A guest column by the American College of Physicians, exclusive to KevinMD.com.

by John Tooker, MD, MBA, MACP

There were two reports from the recent 2011 International Stroke Conference that got my attention.

One report noted the sharp increase in the incidence of strokes in children and young adults.  The second, in the Los Angeles Times (“Mild strokes may be a target for clot-busting drug”), suggested that mild strokes, currently treated conservatively, may be candidates for more aggressive treatment with tPA thrombolysis, currently reserved for more severe thrombotic strokes. The article noted that post stroke disability in about a third of the mild stroke patients might be averted with hundreds of millions of dollars in related costs saved.

Should the findings in these reports be validated with subsequent research, how should we as a nation decide how to provide high quality (yet initially expensive) care to an emerging and potentially large stroke population that may result in downstream savings in quality of life and costs associated with post stroke disability?

Recognizing that we must improve the framework with which we make clinical intervention decisions of benefit and cost with our patients, the American College of Physicians published a concept paper by Owens and colleagues in the Annals of Internal Medicine earlier this month titled “High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions” that provides a framework to think about the treatment of patients in a logical and defensible manner. The paper examines two categories of care that should be examined carefully in the context of value (an assessment of the benefit of an intervention relative to expenditures):

• Treatment or diagnostic interventions that have no or minimal value. In addition to being costly, the interventions may be harmful.
• Interventions that provide a benefit net of the costs of providing the intervention.

Three key concepts for understanding how to assess the value of health care interventions are developed in the article. Quoting from the paper:

“First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value.”

“Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed.”

“Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.”

There is a companion paper by Chou and colleagues, putting into practice how to assess the value of a particular health care intervention — imaging in low back pain — for a real and common clinical problem. Bottom line: in the absence of specific clinical findings, don’t image as the evidence suggests that this intervention, as a routine, has limited or no benefit, and is costly.

There is also an editorial by Gusmano and Callahan from the Hastings Center that cautions us about how difficult it will be to develop a national framework for high-value care, citing the lack of an adequate evidence base, value thresholds and the will to say no when the evidence doesn’t support yes. These three papers are an important contribution to beginning the conversation of how to get the best value for our patients. In the next post, we’ll take a closer look at “value”, interventions that are beneficial and measuring the resources used in interventions.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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