high value care: ruq abdominal pain darwin l. conwell, md, ms professor and director, division of...
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High Value Care:RUQ Abdominal Pain
Darwin L. Conwell, MD, MSProfessor and Director,
Division of Gastroenterology, Hepatology and Nutrition
614-366-3433 office614-293-0861 Fax
Current Health Care
Landscape
The Facts:• Health care costs increasingly
unsustainable• Efforts to control expenditures need to
focus on VALUE in addition to COSTS
• HIGH-VALUE – benefits justify costs• GI reimbursement is dropping• Increasing denial of procedures and tests
• High co-pays steer patients away from academic centers
• Lack of quality metrics in pancreatic disease
• Research funding and long term sustainability is challenging
Abdominal Pain
• Challenging chief complaint• 75% adolescents• 50% adults
• Benign disease • GERD, peptic ulcer
• Serious pathology• Gastrointestinal cancer
• Frequently Irritable Bowel Syndrome• < 50 yr minimal work-up; symptomatic
treatment• > 50 yr rule out malignancy; cross
sectional abdominal imaging (CT scan)
Introduction
Abdominal Pain
Primary Care Physicians are responsible to determine which patients can be:
1. Safely observed
2. Treated symptomatically
3. Require further investigation• ED evaluation• Resuscitation: ABCs
4. Specialist Referral / Consultation• Gastroenterology, Surgery
Triage
Abdominal Pain
The history should include:• Location of pain• Radiation of pain• Factors that exacerbate or improve
symptoms such as food, antacids, exertion, defecation
• Associated symptoms including fevers, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool
History
Abdominal Pain
Past medical and surgical history, including risk factors for cardiovascular disease and details of previous abdominal surgeries• Family history of bowel disorders• Alcohol intake• Intake of medications including over
the counter medications such as aspirin and NSAIDs
• Menstrual and contraceptive history in women
Past Medical History
Abdominal Pain
A typical examination will include:• Measurement of blood pressure, pulse,
and temperature• Examination of the eyes and skin for
jaundice• Auscultation and percussion of the chest• Auscultation of the abdomen for bowel
sounds• Palpation of the abdomen for masses,
tenderness, and peritoneal signs
• Rectal examination including testing of stool for occult blood
• Pelvic examination in women with lower abdominal pain
Physical Examination
Abdominal Pain
Acute• Minutes, hours, days; ill-appearing• Non-narcotic use history• Surgical abdomen: IHOP !!!!!
• Intractability, Hemorrhage, Obstruction, Perforation (IHOP)
• Pain medications help• Pearl – They do not request pain
medications.They request help me! • Scared, anxious, ill
Chronic• Weeks, months, years; looks well• Chronic Narcotic use history• Non-surgical abdomen
• Pain medications ineffective• Pearl - Request pain medication “by name
and dose!”• They are demanding; irritable, unpleasant
Acute versus Chronic
Abdominal Pain
Laboratory Studies: Acute and Chronic Pain• CBC with differential• Electrolytes, BUN, creatinine,
glucose• Liver profile• Lipase
Additional Chronic Pain labs:• TSH, glycohemoglobin• TTG• ESR, CRP• Fecal elastase, fecal fat
Diagnostic Testing
Abdominal Pain
Imaging Studies Price ($)• Ultrasound 420
• EGD 3,000• Colonoscopy 3,000• MRI/MRCP 2,625
Diagnostic Testing
http://www.newchoicehealth.com/Directory
Abdominal Pain
Step 1 – Recognize most are benign (IBS) and a subset have serious pathology (GI cancer)
Step 2 – Acute or chronic pain
Step 3- Triage serious etiology and/or surgical abdomen to ED
Step 4 – Location of pain determines
evaluation: RUQ Pain
Step 5 – Most chronic pain is functional in young (< 50 yr age); caution in older (> 50 yr age)
Summary
Defining High-Value Care
Rationale for High-Value Care- High costs and unsustainable cost increases- Overuse of screening and diagnostic tests
increases costs
Evaluation of High-Value – DIAGNOSTIC TESTS• Principle 1: The diagnostic test should not be
performed if it will not change management
• Principle 2: A low pre-test probability of disease is more likely to result in a false positive test result
• Principle 3: The true cost of a test includes the cost of test itself and downstream costs incurred because the test was performed
Appropriate Use of Screening and Diagnostic
Tests
Qaseem, A., Ann Intern Med 2012
RUQ Pain
The investigation and management of patients with recurrent episodes of right upper quadrant and epigastric pain is challenging, as there are numerous causes, both “organic” and “functional” . Symptoms of functional gallbladder (GB) and sphincter disorders must be distinguished from those due to cholelithiasis, pancreatitis, gastroesophageal reflux disease, irritable bowel syndrome, functional dyspepsia, and peptic ulcer disease.
Peter B Cotton, et al., Am J Gastro 2010
National Trends in Admissions for RUQ Pain (789.01) Are Decreasing
http://hcupnet.ahrq.gov/
p < 0.001
National Trends in Admissions from ED
for RUQ Pain (789.01) are Increasing
http://hcupnet.ahrq.gov/
p < 0.001
National Trends in Charges for RUQ Pain
(789.01) are Increasing
http://hcupnet.ahrq.gov/
p < 0.001
High-Value, Cost-Conscious Health Care
for RUQ Pain
Description of Abdominal Pain• Constant or intermittent? • Duration of pain in weeks/months• Does the pain radiate?• Is the pain exacerbated or improved by food?• Is the pain improved by PPI/H2 blocker/antacid?
Associated symptoms • nausea, vomiting• change in bowel habits• GI bleeding,melena or hematochezia• pruritus, weight loss, anorexia
Essential patient information
High-Value, Cost-Conscious Health Care
for RUQ Pain
Physical exam• jaundice• abdominal mass• rebound tenderness• fever• guarding• Murphy’s sign• ascites• palmar erythema, spider angiomata
Essential patient information
High-Value, Cost-Conscious Health Care
for RUQ Pain
Diagnoses to consider:•Gallstones
•Cholangitis, cholecystitis•Pancreatitis: acute or chronic•Peptic Ulcer Disease•GERD•Sphincter of Oddi dysfunction•Ischemic bowel•Inflammatory bowel disease•Bowel obstruction•Perforation•Liver disease•GI cancer•Irritable bowel syndrome•Myocardial infarction•Pulmonary embolus
Differential Diagnosis
High-Value, Cost-Conscious Health
Care for RUQ Pain
Additional clinical history •abdominal surgery•bariatric surgery•gallstones•pancreatitis•alcohol use•NSAID use•immunocompromisedEssential patient
information
High-Value, Cost-Conscious Health Care
for RUQ Pain
A patient with:
• hemodynamic instability • sudden onset pain• rebound tenderness• fevers• gastrointestinal bleeding
should be referred for urgent evaluation!!!!
Alarm symptoms
High-Value, Cost-Conscious Health
Care for RUQ Pain
Laboratory Tests• CBC• Chemistry panel• AST, ALT, alkaline phosphatase, bilirubin• Amylase, Lipase• Pregnancy test
Imaging Studies• RUQ ultrasound
Essential patient information
Medical therapy should be directed by results of the above tests. A negative evaluation or confirmatory testing should be directed by GI consultation. More costly, studies such as endoscopy, CT, MRI and ERCP should be recommended by specialty consultants.
High-Value, Cost-Conscious Health Care
for RUQ Pain
Laboratory Tests• Stool FOBT• Anti-TTG• Hepatitis A, B, C serology• H. pylori testing
Imaging Studies• Abdominal CT• Abdominal MRI• UGI x-ray
Endoscopy• EGD• ERCP
Additional Information that may be recommended by
GI Consultants
Cotton P, et al., Am J Gastro 2010
Abdominal Pain on NSAIDS
Perforated Duodenal Ulcer
Alcoholic with Acute Abdominal
pain
Alcoholic with Acute Abdominal
pain
Acute Pancreatitis
49 year old abdominal pain
49 year old abdominal pain
Mesenteric Ischemia Transverse Colon
25 year old with abdominal pain
25 year old with abdominal pain
Autoimmune Pancreatitis
Anemia and abdominal
pain
Peptic Ulcer
27 year old female with
RUQ Pain
Fitz Hugh Curtis
Increased pain, anorexia, weight loss
Telephone Call PCP - 1/2009Mutual patientIncreasing abdominal painweight lossjaundice
Reviewed CT Report 2007Findings consistent with chronic pancreatitis with no evidence of acute pancreatitis.
CT 1/15/2009: Mass, malignant ascites, Metastases, biliary dilation
Defining High-Value Care
Rationale for High-Value Care- High costs and unsustainable cost increases
Evaluation of High-Value – MEDICAL OR SURGICAL INTERVENTIONS
• Step 1: Understand Benefits, Harms and Costs of intervention
• Step 2: Downstream costs associated with intervention
• Step 3: Consider Incremental Cost-effectiveness ratio (ICER) calculation to estimate additional costs required to obtain additional health benefit. Key measure of value.
Evaluation of Medical Interventions
Owens, D et al., Ann Intern Med 2011
Incremental Cost-effectiveness
Ratio (ICER)
Owens, D et al., Ann Intern Med 2011
High-Value, Cost-Conscious Health Care
for RUQ Pain
• Uptodate.com • Sleisenger and Fordtrans’s Gastrointestinal and Liver Diseases 9th ed. Chapters 10,52,65,66 • Textbook of Gastroenterology, Yamada. 5th ed. Chapters 40, 74 • ACR Appropriateness Criteria Guidelines - Right upper abdominal pain. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain.pdf • Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. Jun 26 2008;358(26):2804-11.
References
