Highlight on Utah: New tool cuts costs, improves outcomes

In a study published by the Journal of Hospital Medicine,  investigators from the University of Utah Medical Center (UUMC)  found that a Value Driven Outcomes (VDO) tool reduced the number of unnecessary laboratory tests performed on hospitalized patients and cut costs. Investigators Peter Yarbrough, M.D., Kensaku Kawamoto, M.D., Ph.D.,  and three physician colleagues from UUMC estimated that their multifaceted intervention saved the hospital more than $250,000 the first year. Although patients often need daily laboratory work, Yarbrough said, “it can create a culture where you’re ordering tests without thinking about what you’re going to do with the results.” The goal of the study was to try to create a thoughtful process for deciding what laboratory tests to order for hospitalized patients.

Study design

The study compared the changes in laboratory costs between the hospitalists and other physician providers at UUMC.  The hospitalist services were performed by four teams of Internal Medicine residents and medical students. The control group comprised physicians from the surgical, cardiology, pulmonary, hematology, and oncology departments. Patients admitted to the psychiatric, rehabilitation, or obstetrics units were excluded from the study.  Their use of laboratory tests was measured during a seven-month baseline period, after which the intervention was introduced. The study period continued for 15 months. the design controlled for differences in age and took into account the level of comorbidity.

After an informal review of patient charts, an examination of the physicians’ work flow, and a review of the literature, Yarbrough, Kawamoto, and their coauthors noted that interns ordered the most tests and were responsible for the greatest variation in utilization of laboratory services. They noted that unnecessary testing  poses several risks to patients. False positives results lead to additional unnecessary testing. Over long hospital stays, frequent blood draws increase the risk of anemia. One cardiology study found that cardiac patients lost an average of 454 ml of blood per stay, nearly half a liter. Being awakened early in the morning for daily blood draws can deprive patients of needed rest, negatively affecting their hospitalization experience, as well.

The interventions

The first component of the UUMC intervention was education of the physicians involved on the cost of overuse of laboratory services, the results of previous interventions, and the current intervention and its goals. The residents were issued pocket cards with the most common laboratory tests and the amount charged for each. The rounding process was standardized, incorporating a checklist that required review of previous lab results, pain, telemetry, lines and tubes, nursing presence, and follow-up needed for each patient. All plans for lab testing were to be discussed during rounds. A third year medical student was tasked with making sure that the entire checklist was addressed for every patient.

Each month, the hospitalists reviewed laboratory costs using their VDO tool. The data were presented as a monthly average, though individuals could compare their performance to that of other providers in the group.  There was a financial incentive for the Department of Internal Medicine as a whole, in that 50 percent of the savings would be shared with the department to use for future quality improvement projects, but there was no financial incentive for individual physicians. The results were measured every two weeks.

Results

The number of basic metabolic panels, complete metabolic panels, and complete blood counts dropped significantly. The average daily cost of laboratory services per patient fell from $138 to $123. The laboratory cost per visit dropped by $128.  Length of stay was not significantly affected, but remained constant in both the control group and the intervention group. Readmissions within 30 days fell from 14 percent to 11 percent in the intervention group.

The multifaceted nature of the intervention makes it difficult to tease out the relative effects of the various components. The hospitalists involved, however, believed that the use of the VDO checklist and the feedback at monthly meetings were the most important factors affecting the changes in their behavior.

Evidence-based practice important to health outcomes, rarely implemented

Hospitals across the country have failed to implement evidence-based practice (EBP), which integrates best practices, expertise, and patient input, and correlates to high-quality care and improved outcomes. Perhaps related, the Ohio State University found that more than one-third of hospitals are failing to meet nursing performance metrics.

Study

The university’s College of Nursing studied chief nurse executives’ survey results, which included the EBP beliefs scale, EBP implementation scale, the organizational cultural and readiness scale for EBP, CMS core measures, and the national database of nursing quality indicators (NDNQI). The responses indicated that while belief in EBP is relatively high, nurses are unsure of the steps required for implementation and not convinced that EBP could be implemented efficiently. Over half of respondents believed that EBP is either “somewhat” or “not at all” practiced, and almost as many were unsure how to measure the outcomes of their services.

Triple aim

The study’s authors believe that EBP is a fundamental key to reaching the “triple aim” of health care: improving care, improving health, and lowering costs. Although the respondent nurses ranked quality and safety as their top priorities, EBP was farther down the list and almost no money was allocated to EBP implementation. The authors stated that organizations need better EBP resources and tools to increase familiarity with the process. However, clinician behavior and willingness to work in a new way is even more important, and generally does not happen simply due to the availability of information. The authors recommended offering compelling reasons to change processes along with skill-building workshops and clear expectations during EBP implementation.

The CONNECT for Health Act suggests the future isn’t too remote

A new piece of legislation would increase the use of telehealth and remote patient monitoring (RPM) in the Medicare program. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan piece of legislation, is aimed at cutting health care costs while improving care outcomes. The bill is premised on the belief that telehealth is the future of medicine and that the quality of care can be greatly improved, in a cost effective way, through better contact between patients and providers.

Provisions

The CONNECT for Health Act would loosen current restrictions on Medicare reimbursement for telehealth and RPM services. Specifically, the legislation would allow certain providers to use telehealth and RPM without many of the current 42 U.S.C. §1834(m) limitations, which include originating site restrictions, geographic limitations, restrictions on store and forward technologies, limitations on distant site providers, and limitations on covered codes. The act would also permit providers to use telehealth and RPM in alternative payment models without most of the Section 1834(m) restrictions. The act would allow RPM of certain patients with chronic conditions, permit more facilities to serve as originating sites, and enable telehealth and RPM to be considered basic benefits in Medicare Advantage, without most of the Section 1834(m) restrictions.

Response

According to an Avalere study, the bill could save as much as $1.8 billion over the next ten years. The American Medical Association (AMA) has expressed its support for the bill, noting that it stands to strengthen physician-patient relationships and improve care access while maintaining patient safety. The bill was introduced by Senators Brian Schatz (D-Hawaii), Roger Wicker (R-Miss), Thad Cochran (R-Miss), Ben Cardin (D-Md), John Thune (R-SD), and Mark Warner (D-Va). The Senators praised the advances of health information technology and the promise of telehealth, noting the importance of the opportunity to bring together improvements in technology with the prospect of better care quality.

HHS proposes ‘modern’ approach to substance abuse privacy

HHS is proposing to update the Confidentiality of Alcohol and Drug Abuse Patient Records regulations to improve information exchange of the medical records of patients with substance abuse disorders. The proposals are designed to improve care coordination and modernize patient privacy protections by updating rules that were promulgated in 1975 and last updated in 1987. HHS believes that changes must be made to the confidentiality rules in order to permit patients seeking substance abuse treatment to participate effectively in new integrated health care models. The Proposed rule is set to publish in the Federal Register on February 9, 2016. HHS is accepting comments on its proposal through April 11, 2016.

Current protections

The Proposed rule acknowledges that the current laws and regulations governing substance abuse health record confidentiality were developed out of fears that the use of information regarding an individual’s substance abuse treatment in a criminal prosecution would deter individuals from seeking treatment. Under the current regulations, a federally assisted substance use disorder program can only release identifiable information related to substance use disorder diagnosis, treatment, or referral for treatment with the individual’s express consent.

Rationale

The Proposed regulations are HHS’ attempt to revise 42 C.F.R. Part 2 to ensure patients can participate in newer integrated care models while ensuring that patients are not made more vulnerable through increased information sharing. HHS acknowledges the legitimate privacy concerns of patients seeking treatment for substance abuse. Some of the concerns noted by the Proposed rule include the potential for loss of employment, loss of housing, loss of child custody, discrimination by medical professionals and insurers, arrest, prosecution, and incarceration.

“This proposal will help patients with substance use disorders fully participate and benefit from a health care delivery system that’s better, smarter and healthier, while protecting their privacy,” said Secretary Burwell in a press release. “We are moving Medicare, and the health care system as a whole, toward new integrated care models that incentivize providers to coordinate and put the patient at the center of their care, and we are modernizing our rules to protect patients.”

Changes

The specific changes would facilitate electronic exchange of patient records by allowing patients to make a general designation in the “To Whom” section of their patient consent form. HHS believes that the change would facilitate the sharing of patient information within the health care system, while decreasing burdens on participants in integrated health care models. Under the proposal, entities named on a consent form that disclose information under a general designation must, upon request of the patient, provide the patient with a list of entities to which their information has been disclosed. The Proposed rule contemplates that such entities might include entities like Accountable Care Organizations and patient-centered medical homes.