Evidence-based vs Cost-based

clinical pathway

Eddy Rahardjo
FK Unair Surabaya
 Evidence based medicine (EBM)
an approach to medical practice intended to
optimize decision-making by emphasizing the use
of evidence from well-designed and well-
conducted research

suatu pendekatan praktek kedokteran yang

bertujuan meng-optimalkan keputusan dengan
menggunakan bukti yang diperoleh dari
penelitian yang di-disain dan di-laksanakan
dengan baik
 Cost-based medicine

suatu pendekatan praktek kedokteran

yang bertujuan meng-optimalkan
keputusan dengan menggunakan
perhitungan ekonomi
mana yang murah, pokoknya murah
apa yang murah tadi selamet ?
pokoknya sudah diusahakan, mudah-
mudahan selamet.
 Cost-based medicine

suatu pendekatan praktek kedokteran

yang bertujuan meng-optimalkan
keputusan dengan menggunakan
perhitungan ekonomi atas alternatif yang
ditemukan dari EBM
 Cost-based medicine
(atas alternatif hasil EBM)

Short-term Cost-effectiveness
seems unlikely that a good quality is a cheap
solution
Long-term Cost-effectiveness
a result after a long effort to achieve a high
quality level which due to its persistence
will save cost at the end
 cost-base Rp 120 juta / 2015

cost-base Rp 250 juta / 2005

Menabrak bagian belakang Kijang

dalam iring-iringan yang berhenti
mendadak, kecepatan 15km/jam
Tak ada kerusakan
Biaya servis = Rp 0

Kerusakan cukup parah

Biaya servis = Rp 20 juta
 Short-term Cost-effectiveness
In the short term, evidence based
medicine is an expensive option;
research is extremely costly and the
budget for studies into medical conditions
is not infinite
 Long-term Cost-effectiveness

Evidence based medicine is considered by

many as a long-term solution to cutting the
mounting costs; this is principally due to
the ability to eliminate the use of
medications and treatments that are not
effective and focus only on those that have
been proved successful.
 Further, .. decreasing costs

The use of evidence based care over a

prolonged period of time has been proven
to improve patients conditions in the long-
term by
reducing the possibility of further
complications
reducing the need for further treatment,
Components
of EBM

https://www.healthcatalyst.com/5-reasons-practice-evidence-based-medicine-is-hot-topic
 5- Ways EBM Adds Value to Health Systems

1. Helps clinicians stay current on

standardized, evidence-based protocols.
2. Uses near real-time data to make care
decisions.
3. Improves transparency, accountability,
and value.
4. Improves quality of care.
5. Improves outcomes.
 Clinical pathway
is a task-oriented care plan that details essential
steps in the care of patients with a specific
clinical problem and describes the patients
expected clinical course.
The goal of clinical pathways is to standardize
care, improve outcomes and reduce cost.
But how many alternative pathways become
options in a patient with multiple diseases?
 case # 1
Pasien 70 tahun, coma dibawa masuk IGD
Nafas 30x per menit, SpO2 jari 85%, diberi O2
Tekanan darah 90/50, nadi 140 dan di monitor
tampak sangat tidak teratur dan diduga Atrial
Fibrilasi
Auscultasi ronchi kasar tersebar. Suhu 39C
GCS EVM 2-2-3
Pasien sejak 12 jam tidak kencing
Dipasang infus NS 20 tetes per menit
 Pasien 70 tahun, coma dibawa masuk IGD
DD stroke hemorrhagic / ischemic CT scan
COPD gagal nafas, hypoxia, hypercarbia BGA
Nafas 30x per menit, SpO2 jari 85%, diberi O2
intubasi, ventilator, foto thorax
Tekanan darah 90/50, nadi 140 dan di monitor tampak
sangat tidak teratur, diduga Atrial Fibrilasi
Tambah cairan, perlu DC cardioversi
Auscultasi ronchi kasar tersebar. Suhu 39C
pneumonia, antibiotika, kultur,
GCS EVM 2-2-3
Pasien sejak 12 jam tidak kencing
DD dehidrasi atau gagal ginjal perlu lab
Dipasang infus NS 20 tetes per menit
perlu CVP, echo jantung dan IVC
 life support definitive
care

critical
survived get well
high flow oxygen
intubation, ventilator, suction, tracheostomy
fluid, electrolyte, transfusion multiple sputum culture
CT scan, possibly stroke multiple antibiotics
ECG, multiple x-rays surgery for hematoma
multiple lab test, bloodgases artificial nutrition
hemodialysis albumin
sepsis treatment
chest physiotherapy
general exercise
rehabilitation, mobilization
home care
 Prognosis, which one?
1. Epidemiology-based prognosis
90% of the patients will not make it
2. Individually-based prognosis
there are 10% exceptional cases who survive

Data epidemiologi membuat kita berfikir bahwa

terapi mahal dan kemungkinan besar sia-sia.
Maka keputusan kita akan bias dan cenderung
menolak tindakan lebih lanjut.
Hal ini menghilangkan kesempatan pasien
untuk selamat.
Five Things to Stop Doing in the ICU to
Limit Waste
Laird Harrison / January 13, 2014 SAN FRANCISCO

Four critical care provider groups have announced a list of

measures to limit wasteful procedures in the intensive
care unit (ICU) in an attempt to control spiraling healthcare
costs.

Rationing is unavoidable. You cannot reconcile boundless

needs to bounded funds.
The Choosing Wisely campaign acknowledges this reality
with a specific list of 5 "don'ts" that could reduce costs.
 Five Things to Stop Doing in the ICU
(to limit waste)
1. Don't order diagnostic tests at regular intervals,
such as every day. Order in response to
specific clinical questions
2. Don't transfuse red blood cells in
hemodynamically stable, non bleeding ICU
patients with a Hb > 7 mg/dL.
3. Don't use parenteral nutrition in adequately
nourished critically ill patients in the first 7 days
of an ICU stay.
4. Don't deeply sedate mechanically ventilated
patients without a specific indication and
without daily attempts to lighten sedation.
 Five Things to Stop Doing in the ICU
(to limit waste)

5. Don't continue life support for patients at

high risk for death or severely impaired
functional recovery without offering
patients and families care focused
entirely on comfort
 Case # 2
Don't continue life support ?
 Pasien 72 th, severe septic shock akibat
peritonitis setelah laparotomi 4 hari
sebelumnya.
Tekanan darah 90/50, nadi > 140,
ECG Atrial Fibrilasi
GCS 2-2-4 dan urine tidak keluar.
Dont continue life support ?
Dilakukan re-laparotomi. Ditemukan usus
nekrosis dan di-reseksi 1 meter.
Pasien jatuh dalam cardiogenic shock.
Dont continue life support ?
 Menurut protap Amerika tadi, seharusnya
dilakukan care focused on comfort.
NO ventilator, NO antibiotic, NO TPN
Tetapi keluarga minta dirawat maksimal di
ICU dan rela menjual satu rumah cicilan
mereka.
Albumin dan transfusi dilanjutkan.
TPN lalu EN.
Antibiotika dan anti jamur sesuai kultur.
Pasien dibantu ventilator 1 bulan.
Foto ini dibuat 10 th kemudian pada usia 82 th
 cerita SpAn yang melayani banyak BPJS

Ibu hamil, care-plan-1 per vaginam. Waktu

mulai his, sudah 6 jam belum jelas apa
mungkin berhasil. Ganti care-plan-2 : SC
Entah bagaimana, hitungannya biaya
hanya cukup jika semua SC di SAB.
Jatah SpAn: satu ampul bupivacain, satu
spuit 2.5ml dan satu jarum spinal no 27.
Berapa botol RL jatahnya? Adakah
ephedrin, lasix, adrenaline, ketamine?
 pertanyaan kritis
Mengapa pilih SAB, karena murah? Atau
karena diyakini paling aman?
Kalau semua obat di pas jatah, bagaimana
jika variasi pasien memerlukan tambahan
dosis atau pengubahan jenis obat?
 ASA Closed Claims
Dr. H.S. Chadwick (University of Washington) :
Obstetric subset n=157 (11%) from n=1455 claims of
medical malpractice relating to anesthesia care.
Two-thirds of the cases related to Cesarean section.
Despite the use of regional anesthesia in 66% (77% of
vaginal delivery, 61 % of Cesarean section),
respiratory problems predominated: pulmonary
aspiration in 6% (10% of vaginal delivery, 5% of
Cesarean section) compared to only 2% in the non-
obstetric claims.
Injuries include headache, pain during anesthesia,
seizure, newborn brain damage and maternal death.
Payments were made in 51 % of claims, with a median
payment of $225,000
 ASA Closed Claims
Dr. H.S. Chadwick, University of Washington

from n=1455 claims to anesthesia care.

Obstetric subset n=157 (11%), which 2/3 were
related to C- section.
Despite the use of regional anesthesia in 66%,
pulmonary aspiration occurred in 6%
10% of vaginal delivery, 5% of Cesarean section
Injuries include headache, pain during anesthesia,
seizure, newborn brain damage and maternal death.
Payments were made in 51 % of claims, with a
median payment of $225,000
 Cost-Containment Strategies for Anesthesia Drugs in the Operating
Room: The University of Michigan Hospitals' Experience
Julie A. Golembiewski, PharmD, Univ of Michigan Hospitals, Dept of Pharmacy Services

Abstract: To remain competitive in the

marketplace in this time of health care
reform, the University of Michigan (UM)
hospitals determined that reductions in its
overall expense budget must occur.
Suggestions for lower-cost alternatives,
formulary management, waste reduction,
product selection, and stock reduction
were made. [Drug Benefit Trends 9(7):13-14,19-21,25-26, 1997]
 These cost-containment strategies have
resulted in significant reductions in
expenditures for benzodiazepines,
neuromuscular blocking drugs, and
albumin.
Consequently, the overall cost per
case for anesthesia drugs decreased
from $44.00 to $38.80

Begitu besar bangganya menghemat $ 5.20 ?

 cost-base pada out-patients
outpatient cases are rather uniform.
small variations can cleaned with a
generalized approach and will not show
bad results
the big number of denominator will hide
deviations (mean SD, SD-nya kecil)
this is not what happen in ICU cases
 ICU & Emergency patients
there are many variations, as each
individual has big and significant specific
conditions (mean SD, SD-nya besar)
dalam life-support pasien emergensi
semua terapi perlu diberikan untuk segera
membawa vital signs kembali ke harga
normal.
 Take home message
Hati-hati dengan Cost-based medicine
yang tidak berdasar Evidence
Untuk cost-based yang aman kita harus
puas dengan penghematan kecil yang
berjalan dalam jangka panjang
Bukan penghematan drastis besar-besaran
dalam jangka pendek yang segera terlihat
kehebatannya, sebab hal ini potensial
merugikan pasien