Quality

Hospitalists Lead Efforts To Reduce Care Costs, Improve Patient Care

“This is preparing for war in a time of peace, essentially,” says LeRoi S. Hicks, MD, MPH, a hospitalist, researcher, and educator at Christiana Care. “The goal will be, as we move to bundled payment and population health approaches, to minimize the time patients spend in the hospitals and limit the growth curve in spending on the hospital side. We are doing this and not taking on financial risk.”

Dr. Hicks adds that in its most simple form the project “reduces variation in the care we deliver” while improving efficiency and outcomes.

For many physicians, the best way to start is to begin a dialogue with patients who might also be at risk of financial harm due to unnecessary care, Dr. Arora says. “Patients are willing to change their minds and go with the more affordable and more evidence-based treatment and forgo expensive ones if they have that conversation,” she says.

Many resources exist for physicians interested in driving the frontline charge to improve healthcare quality and value. The Costs of Care curriculum provides training and tools for physicians at teachingvalue.org, as do SHM’s Center for Quality Innovation and the Institute for Healthcare Improvement. Dr. Moriates and Dr. Arora also have co-authored a book, along with Neel Shah, MD, founder and executive director of Costs of Care, called “Understanding Value Based Healthcare.” The book will be available this spring.

“We shouldn’t sit by the side of the road waiting for things to pass by,” Dr. Arora says. “I think the key is, we know the needle is shifting in Washington, we know system innovation models are being tested. It would be silly for us to say we’re going to continue the status quo and not look at ways to contribute as physicians.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

SHM convened a subcommittee of representatives from its Hospital Quality and Patient Safety Committee to consider 150 Choosing Wisely submissions from SHM committee members. These were narrowed down, ranked, and sent to all SHM members in a survey. Five evidence-based suggestions were adopted for adult patients. The recommendations are:

  1. Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, peri-operatively for <2 days for urologic procedures; use weights instead to monitor diuresis).
  2. Don’t prescribe medication for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
  3. Avoid transfusions of red bloods cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
  4. Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
  5. Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation to advocate for open dialogue between healthcare providers and patients to ensure appropriate care delivery at the right time.

—Kelly April Tyrrell

References

  1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
  2. Morgan DJ, Wright SM, Dhruva S. Update on medical overuse. JAMA Intern Med. 2015;175(1):120-124.
  3. Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.
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