Scaling Back on the Million Dollar Workup: Sometimes Less is More – How Framing the Problem Affects Vertigo

From the 2019 HVPAA National Conference

Dr. Carlen Yuen (University of Chicago), Dr. Anthony Reder (University of Chicago)

Vertigo is a common presenting symptom in the ED, Urgent Care, and Outpatient settings.  Framing bias can arise when stroke codes are activated on patients who have peripheral vertigo. The Framing Effect influences physicians to make medical decisions based on conceivable losses and gains (defensive medicine, fear of missed central vertigo/posterior circulation stroke), not the likelihood or probability of the final outcome. Healthcare resources are then wasted on unnecessary stroke workup and inpatient admissions.

Framing Bias training and High Value Care interventions incorporated into the resident education curriculum will lead to high-value, cost-conscious medical decision-making.

Aim Statement

For Patient Safety, reduction in unnecessary imaging and radiation exposure by 50% in 1 year. For Effectiveness, reduce number of unnecessary admissions for peripheral vertigo by 50% within 1 year and increase resident cost awareness by 75%, measured by pre and post Knowledge Assessment Surveys. For Patient Centeredness, improve open communication between residents and patients regarding risks and benefits of contrast and radiation exposure. For timeliness, reduction in waiting time in treating peripheral vertiginous symptoms by the Epley maneuver. For efficiency, reduce healthcare waste by $1.25 million within 1 year.

Key stakeholders include: Residents, Attendings, Social Work, Case Management, and Nursing in the Neurology department at University of Chicago

Results

2017 Cost Results:

  • 17% of ED Neurology Consults for peripheral vertigo were Stroke Codes
  • 39% of ED Neurology Consults for peripheral vertigo had NIHSS = 0
  • $154,171 per patient for vertigo workup from ED Neurology Consult
  • $6,360per patient for vertigo workup from Urgent Care

Following acceptance into the HVPAA Future Leaders Program, Knowledge Pre-Assessment was performed and Education Session was completed with the following results:

  • 58% are more likely to admit a dizziness patient for posterior circulation stroke workup, even if the exam is consistent with peripheral vertigo if a stroke code is activated
  • 44% will admit dizziness patients for posterior circulation stroke workup, even if the exam is consistent with peripheral vertigo
  • 100% admit fear of missed diagnosis is a factor in their medical decision-making
  • 88% admit fear of liability is a factor in medical decision-making
  • 72% are confident in performing the Dix Hallpike maneuver
  • 47% are confident in performing the HINTS exam
  • 22% feel a negative CTH head and CTA head and neck is sufficient to rule out a posterior circulation stroke
  • 44% discuss the risk of radiation and contrast with their dizziness patients
  • 59% factor the cost and value of diagnostic testing into medical decision-making.
  • 38% accurately estimate reimbursement for a CTH wo
  • 19% accurately estimate reimbursement for a MRI brain
  • 53% accurately estimate reimbursement for a CTA head and neck
  • 34% accurately estimate reimbursement for a MRA brain and neck
  • 56% accurately estimate reimbursement for a Carotid US
  • 47% accurately estimate reimbursement for a TTE
  • 100% feel reducing healthcare waste

Next Steps

Perform Knowledge Post Assessment and Cost Analysis to determine Cost Savings following Education Session on providing Peripheral Vertigo Cost Conscious Care.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

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