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Su1105 The Development and Evaluation of Coordinated Care Pathways for Inflammatory Bowel Diseases
Su1105
AGA Abstracts
The Development and Evaluation of Coordinated Care Pathways for Inflammatory Bowel Diseases Welmoed K. van Deen, Jennifer M. Choi, Elizabeth K. Inserra, Laurin Eimers, Ellen Kane, Mark Ovsiowitz, Adriana Centeno, Martijn G. van Oijen, Bennett E. Roth, Daniel Hollander, Wendy Ho, Daniel Cole, Terri Getzug, Lynn S. Connolly, Andrew D. Ho, Christina Y. Ha, Eric Esrailian, Daniel W. Hommes Introduction Inefficient care delivery and guideline non-adherence are main drivers of health care costs. Standardization of care into coordinated care pathways has been proposed to decrease expenditures and increase patient value. We developed an evidence based multidisciplinary care pathway and tested its feasibility. In addition, we estimated associated costs per procedure and modeled procedural costs per care pathway to facilitate potential bundle payment under the Affordable Care Act. Methods We reviewed IBD guidelines and complemented these with relevant literature and consensus statements. Care scenarios were designed based on patients' disease activity and treatment strategy. Appropriate tests, procedures and office visits were added to the care scenarios, including standard operational procedures (SOP) for task differentiation and quality indicators relevant for IBD care. Outcomes were assessed using clinical disease activity indices (DAI) (Harvey Bradshaw Index for CD and partial Mayo score for UC) and quality of life (QoL) scores. Healthcare utilization rates were analyzed using insurance claims data from a subset of patients insured through Wellpoint (Anthem Blue Cross) California. UCLA charges were used to develop a cost model. Results Table 1 shows the 10 developed care scenarios: 5 for remission induction, and 5 for maintenance therapy. We assumed that 6 week intensive care scenarios would offer sufficient time to induce remission in active patients, for remissive patients we developed annual care pathways. As of October 2013 642 IBD patients (50% CD, 48% UC, 2% IBDU) had been treated accordingly (mean age 41.8 years (SD 15.7 years), 52% male). Patients were managed by 11 physicians, 3 IBD nurse coordinators and administrative staff across 2 locations. Task differentiation was introduced through SOPs (e.g. nurse coordinators were responsible for instruction, contacting and monitoring patients, and order management). In our IBD center, 35% of patients had active disease at their first visit. Annual relapse rate was 10% (8% CD, 13% UC). Mean DAI in active CD was 4.2 (SD 4.0) (QoL 44.5), versus 1.2 (SD 1.8) in remission (QoL 53.0). Mean DAI in active UC was 3.6 (SD 2.3) (QoL 43.4), versus 0.8 (SD 1.4) in remission (QoL 53.0). Average annual utilization rates were: 2.7 clinic visits, 1.1 colonoscopies, 0.3 hospital admissions, and 0.5 ER visits. A cost model estimating procedural costs per care scenario was developed (Table 1). Conclusion We developed a multidisciplinary coordinated IBD care pathway based on disease activity and treatment strategy. These pathways allowed individual flexibility and greatly harmonized care across providers. The monitoring of health related outcomes and associated health care expenditures was feasible. This IBD care management program design facilitates rapid adoption into Accountable Care Organizations.
Table 1. Designed care scenarios based on patients disease activity and treatment regimen. *This model does not yet include medication costs. Su1106 Fixed Volume Vials Limit Accurate Weight-Based Dosing of Infliximab for IBD: an Opportunity for Quality Improvement and Cost Containment Dean J. Taylor, Siddhartha Y. Parker, Gladys P. Ayala, Corey A. Siegel Background: The advent of infliximab (IFX) has been a significant advance for the treatment of moderate to severe inflammatory bowel disease (IBD). However, it is also a significant contributor to the overall cost of IBD care. IFX is initiated at a weight-based dose of 5mg/ kg. It is only available in 100mg vials, and vials cannot be split between patients. Due to this fixed vial size, the dosing options include rounding up or down, or wasting a portion of the vial. Our aim was to assess the accuracy of IFX weight-based dosing for IBD patients at our institution, and the potential impact on overall cost of care. Methods: Using billing codes, all IBD patients who have received IFX at our institution were identified. Patients who had inadequate records or who received infusions for less than one year were excluded. Out of nearly 500 patients, 100 were randomly selected for review. Each patient chart was reviewed for patient weight, actual IFX dose administered at induction and yearly thereafter, and reasons for dose changes. The actual dose administered was then compared to the expected weight-based dose. We confirmed the cost of both obtaining and administering a 100mg vial through the pharmacy and charge master. Based on the cost of each 100mg vial, estimated average number of infusions per year, and the difference between actual dose and weight-based dose, we estimated the potential annual savings per patient if 50mg vials were available to allow for more targeted dosing. Results: At the time of their induction, 30% of patients received a dose at least 50mg greater (more than half of a vial) than their expected weight based dose. Overall, 22% of 413 total infusions reviewed exceeded the expected weight-based dose by 50mg or more with a mean excess of 74.5mg (standard deviation 21.4 mg). The billable costs at our institution for each 100mg vial are $2500 and on average patients receive 7 IFX infusions per year. If 50mg vials were available, any patient whose actual dose was rounded up more than 50mg could reduce billing charges by approximately $1250 per infusion through more accurate weight-based dosing. This could generate annual healthcare savings of $8750 per patient or $875,000 per hundred patients who currently receive at least 50mg excess IFX per dose. Conclusion: Infliximab is only available in single use 100mg vials. Current prescribing patterns and pharmacy protocols typically round up as opposed to down to avoid under-dosing. We found that up to 30%
AGA Abstracts
S-376
AGA Abstracts
The Development and Evaluation of Coordinated Care Pathways for Inflammatory Bowel Diseases Welmoed K. van Deen, Jennifer M. Choi, Elizabeth K. Inserra, Laurin Eimers, Ellen Kane, Mark Ovsiowitz, Adriana Centeno, Martijn G. van Oijen, Bennett E. Roth, Daniel Hollander, Wendy Ho, Daniel Cole, Terri Getzug, Lynn S. Connolly, Andrew D. Ho, Christina Y. Ha, Eric Esrailian, Daniel W. Hommes Introduction Inefficient care delivery and guideline non-adherence are main drivers of health care costs. Standardization of care into coordinated care pathways has been proposed to decrease expenditures and increase patient value. We developed an evidence based multidisciplinary care pathway and tested its feasibility. In addition, we estimated associated costs per procedure and modeled procedural costs per care pathway to facilitate potential bundle payment under the Affordable Care Act. Methods We reviewed IBD guidelines and complemented these with relevant literature and consensus statements. Care scenarios were designed based on patients' disease activity and treatment strategy. Appropriate tests, procedures and office visits were added to the care scenarios, including standard operational procedures (SOP) for task differentiation and quality indicators relevant for IBD care. Outcomes were assessed using clinical disease activity indices (DAI) (Harvey Bradshaw Index for CD and partial Mayo score for UC) and quality of life (QoL) scores. Healthcare utilization rates were analyzed using insurance claims data from a subset of patients insured through Wellpoint (Anthem Blue Cross) California. UCLA charges were used to develop a cost model. Results Table 1 shows the 10 developed care scenarios: 5 for remission induction, and 5 for maintenance therapy. We assumed that 6 week intensive care scenarios would offer sufficient time to induce remission in active patients, for remissive patients we developed annual care pathways. As of October 2013 642 IBD patients (50% CD, 48% UC, 2% IBDU) had been treated accordingly (mean age 41.8 years (SD 15.7 years), 52% male). Patients were managed by 11 physicians, 3 IBD nurse coordinators and administrative staff across 2 locations. Task differentiation was introduced through SOPs (e.g. nurse coordinators were responsible for instruction, contacting and monitoring patients, and order management). In our IBD center, 35% of patients had active disease at their first visit. Annual relapse rate was 10% (8% CD, 13% UC). Mean DAI in active CD was 4.2 (SD 4.0) (QoL 44.5), versus 1.2 (SD 1.8) in remission (QoL 53.0). Mean DAI in active UC was 3.6 (SD 2.3) (QoL 43.4), versus 0.8 (SD 1.4) in remission (QoL 53.0). Average annual utilization rates were: 2.7 clinic visits, 1.1 colonoscopies, 0.3 hospital admissions, and 0.5 ER visits. A cost model estimating procedural costs per care scenario was developed (Table 1). Conclusion We developed a multidisciplinary coordinated IBD care pathway based on disease activity and treatment strategy. These pathways allowed individual flexibility and greatly harmonized care across providers. The monitoring of health related outcomes and associated health care expenditures was feasible. This IBD care management program design facilitates rapid adoption into Accountable Care Organizations.
Table 1. Designed care scenarios based on patients disease activity and treatment regimen. *This model does not yet include medication costs. Su1106 Fixed Volume Vials Limit Accurate Weight-Based Dosing of Infliximab for IBD: an Opportunity for Quality Improvement and Cost Containment Dean J. Taylor, Siddhartha Y. Parker, Gladys P. Ayala, Corey A. Siegel Background: The advent of infliximab (IFX) has been a significant advance for the treatment of moderate to severe inflammatory bowel disease (IBD). However, it is also a significant contributor to the overall cost of IBD care. IFX is initiated at a weight-based dose of 5mg/ kg. It is only available in 100mg vials, and vials cannot be split between patients. Due to this fixed vial size, the dosing options include rounding up or down, or wasting a portion of the vial. Our aim was to assess the accuracy of IFX weight-based dosing for IBD patients at our institution, and the potential impact on overall cost of care. Methods: Using billing codes, all IBD patients who have received IFX at our institution were identified. Patients who had inadequate records or who received infusions for less than one year were excluded. Out of nearly 500 patients, 100 were randomly selected for review. Each patient chart was reviewed for patient weight, actual IFX dose administered at induction and yearly thereafter, and reasons for dose changes. The actual dose administered was then compared to the expected weight-based dose. We confirmed the cost of both obtaining and administering a 100mg vial through the pharmacy and charge master. Based on the cost of each 100mg vial, estimated average number of infusions per year, and the difference between actual dose and weight-based dose, we estimated the potential annual savings per patient if 50mg vials were available to allow for more targeted dosing. Results: At the time of their induction, 30% of patients received a dose at least 50mg greater (more than half of a vial) than their expected weight based dose. Overall, 22% of 413 total infusions reviewed exceeded the expected weight-based dose by 50mg or more with a mean excess of 74.5mg (standard deviation 21.4 mg). The billable costs at our institution for each 100mg vial are $2500 and on average patients receive 7 IFX infusions per year. If 50mg vials were available, any patient whose actual dose was rounded up more than 50mg could reduce billing charges by approximately $1250 per infusion through more accurate weight-based dosing. This could generate annual healthcare savings of $8750 per patient or $875,000 per hundred patients who currently receive at least 50mg excess IFX per dose. Conclusion: Infliximab is only available in single use 100mg vials. Current prescribing patterns and pharmacy protocols typically round up as opposed to down to avoid under-dosing. We found that up to 30%
AGA Abstracts
S-376