High-value care increasingly tops hospital agendas, which pushed the Society of Hospital Medicine to add a track dedicated to the topic at this year's annual meeting (HM17), with session names such as "Things We Do for No Reason."
Part of that track included choosing for oral presentation the top three abstracts related to high-value care. The winners addressed how to eliminate days of care that insurers won't pay for and that won't benefit patients, and how to decrease unnecessary telemetry use to reduce the frequency of inappropriate transthoracic echocardiography (TTEs).
"High-value care is a hot topic that is influencing practice around the country and is part of the solution to our country's healthcare crisis," said Lenny Feldman, MD, a hospitalist and associate professor of medicine at Johns Hopkins Medicine in Baltimore, Maryland, to Medscape Medical News. "Providers recognize that quality and costs have to be balanced in order for our system to thrive."
Dr Feldman, who was course director for the May HM17 meeting in Las Vegas, said high-value-care committees in hospitals across the country and research efforts like those presented at the conference are setting the agenda.
Decreasing Denied Days
At Los Angeles County/University of Southern California Medical Center (County/USC) researchers targeted reduction of denied days or days of care not reimbursed by insurers, a problem for hospitals nationwide.
Chase Coffey Jr, MD, associate medical director for inpatient services at County/USC, and his colleagues, determined that in 6 months from July to December in 2015, 24.2% of care days in the department of medicine alone were denied, with a cost of $38.7 million to the hospital, a 676-bed safety-net site.[1]
Dr Coffey told Medscape Medical News that there were many reason for denials. The researchers, however, focused on the two causes that physicians had the most control over: level of care not justified and delayed services, for example, days added while a physician awaits imaging results or for a consult to return recommendations, or when a patient is ready for discharge but the discharge plan isn't read.
The intervention included making hospitalists aware of each day denied and soliciting their help to find causes and solutions. The low-hanging fruit, Dr Coffey said, was in poor coding and documentation. Insurance companies were finding that physicians' documentation didn't justify the level of care delivered.
Changes began with daily reports to each team about denied days. That was coupled with face-to-face meetings with the medical and nursing directors of utilization review. In those meetings, charts were reviewed for patients who had care denied by insurers; also addressed were barriers to efficient care.
"Sometimes that was calling radiology to get a chest result or calling the consulting attending to get their recommendations back, or calling the OR to get the patient scheduled earlier," Dr Coffey said. This led to systems change to prevent future delays.
An example of system change was rethinking of admitting patients with osteomyelitis. Until early 2016, providers would routinely admit those patients and get imaging and consults, which could take many days to resolve. However, guidelines suggest that the majority of osteomyelitis patients can be treated as outpatients with oral antibiotics, he said.[2]
The researchers worked with emergency department physicians to identify people who could be treated on an outpatient basis with oral antibiotics.
"We had to scrape off the years of 'this is how we've always done it,'" he said. Key in making the change, he noted, was to provide physicians with an alternative. "Nobody likes to be told no."
As teams became able to stand on their own, they allowed nurse case managers to handle the face-to-face meetings but continued communication about notices of denied days.
Researchers quickly saw results in documentation.
Dr Coffey said that denied days dropped from an average of 200 per month to fewer than 50 per month. Service delays went down by half, from 150 per month to about 75 per month, he added.
The department of medicine went from having a 24.2% denial rate at the beginning of the effort to almost half of that—13%—in March of 2017, he said.
Researchers started with that department because it touches 60%-70% of patients, Dr Coffey said, but the interventions will eventually be spread hospital-wide.
"We're using denied days as canaries in the coalmine to help us identify where there might be opportunities to improve the delivery of high-value care," he said.
Deciding When TTEs Are Necessary
Another target for reduction was one of the most popular tests in healthcare: TTE.
Studies of Medicare beneficiaries, for example, have shown that each year, approximately 20% undergo at least one TTE.[3] Almost one third of the patients who get them have had a prior TTE within the past year.[4]
Craig G. Gunderson, MD, assistant professor of medicine at Yale University School of Medicine in New Haven, Connecticut, and director of the step-down unit at West Haven Veterans Hospital, told Medscape Medical News that hospitalists may overuse the tests out of fear of missing something when a diagnosis isn't clear, especially because the tests are noninvasive and easy to do.
He added, "There's really nothing to guide doctors about when to get another [TTE]. There's very little literature," he said.
Dr Gunderson and colleagues set out to find out how many of the repeat tests resulted in change and how many showed little to no change and, therefore, may have been unnecessary.
The researchers looked at everyone who had repeat TTEs at the Veterans Hospital from October 1, 2013 to September 30, 2014 (211 patients) and analyzed which characteristics were independently associated with changes in TTEs.[5]
From that data they derived a predictive model which they named the CAVES score, which stands for the five predictors: C (chronic kidney disease); A (acute coronary syndrome since the last TTE); V (valvular heart disease found on the prior TTE); E (ECG with major new changes since prior study); and S (heart surgery since the last TTE).
Dr Gunderson says the next step will be validating the CAVES score for other populations.
"This is really a first attempt to have an evidence base to help clinicians know whether a repeat TTE is likely to be helpful," he said.
Decreasing Automatic Use of Telemetry
A team of hospitalists at the Veterans Administration Ann Arbor Healthcare System in Michigan tackled inappropriate heart monitoring (telemetry).
Inappropriate use of telemetry is a problem nationwide, even with American College of Cardiology/American Heart Association (ACC/AHA) guidelines in place since 2004,[6] study coauthor Christopher Michael Petrilli, MD, told Medscape.
In fact, as part of the Choosing Wisely campaign, the Society of Hospital Medicine recommends against using continuous telemetry outside the ICU without a protocol that specifies guidelines for continuation.[7]
Telemetry is appropriately used, the authors note, after cardiac arrest, on patients who have a high degree of heart block, or on those who just had heart surgery and are in danger of developing serious arrhythmias.
Dr Petrilli, however, said that telemetry is often overused for other patients because many physicians assume that monitoring can only help the patient and that more must be better.
The truth, Dr Petrilli says, is that it can harm patients by causing alert fatigue for care providers and contributing to hospital-acquired delirium. Also, tethering patients to machines keeps them from being mobile, and if a tethered patient moves, that motion may look like an arrhythmia and a consult may be required, leading to overtreatment. Not being able to take a shower also decreases quality of life for the patient.
For all of those reasons and the costs that unnecessary telemetry creates, the team created an order set in the electronic health record so that physicians could only choose telemetry if their patients met the guidelines set by the ACC/AHA. The orders also specified a specific time period for the orders. They could be reordered, but a physician would have to actively choose that.
Researchers looked at utilization rates before and after the intervention and then reviewed 294 randomly selected charts after the intervention to make sure that telemetry was used with the appropriate indication for the duration of the stay, not just for what was indicated at admission.[8]
They found that inappropriate use of telemetry went from 23% before the intervention to 10% after. The number of patients monitored continuously from admission to discharge went from 81% to 53% in a year-over-year change from April to October 2016, compared with the same period the year before.
"We knew that if we could see success at the VA, where you use one electronic health record, we could spread it easily to every VA."
Meanwhile, there was no change in the number of inpatient cardiac arrests or medical codes after the order sets were implemented.
The next step for the researchers, he said, is to quantify how much the intervention reduces costs.
Medscape Internal Medicine © 2017 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Hospitalists' Winning Abstracts Target High-Value Care - Medscape - Jun 29, 2017.
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