Prevention Isn’t the (Only) Answer: Two Sobering Findings

True or false:

  1. The best way to reduce health care costs is to prevent costly admissions for the sickest patients.
  2. Diet and exercise will help accomplish this goal for patients with diabetes.

Have you guessed?

Two studies out this week, which have flown under the radar of many news stations, suggests the answer may not be what we intuitively thought.

Almost 90% of Hospitalization Costs are Unavoidable

A new study from Dr. Karen E. Joynt and colleagues, published concurrently with their presentation of the results at the Academy Health conference, suggests that only about 12% of total acute care costs are actually “preventable”. They looked at 2009-2010 spending data for over 1 million Medicare beneficiaries and categorized their ED and hospitalization costs as “preventable” and “non-preventable” based on validated algorithms. This is what they found:

  • The top 10% most costly patients (“high-cost”) were responsible for 73.0% of total acute care costs. No surprise there, for anyone who’s read Atul Gawande’s “The Hot Spotters“, or heard of the 80-20 rule.
  • For both high-cost and non-high-cost  patients, slightly more than 40% of ED visits and costs were deemed preventable. Sounds promising…
  • However, total ED costs (~$124 million) paled in comparison to total hospitalization costs (~$3.0 billion). For these costs, “preventable” costs constituted only 9.6% of costs for high-cost patients and 16.8% for everyone else.

I’ve thrown together a graphic to illustrate this. Preventable costs are shaded darker:

Data source: Joynt KE, Gawande AA, Orav EJ, Jha AK. 2013. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013 June 24;309(24):doi:10.1001/jama.2013.7103.

Data source: Joynt KE, Gawande AA, Orav EJ, Jha AK. 2013. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013 June 24;309(24):doi:10.1001/jama.2013.7103.

This means that even if a health system succeeds in preventing 100% of its unnecessary ED visits, and in preventing all hospitalizations related to congestive heart failure, bacterial penumonia, COPD, urinary tract infections, etc. (diseases deemed to be “preventable” given effective outpatient management), total costs would only drop by 12.5%. That’s not very enticing, especially considering the formidable investment required to develop such care management capacity.

The main issue appears to be that the most costly hospitalizations, such as orthopedic conditions and cancer, can’t be prevented simply with better outpatient care management. You can do as much health coaching as possible, but short of confining granny to solitary confinement, she might eventually need that hip replacement.

The authors offer some cautious takeaways:

“These findings suggest that strategies focused on enhanced outpatient management of chronic disease, while critically important, may not be focused on the biggest and most expensive problems plaguing Medicare’s high-cost patients. Indeed, while a proportion of these very expensive inpatient episodes may be potentially preventable (such as acute myocardial infarction or degenerative joint disease leading to orthopedic procedures), their prevention would likely require a long time horizon and substantial investments in population wellness.” (emphasis mine)

Of course, hit those expensive diseases early with the one-two punch of diet and exercise! But just how long of a time horizon is needed? If you’re trying to prevent heart attacks in diabetics, it appears the answer is: longer than 9.6 years.

Diet and Exercise Failed to Reduce Heart Attack/Stroke Among Diabetics

It was not a heartening day for proponents of care management and prevention. Another study, from the Look AHEAD (Action for Health in Diabetes) Research Group, implemented a randomized intervention of diet and exercise for overweight diabetic patients and set out to track them for 13.5 years, hoping to prove some health benefits. They stopped it at a median of 9.6 years based on a futility analysis; it didn’t work.

Most strikingly, the diet and exercise intervention seemed to work just fine. When the study ended, intervention patients had achieved significantly greater weight loss (-6.0% vs -3.5%), reduction in waist circumference (-1.8% vs -0.9%), and improvement in fitness score (+3.7% vs -2.0%). Not only that, they had significantly greater improvements in almost all measured cardiovascular risk factors (including glycated hemoglobin, blood pressure, and triglycerides).

So it’s puzzling that the incidence of cardiovascular-related hospitalizations or death was statistically indistinguishable between the two groups (P=0.51).

Don’t Put All Your Eggs in the Care Management/Prevention Basket

Despite these sobering findings, I’m still of the opinion that care management and prevention are worthy efforts, as Drs. Carroll and Frakt point out in an accompanying editorial. After all, 12.5% of a very large number is still a very large number. And the diabetes study did show many indicators between the intervention and control groups converging after the first year; if we could figure out a way to sustain the benefits of exercise and diet, perhaps the longitudinal effects on outcomes would be more pronounced.

That said, maybe we should focus on two additional sources of cost savings:

  1. Streamline care processes and avoid costly errors during (non-preventable) hospitalizations. In fact, one of the study authors wrote the book on how a 5-step checklist prevented 43 central line infections and saved ~$2 million over 2 years. He’s now bringing the approach to birth and end-of-life care. And he’s not the only one achieving breakthrough results with simple solutions.
  2. Take a closer look at post-acute care. A provocative article last month pointed the finger at post-acute care for variations in Medicare spending. Since post-acute care made up 13.4% of national health expenditures in 2012 (compared to hospital care’s 31.5%), there could definitely be substantial opportunity to reduce costs there.

But perhaps the most important takeaway is: Never assume a strategy will work, even if it sounds logical, until you’ve looked at the data.

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2 thoughts on “Prevention Isn’t the (Only) Answer: Two Sobering Findings

  1. Here’s my question: how many of those hospitalizations were Unnecessary?

    Shared decision-making data shows that if patients are given full information about the risks and benefits of knee and hip replacement– as well as recovery time– at least 20%
    decided not to have the surgery.l

    They may benefit from physical therapy. If the patient is a fairly sedentary 68 year old woman she may decide that inexpensive pain-killers are sufficient.

    We know that many angioplasties are unnecessary (they will temporarily relieve angina, but they won’t save lives.) And we know how to identify them.

    We know that we overtreat many cancer paitents –with treatments that may give them another 9 months or so, but poor quality of life. In many cases, they might live as long or logner, with better qualify of life, if they were at home with palliative care.

    We know that a great many C-sections are unnecessary–and they lead to longer, more expensive hospitalizations.

    On three separate occasions, doctors have tried to talk my husband into surger: for prostate cancer, for a shoulder injury and knee surgery.

    Each time he said no thanks.
    20 years later, he shows no symptoms of prostate cancer.
    He solve the shoulder problem by seeing a physical therapist.
    He stretches an d the knee pain is manageable (despite the fact that he is very active.)

    I don’t have access to the full article, but I’m wondering if they factored in “over-treatment.”

    As Gawande has written we do far more surgeries than virtuallly any other developed country– and it’s not clear that we are getting value for the money . .

    • Excellent point. The study did not categorize admissions as necessary vs unnecessary. Rather, it used the Agency for Healthcare Research and Quality’s “Prevention Quality Indicators” (http://www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V42/PQI%20Brochure%2010%20update.pdf), which list 14 conditions as “ambulatory sensitive”, i.e. could in theory be completely preventable with perfect outpatient management. But as you point out, I’m sure a substantial percentage of the admissions deemed “non-preventable” were also medically unnecessary, and could have been avoided if health systems have had clear guidelines, decision-support tools, a culture of practicing evidence-based medicine, etc.

      Thanks for reading and sharing your thoughts!

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