1 PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2017 COUNCIL MEETING. RESOLUTIONS ARE NOT 2 OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE). 1

2 3 4 RESOLUTION: 50(17) 5 6 SUBMITTED BY: Hawaii Chapter 7 8 SUBJECT: Promoting Clinical Effectiveness in Emergency Medicine 9 10 PURPOSE: Create a Clinical Effectiveness Committee responsible for identifying, assessing, and promoting evidence-based 11 cost-effective emergency medicine practice. 12 13 FISCAL IMPACT: 50% FTE staff, in-person meeting at Scientific Assembly. $100,000 recurrent annual expense. 14 15 WHEREAS, The American College of Emergency Physicians (ACEP) is a leader amongst medical specialties and an 16 advocate for our patients and cost-effective health care; and 17 18 WHEREAS, The Organization for Economic Cooperation and Development (OECD) reports that in 2016 the United States 19 expenditure on health, as a percent of gross domestic product, was 17.2% (OECD, 2017); and 20 21 WHEREAS, ACEP has previously investigated and commented on value based care as per the Value Based Emergency 22 Care (VBEC) Task Force (2009) (ACEP, 2009); and 23 24 WHEREAS, ACEP partnered with Choosing Wisely in 2013 to create a list of tests and procedures that may not be cost 25 effective (ACEP, 2013); and 26 27 WHEREAS, Other medical organizations maintain recommendations that impact emergency physicians such as the 28 “Appropriateness Criteria” published by the American College of Radiology (ACR, 2017); and 29 30 WHEREAS, ACEP has 27 committees, none of which are focused on cost effective quality care (ACEP, 2016); therefore be 31 it 32 33 RESOLVED, That ACEP create a Clinical Effectiveness Committee that is responsible for identifying, assessing, and 34 promoting evidence-based, cost-effective emergency medicine practices. 35 References 36 ACEP. (2009). Report of the Value Based Emergency Care (VBEC) Task Force. Retrieved July 19, 2017, from 37 https://www.acep.org/advocacy/value-based-emergency-care-(vbec)-task-force-report 38 ACEP. (2013, October 14). ACEP Announces List of Tests As Part of Choosing Wisely Campaign. Retrieved July 19, 2017, from 39 https://www.acep.org/Clinical---Practice-Management/ACEP-Announces-List-of-Tests-As-Part-of-Choosing-Wisely-Campaign/. 40 ACEP. (2016). ACEP Committees. Retrieved July 19, 2017, from https://www.acep.org/Content.aspx?id=23014. 41 ACR. (2017). ACR Quality-Safety/Appropriateness-Criteria. Retrieved July 19, 2017, from https://www.acr.org/Quality-Safety/Appropriateness- 42 Criteria. 43 OECD. (2017). Current expenditure on health, % of gross domestic product. Retrieved July 19, 2017, from http://www.oecd.org/els/health- 44 systems/OECD-Health-Statistics-2017-Frequently-Requested-Data.xls. 45 46 47 Background 48 49 This resolution calls for ACEP to create a new Clinical Effectiveness Committee responsible for identifying, assessing, and 50 promoting evidence-based cost-effective emergency medicine practice. Resolution 50(17) Promoting Clinical Effectiveness in Emergency Medicine Page 2 51 Cost effectiveness analysis weighs the benefits of a treatment or testing modality for a population. This rigorous analysis includes 52 factors such as the cost and outcome of screening (identification of false positives and false negatives), treatment and mortality. It is 53 a very effective tool, when done with precision, to guide clinicians and determine best practices for a population. Such cost 54 effective analysis has led to recommendations by the U.S. Preventive Services Task Force for prostate cancer screening. 55 56 The American College of Radiology has embarked on a high profile cost effectiveness analysis for imaging with their 57 Appropriateness Criteria. Using large panels of radiologists and representatives from stakeholder organizations, ACR has developed 58 cost effective approaches to many common conditions. ACEP has participated in several of these panels. The results of those 59 analyses have formed the basis of ACR Select, which is now required in some hospitals for ordering images. 60 61 ACEP’s clinical policies have long been one of the more popular products of the College, and among the most frequently 62 downloaded documents. These policies are created by an expert panel who review and grade the literature and answer specific 63 question regarding preferred practice guidelines. These reviews may cover effectiveness, but rarely consider cost as a variable. 64 65 Though not a formal cost effectiveness program, the Emergency Quality Network (E-QUAL) offers analysis and recommendations 66 for cost effective treatment. The Network offers learning collaboratives in three main areas: sepsis, reducing avoidable imaging 67 (low back pain, minor head injury, pulmonary embolism, and renal colic) and low risk chest pain. The network offers a toolkit with 68 best practices and sample guidelines, as well as access to benchmarking data. It provides free CME and meets the CMS 69 Improvement Activity requirements of the new CMS Quality Payment Program (MIPS). Any ACEP member may join the network 70 for free. The network is financed through a CMMI grant. Additional modules may be added. The E-QUAL Network may be a 71 reasonable alternative to a cost effectiveness committee. 72 73 Cost effective analysis may provide a basis to control cost while improving outcomes. However, the analysis is based on what is 74 best for a population, not necessarily what is best for the individual. For example, the recommendations from the US Preventive 75 Services Task Force regarding prostate cancer screening will reduce the number of unnecessary biopsies and the morbidity and even 76 occasional mortality associated with false positive screenings. However, the individual whose cancer was detected in situ may view 77 this recommendation differently. It is said that every test (or treatment) has a ‘U curve’ of effectiveness. On the right side of the U 78 are the individuals who benefit from the test. In the middle are those who neither benefit nor are harmed. On the left side of the U 79 are the individuals who are harmed, either by the test/procedure itself, or by unnecessary follow-up testing. Cost effectiveness 80 analysis attempts to analyze this U curve. 81 82 ACEP has made some recommendations to reduce cost through its Choosing Wisely recommendations. Though not based primarily 83 on true cost-effectiveness criteria, these are recommendations to reduce testing. While the literature was thoroughly reviewed by the 84 expert panel, final selection was based on consensus. 85 86 A cost effectiveness program would require effort by ACEP similar to what is expended on clinical policies. Currently, the clinical 87 policies process requires two FTE ACEP staff with an eventual output of 6-8 clinical policies per year. 88 89 ACEP Strategic Plan Reference 90 91 Goal 1 – Reform and Improve the Delivery System for Acute Care 92 Objective A – Develop and promote delivery models that provide effective and efficient emergency medical care in 93 different environments across the acute care continuum. 94 95 Fiscal Impact 96 97 50% FTE staff member and in-person meeting at Scientific Assembly. Approximately $100,000 recurrent annual cost. 98 99 Prior Council Action 100 101 Resolution 15(12) Choosing Wisely Campaign not adopted. Called for the College to formally join the Choosing Wisely Campaign. 102 103 Prior Board Action 104 105 June 2014, approved the second list of ACEP Choosing Wisely recommendations (6-10) 106 Resolution 50(17) Promoting Clinical Effectiveness in Emergency Medicine Page 3 107 June 2013, approved ACEP Choosing Wisely recommendations (1-5) 108 109 June 2012, approved the recommendation from the review panel to not join the Choosing Wisely campaign. 110 111 October 2011, approved the action taken to decline the invitation to join the Choosing Wisely campaign. 112 113 114 Background Information Prepared by: Sandra M. Schneider, MD, FACEP 115 Associate Executive Director, Policy, Practice, & Academics 116 117 Reviewed by: James Cusick, MD, FACEP, Speaker 118 John McManus, MD, FACEP, Vice Speaker 119 Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director