why there is variation in practice. And in there, what you are looking at is overuse and misuse of care. You can also look at the comparative effectiveness work which is looking to evaluate interventions that provide little or no value or health gain over current practice, and finally, to go to expert panels to identify areas that might warrant evaluation for disinvestment. So there are obviously challenges here. The challenges, I am sure, are pretty straightforward. 

First of all, sometimes...or a lot of times it is difficult to identify the low-value services and the subgroups because a service that might benefit a particular subgroup may be harmful or wasteful for another subgroup. For example, Pap smears for younger people are wasteful for people over 75. There are a lot of politics about services and services provided. It is very difficult to discourage care for children, cancer patients, and people at end-of-life. There are strong clinical advocates for various treatments and treatment protocols. And in the...both in the VA and in the external non-VA world, there is an extensive product manufacturer network focused on enhancing the use of their products, so that is a challenge. There may be unintended consequences to disinvestment that need to be considered as you develop a disinvestment program. You all, I believe, are familiar with the evidence that changes in copays or tiering for medication or even for provider types in order to disincent low-value care can actually have changes...produce changes in treatment adherence, in adverse events, ED use, and hospital length of stay. 

And then increased screening or testing can generate increased utilization for otherwise benign conditions, so you have to take the potential for unintended consequences into consideration. And finally, the framework and theories for disinvestment are not known. We do not know if they are the same for implementation or adoption or if they are different, and that is an area that we really need to explore. So my recommendation is...the first place to start is at the HERC Website where we have a terrific resource. It is FAQ 9, which you can see here. This is about...the title is How to Identify Services that Are Not Cost-Effective. This provides links to many of the resources that I have highlighted today, and that should lead you then back into the other resources that are highlighted and linked into the presentation. So I am here for questions. Are there any questions? 

Molly:Excellent, thank you very much. For those of you that joined us after the top of the hour, to submit your questions, simply go to the questions section of your GoToWebinar dashboard and submit your question or comment there. We do have one question pending at this time: What is the basis of “cost savings”? Savings in the immediate health facility, quality-adjusted life years? 

Patsi:Well, cost savings is defined by what you define as your period. So is it cost saving in the short run? Is it cost saving in the long run? And when you talk about cost savings, you are not talking about changes in outcome. You are just talking about changes in cost, so it is not about quality-adjusted life years. It is just about cost. So you can have two treatments...let us say you have the usual treatment and a new treatment. The new treatment can be much more expensive in the short run and much more expensive in the long run, but it also, separately, could have no effect. Or it could be harmful. So when you talk about cost savings, you are only talking about the cost, and you have to provide the framework for the timeframe that you are talking about. 

Molly:Great. Thank you for that replay. The next question we have: What are your thoughts about where to start with the development or exploration of disinvestment frameworks?

Patsi:And I am assuming this is about theoretical models at the very end, and as I said, we do not know anything. And I would...I would start with looking at the guideline adoption literature and start there. But I am sure there are implementation people out there who have a lot more experience in the adoption and dissemination literature than I do because you are talking about giving up your beat up old car...your favorite beat up old car, which is the only car that you have to drive without changing your entire mindset, changing your patterns of care...driving, changing equipment that you use. I would want to sit down and talk to some implementation researchers and create a theoretical framework to start from. 

Molly:Thank you for that reply. We do have several people that have written in saying, “Thank you for the excellent presentation.” And we also have a request. Someone is wondering if the complete references can be made available. Some of the images that were in the presentation were not in the handouts. Can they be added? 

Patsi:Can you reply to that? What I can do is...

Molly:Yeah, if you want to send them to me, I can just tack them on to the emails for the archive. 

Patsi:Okay.

Molly:Great, sounds good. Well, that is the last question that we have at this time. Would you like to make any concluding comments?

Patsi:No, just that I think this is a terrifically interesting area of potential research and, in particular for the QUERI program, which is about providing the best care at the right time to the right people and getting providers and systems to do so. So right care and right time means doing the right thing and stop doing the wrong thing, so I think it is a particularly interesting area of research. And I look forward to working with folks on this. 

Molly:Excellent. Well, thank you very much for lending your expertise for this presentation, and thank you to our attendees for joining us. As you exit today’s session, please do wait just a moment while the feedback survey pops up on your screen. Take just a moment to answer those questions. We do take your feedback into consideration and adjust the program as necessary. So thank you once again, and everybody have a wonderful day. 

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