COMMISSIONING DIAGNOSTICS:System Biases & How to Influence

Dr Imran Sajid | MBBS BSc AICSM MRCGP DipSEM DPMSA DCP CMCBT DipFIPT

GENERALIST | HEALTHCARE COMMISSIONER

LONDON, UNITED KINGDOM

@imransajid

Academics Clinician Leaders

Policy MakersCare Providers

Patients

THE NEED FOR SPEED

DIAGNOSTICS can be

a CASH COW

PROFIT or

LOSS

Of primary care visits

result in blood test

requests

Of blood tests are

unnecessary / inappropriate

PATHOLOGY KEY INFO

Cadoga, Brown, Bradley 2015

Fryer, Smellie 2016

PRE-

ANALYTIC

ANALYTICEg Reflex Testing,

Add Ons etc

POST-ANALYTICEg Sensitivities,

Suppression of certain

results etc

LOW UNITCOST

HIGH VOLUME

- CHANGING DEFAULTS

- MINIMUM RETEST INTERVALS

- DECISION TREES

(COMPUTER SAYS NO)

CHOICE ARCHITECTURE

*NUDGES DON’T ALWAYS WORK*

↑60-90%

↓20-30%

Zaat et al 1992

Shalev et al 2008

Kahan et al 2009

PROFILES for key indications, eg a group of tests for tiredness

COST INDICATORS?

Horn et al 2014

MUSCULO-SKELETAL IMAGING

Age + 10

=

Prevalence of

Incidental Disc

Protrusion

Knee X-rays Shoulder

USS

Back MRI

Brinjinki et al 2014

Over Age 40:

90+% have

‘something’ on USS

Girish et al 2011Bedson 2008

PERSISTENT PAIN TISSUE DAMAGE

80% of Patients would want imaging for low back pain

Findings should be expected and are

often normal age-related changes

unrelated to harm or pain.

Kendrick 2001

LOCAL AUDIT: 156 Musculoskeletal MRI Scans in Primary Care

10%

Clinically

indicated

68%

Incorrectly

interpreted:

False Positives

25

Unnecessary

Surgical Referrals

(0% conversion

rate)

52% of Results

discussed with

different GP

43%

Psychological

Yellow Flags

31 Days

Median

Delay to

action*NOCEBIC LANGUAGE*

GP ENGAGEMENT & SURVEY• Cognitive Dissonance

• Dunning-Kruger Effect

• Availability Bias / Impact Bias /

Uncertainty Bias

• Patient Expectations: 85% of GPs said

‘sometimes’, ‘often’, or ‘always’ their

imaging is influenced by patient

pressure

Limitations:

1) PRACTICE-LEVEL DATA, NOT

INDIVIDUAL DATA

2) LOWER REFERRERS DID NOT

SHOW IMPROVED QUALITY OF

REFERRAL OR INTERPRETATION

3) FOCUSING ON OUTLIERS CAN

HAVE AN OPPORTUNITY COST

BENCHMARKING

Yay or Nay?

Rogers Diffusion Curve

WHAT TO DO?BENCHMARKING & EDUCATION

Starts the conversation; that’s all.Limited detail of data. Less imaging doesn’t equal better clinical value of imaging. Limited reach of education. Don’t focus only on the ‘outliers’

AMEND REPORTS Limited impact (McCullough 2012)

POLICE REQUESTS (ieREFERRAL MANAGEMENT CENTRES)

High cost; limited return on investmentIllegitimate learning develops to bypass barrier

ELECTRONIC ORDER COMMS (EG DECISION AIDS)

Up against strong pre-held beliefs.No benefit on post-analytic errors

SWITCH OFF MSK IMAGING (ENSURE ‘RED FLAG’ PATHWAYS IN PLACE)

Risks de-skilling primary care, but harm > benefitSaves unethical resource spend / iatrogenic harm

EFFECTS OF PAYMENT MODELS

‘Unbundling’ EffectActivity-Based Billing for Diagnostics: ECG

HOW UNETHICAL?

• EXPLICIT (’Cross-Subsidising’)

• IMPLICIT (Unintentional Bias)600% increase in

ECGs after

introduction of

activity-based /

fee-for-service

invoicing

How to COMMISSIONING the SYSTEM

■ ACTIVITY-BASED TARIFFS – AVOID!!!

■ BLOCK CONTRACTS – Quality may suffer

■ TRANSPARENT ACCOUNTING – Need Honest Conversations

■ RISK/GAIN SHARES – to kickstart the right culture?

■ ACCOUNTABLE CARE ORGANISATIONS??

TAKE HOME MESSAGES

1) Era of Excess Diagnostic Complexity:

(CAREFULLY) ADJUST (REDUCE) THE CHOICE ARCHITECTURE

2) Financial Influences:

YOUR PAYMENT SYSTEM MUST MATCH YOUR STRATEGY

Dr IMRAN SAJID

imransajid@nhs.net

@imransajid